Journal of Clinical Child and Adolescent Psychology
2006, Vol. 35, No. 3, 446–455
Copyright © 2006 by
Lawrence Erlbaum Associates, Inc.
Peer Victimization in Children With Obsessive–Compulsive Disorder:
Relations With Symptoms of Psychopathology
Eric A. Storch
Department of Psychiatry and Department of Pediatrics, University of Florida
Deborah Roth Ledley
Department of Psychology, Temple University
Adam B. Lewin
Department of Clinical and Health Psychology, University of Florida
Tanya K. Murphy, Natalie B. Johns, Wayne K. Goodman, and Gary R. Geffken
Department of Psychiatry, University of Florida
This study examined the frequency of peer victimization and psychological symptom
correlates among youth with obsessive–compulsive disorder (OCD). The Schwartz
Peer Victimization Scale, Children’s Depression Inventory, and Asher Loneliness
Scale were administered to 52 children and adolescents diagnosed with OCD. The
child’s parent or guardian completed the Child Behavior Checklist, and a trained clinician administered the Children’s Yale–Brown Obsessive–Compulsive Scale (CY–
BOCS). Fifty-two healthy controls and 52 children with Type 1 diabetes (T1D) who
were administered the Schwartz Peer Victimization Scale as part of another study
were included for comparison purposes. Greater rates of peer victimization were reported in youth with OCD relative to healthy controls and children with Type 1 diabetes (T1D). Peer victimization in the OCD sample was positively related to loneliness,
child-reported depression, parent-reported internalizing and externalizing symptoms, and clinician-rated OCD severity. Peer victimization fully mediated the relation
between OCD severity and both depression and parent reports of child externalizing
behaviors and partially mediated the relation between OCD severity and loneliness.
Recognition of the magnitude of the problem and contribution problematic peer relations may play in comorbid psychological conditions is important for clinicians who
see children with OCD.
Peer relationships play critical roles in youngsters’
emotional development and adjustment (Ladd, 1999).
Within the context of peer relations, children develop
social skills and empathy and in positive circumstances
receive tangible and emotional support (Hartup, 1996).
Unfortunately, negative peer interactions are a common childhood experience (Storch & Masia-Warner,
2004) and can have a profound impact on current
(Kochenderfer, & Ladd, 1996; Kupersmidt & Coie,
1990; Storch, Nock, Masia-Warner, & Barlas, 2003)
and future adjustment (Roth, Coles, & Heimberg, 2002;
Storch, Roth, et al., 2004; Woodward, & Fergusson,
2000). Consequently, it is critical to examine populations that may be at increased risk for problematic peer
relationships.
When considering such populations, most studies
have focused on youth with disruptive behavior prob-
lems with markedly fewer investigations of youngsters
with anxiety disorders. As interest in the nature and
treatment of childhood anxiety has increased, however,
evidence has accumulated that anxious children demonstrate impairments in their peer relations. For example, Strauss, Lahey, Frick, Frame, and Hynd (1988)
found that children with anxiety disorders were less
well liked by peers as compared to nonclinical children. Ginsburg, La Greca, and Silverman (1998) found
that clinically anxious youth reported low levels of social acceptance and global self-esteem and frequent
negative peer interactions. In an observational study
(Panella & Henggeler, 1986), anxious–withdrawn adolescents displayed less social competence and positive
affect and more apprehension than well-adjusted adolescents when interacting with both friends and strangers. Finally, a number of reports in nonclinical samples
have documented high rates of rejection and low rates
of peer acceptance among youth who self-reported
high rates of anxiety (La Greca & Lopez, 1998; La
Greca & Stone, 1993; Walters & Inderbitzen, 1998).
Correspondence should be addressed to Eric A. Storch, Department of Psychiatry, University of Florida, Box 100234, Gainesville,
FL 32610. E-mail: estorch@psychiatry.ufl.edu
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PEER VICTIMIZATION
Anecdotal clinical reports support empirical findings
such as these, as anxious youth and their parents frequently report being bullied, marginalized, and having
difficulty making friends.
Despite the importance of studying the peer relations of anxious children and adolescents, the literature
remains in its infancy. In this regard, one largely neglected yet relatively prevalent condition among youth
is obsessive–compulsive disorder (OCD). Affecting
between 1% and 4% of youth (Douglass, Moffit, Dar,
McGee, & Silva, 1995; Zohar, 1999), OCD is characterized by the presence of obsessions, compulsions, or
both that cause distress, are time-consuming, or interfere with age-appropriate functioning (American Psychiatric Association, 2000). Recent estimates suggest
that between 50% and 80% of cases have a childhood
onset (Pauls et al., 1995), which suggests that many afflicted individuals may struggle in the development of
healthy peer relationships. OCD follows a chronic,
fluctuating course (Murphy et al., 2004) and is associated with significant impairment in academic, family,
and social realms due largely to ritual engagement and
distress (Piacentini, Bergman, Keller, & McCracken,
2003).
Although important, the relevant literature has been
largely confined to examinations of the general peer
relations of youth with anxiety disorders other than
OCD. Subsumed within the definition of peer relations
is the experience of peer victimization, a specific form
of peer maltreatment in which a child is targeted by a
peer or group of peers. Peer victimization of boys and
girls occurs frequently and takes diverse forms, including overt (e.g., hitting, kicking, yelling) and relational
attacks (e.g., spreading rumors, excluding a peer from
social interactions; Crick & Bigbee, 1998; Crick &
Grotpeter, 1996). Although most children are victimized by their peers at some point during youth, chronic
victimization has been linked to depression, anxiety,
and loneliness concurrently and prospectively (see
Hawker & Boulton, 2000). For example, in a meta-analytic review, Hawker and Boulton found the mean correlations between peer victimization and depression (r
= .45), anxiety (r = .25), and loneliness (r = .32) to be
positive and significant.
There are a number of reasons to hypothesize that
peer victimization may be a frequent experience in
the lives of youngsters with OCD. First, many rituals
and avoidance behaviors are observable to peers. For
example, children might leave the classroom frequently during the school day to wash their hands or
might take longer than other children to complete
schoolwork because they have to reread or rewrite assignments. The nature of some children’s OCD symptoms might cause them to avoid classmates because of
fear of contamination or of “catching” qualities of
other children, such as becoming rude by touching a
child who is rude. As other children are unlikely to un-
derstand the nature of these behaviors, children with
OCD may be labeled as “ odd or different” or having
special needs, providing bullies with ammunition to
fuel attacks. Second, children with OCD may have a
smaller network of friends due to others’ perceptions of
differences and mental illness or because they miss out
on age-appropriate activities secondary to OCD. Although it is difficult to avoid school despite OCD,
many children with the disorder refuse to participate in
optional extracurricular activities. These activities can
be triggers for OCD (e.g., sharing a baseball glove is
very difficult for a child with contamination-related
OCD), may be too exhausting for children after a day
of having to cope with OCD, and may interfere with
rituals that must be done at home once the school day is
over. Small friendship networks have been linked to
the experience of peer victimization because children
do not have peers to provide physical or emotional support (Storch et al., 2003). Finally, many children with
OCD display anxiety or behaviors characteristic of
comorbid diagnoses (e.g., poor social skills in Asperger’s disorder, tics in Tourette’s Syndrome, poor social skills and assertiveness skills in social phobia) that
invite further teasing and make it difficult for children
to defend themselves.
Despite these intuitive reasons for youth with OCD
to be at increased risk for problematic peer relations,
few data exist on the rates of peer victimization or psychological symptom correlates of peer victimization in
this population. Storch et al. (2005) documented the
case of an adolescent boy whose OCD was precipitated
by peer victimization. Piacentini and colleagues (2003;
Langley, Bergman, McCracken, & Piacentini, 2004)
have reported that children with OCD have impaired
social relations. For example, 37% of youth reported difficulty making friends, 31% reported difficulty
keeping friends, and between 34% and 43% reported
difficulty engaging in age-appropriate peer activities
(e.g., sleeping at a friend’s house).
Peer victimization may be directly linked to OCD
symptom severity in several ways. Peer victimization
may directly contribute to poor adjustment as the child
internalizes the content of peer attacks (Storch, Roth,
et al., 2004). For example, Storch et al. (2005) described an adolescent boy whose OCD onset was
linked to peers’ remarks about his masculinity and sexuality. After being victimized, this youth would go
home and wash excessively to cleanse himself of peers’
remarks. Alternatively, children with OCD may be targeted due to various illness-related behavioral and
emotional factors. Finally, peer victimization may
serve to mediate the relations between OCD severity
and depression and loneliness, providing insight into
the high rates of comorbidity commonly found in
youth with OCD (e.g., depression; King, Leonard, &
March, 1998; Swedo, Rapoport, Leonard, Lenane, &
Cheslow, 1989). Others have found peer victimization
447
STORCH ET AL.
to mediate other relations. For example, peer victimization mediated the prospective relations between
shyness and social withdrawal and later negative affect
(Dill, Vernberg, Fonagy, Twemlow, & Gamm, 2004).
This model proposed that OCD severity would positively affect peer victimization that, in turn, would lead
to greater levels of depressive symptoms and loneliness. For example, we believe that victimized youth
with OCD would, at least in part, incorporate the negative evaluations inherent to peer assaults into their
self-views,
resulting
in
greater
depressive
symptomatology and feelings of loneliness (Grills &
Ollendick, 2002; Storch et al., 2003). A social information processing bias may also predispose victimized
children to misinterpret peers’ behavior in an overly
hostile or negative manner (Crick, Grotpeter, &
Bigbee, 2002; Lochman & Dodge, 1994), resulting in a
higher incidence of disruptive behavior (Storch,
Bagner, Geffken, & Baumeister, 2004). Thus, peer victimization is expected to mediate the anticipated relation between levels of OCD severity and psychological
symptom indexes. A mediating effect for peer victimization would be established if the statistical association between OCD severity and psychological symptom indexes diminishes once associations between
peer victimization and the respective criterion were
specified (Baron & Kenny, 1986).
This research aims to provide initial data on peer
victimization, symptoms of psychopathology, and a
possible mediational model explaining these relations
in children and adolescents with OCD. Our specific
goals were to (a) examine rates of peer victimization
in children with OCD relative to healthy children
and chronic disease controls (children with T1D),
(b) examine if peer victimization is associated with
OCD symptom severity and other psychological symptom indexes, (c) examine if obsessions and compulsions are differentially related to outcomes, and
(d) examine if peer victimization mediates the relation
between OCD severity and psychological symptom
indexes. Based on findings in anxious youth and
our clinical experiences, we predicted that peer victimization would be elevated relative to control samples
and positively correlate with child-rated indexes of depression and loneliness, parent-rated indexes of internalizing and externalizing adjustment, and clinicianratings of OCD severity. Given that youth may internalize peer assaults, which is considered core to the development of internalizing difficulties, we predicted
that peer victimization would serve as a mediator in
the relation between OCD severity and psychological symptom indexes. Specifically, more severe OCD
symptoms are expected to relate to increased peer victimization, resulting in increased depression and loneliness and parent-reported internalizing and externalizing symptoms.
448
Method
Participants
Participants were obtained from three sources: (a)
children and adolescents with a primary diagnosis of
OCD (n = 52; 31 boys, 21 girls) consecutively seen for
outpatient clinical management appointments in the
Department of Psychiatry Child and Adolescent OCD
and Tic Clinic at University of Florida; (b) children and
adolescents diagnosed with T1D (n = 52; 24 boys, 28
girls) consecutively seen for outpatient clinical management of their diabetes in the Department of Pediatrics; and (c) a sample of children and adolescents attending well-child visits to their pediatrician (n = 52,
23 boys, 29 girls). Participants’ ages ranged from 8 to
17 years, with an average age of 12.0 years (SD = 2.5
years). The sample was largely White (88%), followed
by African American (7%), Hispanic (2%), Asian (2%),
and other (1%). No gender, age, or ethnic differences
existed among groups (p > .05; see Table 1). Only
youngsters with OCD completed all study forms. Forty
mothers and 12 fathers of participants with OCD completed parent forms. OCD and comorbid diagnoses
were made by a board-certified child psychiatrist
with 10 years of experience by using all available clinical information (Leckman, Sholomskas, Thompson,
Belanger, & Weissman, 1982), which included the
Children’s Yale–Brown Obsessive–Compulsive Scale
(CY–BOCS) results, clinical interview, and responses
to other measures. OCD and comorbid diagnoses were
also confirmed by one of two licensed clinical psychologists with extensive experience in pediatric OCD.
Forty-one children had a comorbid diagnosis (19 had
one comorbid diagnosis; 17 had two comorbid diagnoses; 5 had three comorbid diagnoses). Comorbid diagnoses for the OCD group were as follows: Tic Disorder
(n = 29), attention deficit hyperactivity disorder (any
subtype; n = 17), major depression (n = 7), generalized
anxiety disorder (n = 4), separation anxiety disorder (n
= 3), oppositional defiant disorder (n = 3), social phobia (n = 2), Asperger’s disorder (n = 2), panic disorder
with agoraphobia (n = 1), and trichotillomania (n = 1).
Diagnoses of T1D were made by a board-certified pediatric endocrinologist with 25 years of experience
based on all clinical information available at their reTable 1. Descriptive Information for Study Groups
Group
OCD
Diabetes
Control
Age
M
SD
Female (%)
Caucasian (%)
11.3
2.3
40.4
94.2
12.3
2.3
57.7
82.7
12.2
2.7
55.8
88.5
Note: OCD = obsessive–compulsive disorder.
PEER VICTIMIZATION
spective endocrinology clinic visit (e.g., plasma Cpeptide test, fasting glucose test).
Measures
Schwartz Peer Victimization Scale. The Schwartz
Peer Victimization Scale (Schwartz, Farver, Change, &
Lee-Shin, 2002) is a five-item self-report measure rated
on a 4-point scale of 1 (never) to 4 (almost every day) of
peer victimization that occurred over the past 2 weeks
(possible range = 4 to 20). Items focused on overt and relational forms of victimization consistent with contemporary definitions (cf. Storch & Ledley, 2005). An example item is “How often do other kids gossip or say
mean things about you?” The measure has good internal
consistency (α = .75), a stable one-factor structure, and
correlated strongly and positively with teacher and peer
reports of victimization (Schwartz et al., 2002).
Cronbach’s α in this sample was .85.
CY–OCS. The CY–OCS (Scahill et al., 1997) is
a 10-item semistructured clinician-administered measure of obsession and compulsion severity. Items are
rated over the previous 7 days on a 5-point Likert scale,
with higher scores corresponding to greater symptom
severity. Items about obsessions and compulsions are
summed to derive the Obsession and Compulsion Severity Scales. These scales are summed to derive the
Total Severity score. Internal consistency is good for
the CY–BOCS Obsession and Compulsion Severity
scores (α = .80 and .82) and Total score (α = .90).
Six-week test–retest reliability is good for the Obsession and Compulsion Severity scores (intraclass coefficient = .70 and .76) and Total score (intraclass coefficient = .79; Storch, Murphy, et al., 2004). The CY–
BOCS scores correlated highly with clinician impairment ratings and ratings on the Tourette’s Disorder
Scale–Clinician Rated Version (Shytle et al., 2003)
OCD factor. The CY–BOCS scores were moderately
associated with measures of depression and clinician
ratings of aggression and attention deficit hyperactivity disorder symptoms, yet not significantly related to
self-reports of anxiety or clinician ratings of tic severity (Scahill et al., 1997; Storch, Murphy, et al., 2004).
Cronbach’s α for the CY–BOCS Total Score and Obsession and Compulsion Severity scores in this sample
were .90, .89, and .79.
Children’s Depression Inventory.
The Children’s Depression Inventory (Kovacs, 1992) is a commonly used 27-item child-report measure of the presence and severity of cognitive, affective, or behavioral
symptoms of depression during the previous 2 weeks.
The Children’s Depression Inventory has good internal
consistency, test–retest reliability, and discriminative
validity (Carlson & Cantwell, 1979). In addition, the
Children’s Depression Inventory is construct valid
as determined by high correlations with other depression measures and a stable factor analysis (Craighead,
Smucker, Craighead, & Ilardi, 1998; Kovacs, 1992).
Cronbach’s α in this sample was .80
Child Behavior Checklist. The Child Behavior
Checklist (Achenbach, 1991) is a 113-item parentreport form designed to assess a wide range of child
behavioral and emotional problems. Parents are instructed to use a 3-point scale of 0 (not true), 1 (somewhat or sometimes true), or 2 (very or often true). This
widely used index has established psychometric properties across a variety of clinical and nonclinical populations (Achenbach, 1991). For the purposes of this
study, the Internalizing and Externalizing scale scores
were used. Cronbach’s α for each in this sample were
.88 and .77, respectively.
Asher Loneliness Scale. The Asher Loneliness
Scale (Asher, Hymel, & Renshaw, 1984) is a self-report measure consisting of 24 items endorsed on a
5-point scale indicating how true each item is for the
participant. The 16 items that focus on feelings of loneliness, social adequacy, and subjective estimations of
peer status were included in this study, whereas eight
filler items that inquire about the participants’ hobbies
were excluded to minimize the time needed to complete the assessment battery. Factor analysis of the
measure revealed one primary factor for the 16 items
(Asher & Wheeler, 1985). In addition, the Asher Loneliness Scale was positively correlated with negative
peer nominations and depression (Asher & Wheeler,
1985; Bagner, Storch, & Roberti, 2004) and negatively
associated with positive peer nominations and play ratings (Asher & Wheeler, 1985). Cronbach’s α in this
sample was .90.
Procedures
The University of Florida Institutional Review
Board granted permission to conduct this research. Active parental consent and child assent was obtained for
each of the participating youth prior to the administration of the questionnaires. Parents were told that their
and their child’s involvement in the project was voluntary and that they could refuse permission without negative consequences of any kind. Children were also informed that their involvement was voluntary and they
could decline participation without penalty.
Participants with OCD completed questionnaires
following the clinical interview and the CY–BOCS.
Instructions were provided for each measure by a
trained research assistant, who was available to answer
questions. Experienced clinicians (either a psychiatric
nurse or postdoctoral fellow) administered the CY–
449
STORCH ET AL.
BOCS to both the child and parent jointly in a private
clinical office before completion of study questionnaires. Clinician training consisted of an instructional
meeting about the CY–BOCS content and structure
with the first or final author, two practice interviews,
and two directly observed interviews. Children with
T1D and healthy controls completed the Schwartz Peer
Victimization Scale and several measures relevant to
other studies during their regularly scheduled endocrinology or well-child appointment. Consent rates for
each were high (52/70 = 74% for children with T1D,
52/60 = 80% for healthy children). The consent rate for
the OCD sample was 93% (52/56).
Results
Study Aim 1: Descriptive Analyses
and Group Differences
Using a cutoff score of 1 SD above the nonclinical
mean of this sample (cutoff = 9.8), 27% of the OCD
population reported clinically significant victimization
scores compared to 9% of children with T1D and 9%
of healthy controls. Using a cutoff score of 1 SD above
the mean for the normative sample in Asher et al.
(1984), clinically significant loneliness was reported
by 14% of children with OCD. Twelve percent of children with OCD reported clinically significant levels of
depression based on the standardized normative data
for the Children’ Depression Inventory (Kovacs,
1992). For this sample, 30.8% (n = 18) of children with
OCD had clinically significant internalizing symptoms
and 21.2% (n = 14) had clinically significant externalizing symptoms (based on the cutoff of T ≥ 70;
Achenbach, 1991). T scores ranged from 38.3 to 117.0
and 36.0 to 89.0 for the Internalizing and Externalizing
scales, respectively.
A one-way analysis of variance indicated significant group differences on child ratings of peer victimization F(2, 153) = 4.4, p < .01. The Scheffé post hoc
test revealed that children with OCD (M = 8.5 ± 3.0)
reported significantly higher peer victimization than
children with diabetes (M = 7.1 ± 2.8, p < .03, effect
size = .50) and controls (M = 7.1 ± 2.7, p < .04, effect
size = .52). Reports of peer victimization did not differ
between children with diabetes and controls (p = .99).
Study Aim 2: Relations Between Peer
Victimization and Psychological
Symptom Indexes Among Children
with OCD
The relations among peer victimization and psychological symptom indexes were examined by Pearson
product–moment correlations (see Table 2). Strong
positive correlations were found between peer victimization and OCD symptom severity, loneliness, depressive symptoms, and parental reports of externalizing
and internalizing behavioral problems.
Study Aim 3: Relations Among
Obsessions, Compulsions,
and Psychological Symptom Indexes
Compulsion and obsession severity were positively
and significantly related to peer victimization. No differences in the magnitude of relations with symptom
indexes were found (see Table 2).
Study Aim 4: Peer Victimization
as a Mediating Variable
Our hypothesized mediational model states that
more severe OCD symptoms were expected to result in
more victimization from peers, which in turn would increase symptoms of depression and loneliness and parental reports of child externalizing and internalizing
behaviors (see Figures 1 through 3). Support for mediation would provide a more comprehensive explanation of the process by which youth with OCD become
Table 2. Pearson Product–Moment Correlations Between Peer Victimization and Indexes of Psychological Symptoms
for Children With Obsessive–Compulsive Disorder
CY–BOCS Obsession Scale
CY–BOCS Compulsion Scale
CY–BOCS Total Score
Peer Victimization
CDI
ALS
CBCL–Externalizing
CBCL-Internalizing
M
SD
1
2
3
4
5
6
7
8
1.00
0.68***
1.00
0.93***
0.90***
1.00
0.28*
0.40**
0.36**
1.00
0.32**
0.33**
0.35**
0.64***
1.00
0.37**
0.43**
0.43***
0.57***
0.59***
1.00
0.00
0.30*
0.27*
0.37**
0.42**
0.33*
1.00
0.43**
0.41**
0.46***
0.31**
0.49***
0.30*
0.44***
1.00
15.60
10.40
9.20
5.30
10.30
4.50
19.50
9.00
8.50
3.00
35.00
13.50
2.90
3.10
12.10
8.10
Note: CY–BOCS = Children’s Yale–Brown Obsessive–Compulsive Scale; ALS = Asher Loneliness Scale; CDI = Children’s Depression Inventory, Short Form; CBCL = Child Behavior Checklist. Means and standard deviations represent raw scores.
*p < .05. **p < .01. ***p < .001, two-tailed.
450
PEER VICTIMIZATION
Figure 1. Mediational model for associations between OCD symptom severity and loneliness as mediated by peer victimization. Note:
Values on the paths represent zero-order correlations (rs) outside the parentheses and path coefficients (standardized regression coefficients [β]) inside the parentheses. Sobel’s test is represented as a z value. *p < .05. **p < .01. ***p < .001.
Figure 2. Mediational model for associations between OCD symptom severity and depression as mediated by peer victimization. Note:
Values on the paths represent zero-order correlations (rs) outside the parentheses and path coefficients (standardized regression coefficients [β]) inside the parentheses. Sobel’s test is represented as a z value. *p < .05. **p < .01. ***p < .001.
Figure 3. Mediational model for associations between OCD symptom severity and externalizing behaviors as mediated by peer victimization. Note: Values on the paths represent zero-order correlations (rs) outside the parentheses and path coefficients (standardized regression coefficients [β]) inside the parentheses. Sobel’s test is represented as a z value. *p < .05. **p < .01. ***p < .001.
depressed and isolated. Baron and Kenny’s (1986)
guidelines for mediation were followed to test a model
of the influence of OCD symptom severity on symptom indexes via peer victimization. In our sample, age
was not related to peer victimization (r = –.067, p = .4).
Accordingly, age-moderated mediation was not tested.
Additionally, gender differences in peer victimization
were not identified (t = .12, p < .3). Separate regression
analyses were computed for the four dependent variables: loneliness, depression, externalizing behaviors,
and internalizing behaviors. In each model, four separate regressions were conducted to determine if mediation was present.
The following criteria are necessary for mediation:
1. the predictor (OCD symptomatology) is significantly associated with the outcome (loneliness
or depression).
2. the predictor is significantly associated with
the mediator (peer victimization).
3. the mediator is associated with the outcome
variable (with the predictor accounted for).
4. the addition of the mediator to the full model
reduces the relation between the predictor and
criterion. In criteria 4, peer victimization was
entered in Step 1, and both peer victimization
and OCD severity was entered in Step 2.
Loneliness as the outcome.
Regression techniques were used to identify the direct effect of OCD
symptom severity on loneliness (criterion a) and peer
victimization (criterion b). Results indicated that OCD
symptom severity significantly predicted 20%, F(1,
50) = 11.5, p < .001, of the variance in loneliness,
meeting the first requirement for mediation and predicted 14%, F(1, 50) = 7.6, p < .01, of the variance in
peer victimization, satisfying the second requirement
for mediation. In accordance with criterion c of the
guidelines, peer victimization predicted 34%, F(2, 49)
= 26.1, p < .001, of the variance in loneliness with the
effects of OCD symptom severity accounted for in the
equation. Finally, the relation between OCD symptom
severity and loneliness was reduced from 20% to 5%,
F(1, 49) = 4.5, p < .05, when peer victimization was ac451
STORCH ET AL.
counted for, demonstrating criteria 4 for mediation (see
Table 3). The Sobel significance test (Sobel, 1988),
which tests for a decrease in the total effect of the predictor on the criterion after controlling for the mediator, also supports criteria 4 (Sobel z = 2.44, p < .01),
namely that peer victimization mediates the relation
between OCD symptom severity and loneliness. The
addition of the mediator reduced the size of the direct
effect but did not reduce the effect to a nonsignificant
value, suggesting partial mediation. As such, OCD
symptoms were predictive of unique variance above
and beyond peer victimization, indicating direct and
indirect effects of OCD symptom severity on loneliness. However, it is noteworthy that the more comprehensive model accounted for significantly more variance (20%) than the parsimonious direct effects model.
Depression as the outcome. Data support criteria 1 and 2 for mediation: OCD symptom severity significantly predicted 13%, F(1, 50) = 7.0, p < .01, of the
variance in depression and predicted 14%, F(1, 50) =
7.6, p < .01, of the variance in peer victimization. The
path between the mediator and the criterion variable
was also verified; peer victimization predicted 40%—
F(2, 49) = 33.9, p < .001—of the variance in depression with the effects of OCD symptom severity accounted for in the equation supporting criterion c for
mediation. Finally, the relation between OCD symptom severity and depression was reduced from 13% to
1%, F(1, 49) = 1.4, p = .24, when peer victimization
was accounted for, demonstrating criterion d for mediation (see Table 3). The Sobel test (z = 2.6, p < .009)
provides further support for criterion d, indicating that
peer victimization mediates the relation between OCD
symptom severity and depression. These data are presented in Figure 2. The addition of the mediator reduced the direct path between OCD symptom severity
and depression to a nonsignificant value, suggesting
full mediation. As such, OCD symptoms were not predictive of unique variance above and beyond peer victimization in this sample. Similar to the loneliness
model, this mediating model accounted for 30% more
variance in depression that the simple direct effects
model.
Externalizing behavior as the outcome. Regression analysis provided support for criteria 1 through 3
for mediation: OCD symptom severity significantly
predicted 7.5%, F(1, 50) = 4.0, p < .05, of the variance in
externalizing behaviors and predicted 14%, F(1, 50) =
7.6, p < .01, of the variance in peer victimization; peer
victimization predicted 14%, F(2, 49) = 7.8, p < .01, of
the variance in externalizing behavior with the effects of
OCD symptom severity accounted for in the equation.
The relation between OCD symptom severity and child
externalizing behavior was reduced from 7.5% to 2%,
F(1, 49) = 1.2, p = .27, when peer victimization was ac452
counted for, demonstrating criterion 4 for mediation
(see Table 3). Sobel’s test (z = 1.7, p < .05) corroborates
this report, indicating that peer victimization mediates
the relation between OCD symptom severity and child
externalizing behavior (see Figure 3). Similar to the
prior model, the mediator reduced the direct path between OCD symptom severity and externalizing behaviors to a nonsignificant value, suggesting full mediation.
As such, OCD symptoms were not predictive of unique
variance above and beyond peer victimization in this
sample. This mediating model accounted for 8% more
variance in child externalizing behavior that the simple
direct effects model.
Internalizing behavior as the outcome. Analyses did not support the hypothesis that peer victimization mediates the relation between OCD symptom severity and parent report of child internalizing problems.
Although criteria 1 and 2 were substantiated, the third
criterion for mediation was not upheld. The relation
between the mediator and outcome was not preserved
when the predicator was accounted for in the equation.
Discussion
The findings from this data offer a number of
unique contributions to the literature on peer relationships among children with OCD. Similar to others
(e.g., Ginsburg et al., 1998; Strauss et al., 1988), these
data suggest that peer victimization is a common experience among children with OCD, with more than one
quarter being victimized regularly by their peers. Furthermore, in this sample, children with OCD were significantly more likely to report victimization than were
children with diabetes or healthy children. Although
children with diabetes also engage in behaviors that set
them apart from their peers (e.g., taking insulin shots,
avoiding junk food, and so on.), their behaviors may
not be seen as aberrant, perhaps explaining the higher
rates of victimization in children with OCD.
The other important finding from these data comes
from the mediational analyses. We hypothesized that
more severe OCD symptoms would result in more victimization from peers, which in turn would increase
symptoms of depression and loneliness and parental
reports of child externalizing and internalizing behaviors. These hypotheses were generally supported. Peer
victimization fully mediated the relation between
OCD severity and both depression and parent reports
of child externalizing behaviors and partially mediated
the relation between OCD severity and loneliness.
Analyses did not support the hypothesis that peer victimization mediated the relation between OCD severity and parent reports of child internalizing problems.
These results suggest that OCD in and of itself may
not fully explain high comorbidity with depression or
PEER VICTIMIZATION
problematic externalizing behaviors. Rather, the peer
victimization suffered by children with OCD (in addition to other variables not explored in this study) may
contribute in a modest fashion to these outcomes. Theoretically, this outcome points to the impact of peer
factors in understanding overall symptom presentation. Although the biological component of OCD is
widely recognized (cf. Lewin et al., 2005), environmental factors undoubtedly play an important role.
This finding also has important clinical implications.
Although it is essential that children with OCD receive
appropriate treatment, it is not clear that resolution of
the unusual behaviors associated with OCD would be
sufficient to improve children’s peer relations and, by
extension, the other difficulties that they experience.
Rather, it might be necessary to help children re-engage in the social world that they both overtly and more
subtly avoided due to OCD. This might include helping children to discover interests that they want to pursue (e.g., joining a sports team, trying out for the
school play) and developing the skills to establish and
maintain friendships with children who seem as if they
might be receptive to such advances.
It was surprising to find that peer victimization did
not mediate the relation between OCD severity and
parent reports of child internalizing problems. It is
possible that parents are more aware of peer victimization in children with externalizing problems
than in children with internalizing problems. When
children react to peer victimization with sadness and
feelings of loneliness (i.e., internal experiences), the
experience might be much less noticeable to parents
than when children react with anger and aggression
(i.e., overt behaviors). It is also possible that children
with internalizing problems might be less likely than
other children to share peer victimization experiences with their parents. This leaves parents recognizing a link between OCD symptoms and internalizing problems but not seeing the connection with peer
victimization experiences. It might be important for
clinicians to alert parents of children with OCD (particularly parents of children with internalizing problems) to the fact that their children are at increased
risk of being victimized by peers. Clinicians and parents can then work together to try to reduce the risk
of victimization, particularly during the early stages
of treatment when children might still be exhibiting
bizarre behaviors. For example, clinicians and parents
can coach children to try to “put off” their compulsions until the end of the school day when they get
home. Some, but not all, people with OCD can accomplish this by reassuring themselves that they can
wash their hands, or recopy their work, or engage in
some other compulsion eventually, even if not right
now. Although this sort of instruction maintains OCD
over the long term, for a short period of time it might
help the peer relations of children with OCD, thereby
also lessening other problems such as loneliness, depression, and externalizing behaviors.
This study is not without limitations. First, this sample was demographically homogeneous, which may
constrain the generalizability of our results. Second,
the correlational nature of this study prevents the directionality of the relations from being established.
Well-designed, prospective studies will help elucidate
causal pathways. Third, the use of child reports of peer
victimization may provide an under- or overestimate of
negative peer interactions. On balance, the Schwartz
Peer Victimization Scale has good psychometric properties, and some have suggested that self-reports provide a more complete assessment (vs. peer or parental
reports) of peer maltreatment that takes place outside
of the school setting or may be of a more secretive
nature (e.g., relational attacks; Storch & Ledley, 2005).
Finally, these models only accounted for modest
amounts of variance. Thus, a significant amount of
variance remains to be explained by variables other
than peer victimization.
There is much to still be learned about the peer relations of children with OCD. First, it is important to
ascertain whether certain types of OCD are more
strongly related to peer victimization than others. For
example, it is possible that overt rituals (like handwashing) lead to more problems than mental rituals.
Alternatively, it is possible that mental rituals also
cause problems because they might make children
come across as “spacey” and disinterested in others or
in what is going on around them. Perhaps it is the
amount of time occupied by a child’s OCD during the
school day that determines its impact on peer relations
and on other problems like depression and loneliness.
It is also important to better understand the peer relation problems that some children with OCD experience. The data from this study suggest simply that
OCD is associated with peer victimization. Left unanswered is the question of what these children are doing
to provoke victimization. Is it their overt OCD behaviors or related problems (e.g., tics)? Or is it social skills
deficits that might have developed over time as children were unable to participate in social activities due
to their OCD symptoms? Each of these questions underscores the correlational nature of this study and that
numerous other models may be relevant (e.g., OCD severity mediating the relation between peer victimization and other outcomes). Longitudinal studies that include youth from multiple cultures will be needed to
uncover the directionality of these relations, enhance
the cross-cultural relevance of this research, and explore other variables that may be related. Discovering
the answers to these questions would help clinicians
and parents understand ways to help children with
OCD better manage the social world.
Finally, it is important to learn whether successful
treatment for OCD, in and of itself, ameliorates peer
453
STORCH ET AL.
relation problems. It is reasonable to predict that this
might be the case for some children but not for others.
Once children are no longer performing compulsions
and feeling distracted by obsessive thoughts, it is certainly possible that some will naturally reengage in the
social world and find success with peers. Other children, however, might have significant social skills deficits from years of avoidance or might have suffered
such significant peer relation problems that their peers
are unwilling to give them a “second chance.” As noted
previously, these children might very well need specific interventions to help them succeed in the social
world. It is very likely (and another question open to
research) that such success might be an important predictor of relapse of OCD symptoms.
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Received August 3, 2005
Accepted March 6, 2006
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