Effect of Comorbidity on Treatment Outcome in Oppositional Defiant Disorder (ODD) Sample
Study presented at the European Association for Behavioral and Cognitive Therapies in Reykjavik, Iceland, focused on the impact of comorbidity on treatment outcomes in children with ODD. The research highlighted the prevalence of ODD and anxiety, their distinguishing characteristics, and the potential risk for other psychiatric disorders. It explored the relationship between anxiety and ODD, considering multiple hypotheses and treatment approaches to address these challenges effectively.
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European Association for Behavioral and Cognitive Therapies, Reykjavik, Iceland, September 2011 The Effect of Comorbidity on Treatment Outcome in an ODD Sample 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 2
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) 3
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) 4
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? 5
Multiple problem hypothesis Anxiety exacerbates ODD Buffer hypothesis Anxiety mitigates ODD 6
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 7
Empirically supported and well established treatment (Brestan & Eyberg, 1998) Manualized with specified content (Barkley, 1997) Goal: Diminish negative behaviors through parent behavior management skills 8
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 9
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? 10
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 11
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 12
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 13
Repeated Measures ANOVA: ODD CSRs Effect 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 * = p < .05 Additionally, a Chi-Square test revealed a significant difference. Children with an anxiety disorder were significantly more likely to be diagnosis free post treatment, 2 = 5.333, p = .021. 14
Means Table for Mothers DBDRS Pre Post Mean (SD) Mean (SD) 5.067 (1.710) 2.87 (2.532) PMT No Anxiety 6.214 (1.369) 2.50 (2.653) Anxiety 5.182 (1.250) 3.27 (2.649) CPS No Anxiety 5.750 (1.485) 3.25 (2.563) Anxiety n = 52 15
Repeated Measures ANOVA: Disruptive Behavior Disorders Rating Scale Effect F value Significant Level .469 .497 Treatment .486 .489 Anxiety 5.613 .022* Time .876 .354 Treatment x Time 2.50 .121 Anxiety x Time 1.801 .186 Treatment x Anxiety x Time 16
Means Table for Primary Anxiety CSR Pre Post Mean (SD) Mean (SD) 4.68 (1.460) 2.41 (1.943) PMT 4.47 (1.219) 2.21 (1.789) CPS n = 41 17
Primary Anxiety CSR Effect F value Significance Level Treatment .259 .614 Time .603 .442 Treatment x Time .042 .874 18
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 19
Anxiety can contribute to ODD treatment in a positive way Anxiety does not change during an ODD treatment however Comorbid children would benefit from combined treatments 20
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. 22
