The Effect of Comorbidity on Treatment Outcome in an ODD Sample

European Association for Behavioral and Cognitive Therapies, Reykjavik, Iceland, September 2011

Maria G Fraire, M.S.Emily F. McWhinney, B.S. Thomas H. Ollendick, Ph.D.

ODD, Anxiety, and Comorbidity Dual Pathway Model Treatment Approaches Present Study Implications and Future Directions

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Overview

Pattern of negativistic, hostile, and defiant behavior (APA, 2000)

Prevalence: 2.6% - 15.6% in community samples and 28% - 65% in clinical samples (Boylan et al., 2007)

Can be distinguished from typical behavior as early as preschool (Loeber, Burke, & Pardini, 2008)

Increased risk for another psychiatric disorder, including conduct disorder, substance abuse and depression (Loeber et al., 2000)

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Oppositional Defiant Disorder (ODD)

Oppositional Defiant Disorder (ODD)

Excessive worries or fears (APA, 2000)

Prevalence rates for at least 1 anxiety disorder: 6-20% (Costello et al., 2004)

No significant gender differences in childhood, but adolescence shows an increase in anxiety for girls (Van Oort, Greaves-Lord, Verhulst, Ormel & Huizink, 2009)

Risk for another anxiety disorder, depression, and substance abuse (American Academy of Child and Adolescent Psychology, 2007)

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AnxietyAnxiety

About 40% of those with ODD have comorbid anxiety (Drabick, Ollendick, & Bubier, 2010)

High risk for negative outcomes (Brunnekreef et al., 2007, Franco, Saavedra, & Silverman, 2007)

◦ peer relations◦ poor academic performance◦ information processing deficits

Directionality◦ Anxiety or ODD?

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ComorbidityComorbidity

Multiple problem hypothesis◦ Anxiety exacerbates ODD

Buffer hypothesis ◦ Anxiety mitigates ODD

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Dual Pathway Model(Drabick, Ollendick, & Bubier, 2010)

Method Children and families were thoroughly

assessed

Families were randomized to either PMT or CPS

12 weekly sessions

One week post, six months, and one year follow-ups

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• Empirically supported and well established treatment (Brestan & Eyberg, 1998)

• Manualized with specified content (Barkley, 1997)

• Goal: Diminish negative behaviors through parent behavior management skills

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Parent Management Training (PMT)

Parent Management Training (PMT)

• Not yet empirically supported

• Focus on lagging skills in the child and unsolved problems in the family

• Goal: Diminish negative behaviors through collaborating on solutions to unsolved problems

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Collaborative Problem Solving (CPS)

Collaborative Problem Solving (CPS)

1. Does anxiety comorbidity affect treatment outcome as measured by ADIS CSR and the DBDRS?

2. Is there a difference between PMT and CPS in relation to comorbidity and treatment outcome?

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Present StudyPresent Study

H1: Presence of anxiety disorder will enhance treatment outcome ◦Dual Pathway Model

H2: Children with comorbid anxiety will do better in the CPS condition than the PMT condition ◦Emphasis on child regulation skills

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HypothesesHypotheses

78 children with ODD from NIMH RCT (Ollendick & Greene, 2007 -2012)

7 to 14 years old (m=9.62) 47 males (60.3 %) 31 females

(39.7%) 53.8% with comorbid anxiety 41 (52.6%) in PMT 37 (47.4%) in CPS

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SampleSample

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ResultsResults

Means Table for ODD CSRs

Pre Post

Mean (SD) Mean (SD)

PMT No Anxiety 5.84 (1.068) 4.58 (1.924)

Anxiety 6.09 (1.019) 3.27 (2.097)

CPS No Anxiety 5.88 (1.054) 4.00 (1.837)

Anxiety 5.50 (1.00) 2.95 (1.986)

n = 78

ResultsEffect F value Significant Level

Treatment 1.555 .216

Anxiety 5.381 .023*

Time 3.640 .060

Treatment x Time .098 .755

Anxiety x Time 6.243 .015*

Treatment x Anxiety x Time 1.314 .255

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* = p < .05

Repeated Measures ANOVA: ODD CSRs

• Additionally, a Chi-Square test revealed a significant difference. Children with an anxiety disorder were significantly more likely to be diagnosis free post treatment, χ2 = 5.333,

p = .021.

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ResultsResults

Means Table for Mother’s DBDRS

Pre Post

Mean (SD) Mean (SD)

PMT No Anxiety 5.067 (1.710) 2.87 (2.532)

Anxiety 6.214 (1.369) 2.50 (2.653)

CPS No Anxiety 5.182 (1.250) 3.27 (2.649)

Anxiety 5.750 (1.485) 3.25 (2.563)

n = 52

Effect F value Significant Level

Treatment .469 .497

Anxiety .486 .489

Time 5.613 .022*

Treatment x Time .876 .354

Anxiety x Time 2.50 .121

Treatment x Anxiety x Time 1.801 .186

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ResultsRepeated Measures ANOVA: Disruptive Behavior Disorders Rating Scale

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Exploratory Analyses

Exploratory Analyses

Means Table for Primary Anxiety CSR

Pre Post

Mean (SD) Mean (SD)

PMT 4.68 (1.460) 2.41 (1.943)

CPS 4.47 (1.219) 2.21 (1.789)

n = 41

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Exploratory AnalysesExploratory Analyses

Primary Anxiety CSR

Effect F value Significance Level

Treatment .259 .614

Time .603 .442

Treatment x Time .042 .874

ODD CSR ratings significantly reduced for children with an anxiety disorder

Number of symptoms, as reported on the DBDRS, significantly reduced from pre to post treatment

While the Anxiety CSRs did reduce, the change was not significant

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Results Summarized

Anxiety can contribute to ODD treatment in a positive way

however Anxiety does not change during an ODD

treatment

Comorbid children would benefit from combined treatments

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Implications and Future DirectionsImplications and Future Directions

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Special Thanks

The National Institute of Mental Health (NIMH)

Assessors and Therapists at the Child Study Center

Special Thanks

The National Institute of Mental Health (NIMH)

Assessors and Therapists at the Child Study Center

American Academy of Child and Adolescent Psychology. (2007). Practice parameter for the assessment and treatment of children and adolescents with anxiety disorders. Journal of the American Academy of Child & Adolescent Psychiatry, 46(2), 267-283.

American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders: Text revision (4th ed.). Washington, DC: American Psychiatric Press.

Barkley, R. A. (1997). Defiant children: A clinician’s manual for parent training, 2nd Edition. New York: Guilford.

Costello, E. J., Egger, H. L., & Angold, A. (2004). Developmental epidemiology of anxiety disorders. In: Phobic and Anxiety Disorders in Children and Adolescents, Ollendick TH, March JS, eds. New York: Oxford University Press

Drabick, D. A. G., Ollendick, T. H., & Bubier, J. L. (2010). Co-occurrence of ODD and anxiety: shared risk processes and evidence for a dual-pathway model. Clinical Psychology: Science and Practice. 17(4), 307-318.

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ReferencesReferences