The Effect of Comorbidity on Treatment Outcome in an ODD Sample

1. 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.

2. Overview • ODD, Anxiety, and Comorbidity • Dual Pathway Model • Treatment Approaches • Present Study • Implications and Future Directions

3. Oppositional Defiant Disorder (ODD) • 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)

4. Anxiety • 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)

5. Comorbidity • 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?

6. Dual Pathway Model(Drabick, Ollendick, & Bubier, 2010) • Multiple problem hypothesis • Anxiety exacerbates ODD • Buffer hypothesis • Anxiety mitigates ODD

7. 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

8. Parent Management Training (PMT) • Empirically supported and well established treatment (Brestan & Eyberg, 1998) • Manualized with specified content (Barkley, 1997) • Goal: Diminish negative behaviors through parent behavior management skills

9. Collaborative Problem Solving (CPS) • 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

10. Present Study • Does anxiety comorbidity affect treatment outcome as measured by ADIS CSR and the DBDRS? • Is there a difference between PMT and CPS in relation to comorbidity and treatment outcome?

11. Hypotheses • 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

12. Sample • 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

13. Results Means Table for ODD CSRs n = 78

14. Results Repeated Measures ANOVA: ODD CSRs * = 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, χ2 = 5.333, • p = .021.

15. Results Means Table for Mother’s DBDRS n = 52

16. Results Repeated Measures ANOVA: Disruptive Behavior Disorders Rating Scale

17. Exploratory Analyses Means Table for Primary Anxiety CSR n = 41

18. Exploratory Analyses Primary Anxiety CSR

19. Results Summarized • 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

20. Implications and Future Directions • 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

21. Special ThanksThe National Institute of Mental Health (NIMH)Assessors and Therapists at the Child Study Center

22. References 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.