The Effect of Comorbidity on Treatment Outcome in an - PowerPoint Presentation

1. The Effect of Comorbidity on Treatment Outcome in an ODD SampleEuropean 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.

2. ODD, Anxiety, and ComorbidityDual Pathway ModelTreatment ApproachesPresent StudyImplications and Future Directions2Overview

3. 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) 3Oppositional Defiant Disorder (ODD)

4. 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)4Anxiety

5. 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 relationspoor academic performanceinformation processing deficitsDirectionalityAnxiety or ODD?5Comorbidity

6. Multiple problem hypothesisAnxiety exacerbates ODDBuffer hypothesis Anxiety mitigates ODD6Dual Pathway Model(Drabick, Ollendick, & Bubier, 2010)

7. MethodChildren and families were thoroughly assessedFamilies were randomized to either PMT or CPS12 weekly sessions One week post, six months, and one year follow-ups 7

8. Empirically supported and well established treatment (Brestan & Eyberg, 1998)Manualized with specified content (Barkley, 1997)Goal: Diminish negative behaviors through parent behavior management skills8Parent Management Training (PMT)

9. Not yet empirically supportedFocus on lagging skills in the child and unsolved problems in the familyGoal: Diminish negative behaviors through collaborating on solutions to unsolved problems 9Collaborative Problem Solving (CPS)

10. 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? 10Present Study

11. H1: Presence of anxiety disorder will enhance treatment outcome Dual Pathway ModelH2: Children with comorbid anxiety will do better in the CPS condition than the PMT condition Emphasis on child regulation skills11Hypotheses

12. 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 PMT37 (47.4%) in CPS12Sample

13. 13ResultsMeans Table for ODD CSRsPrePostMean (SD)Mean (SD)PMTNo Anxiety5.84 (1.068)4.58 (1.924)Anxiety6.09 (1.019)3.27 (2.097)CPSNo Anxiety5.88 (1.054)4.00 (1.837)Anxiety5.50 (1.00)2.95 (1.986)n = 78

14. ResultsEffectF valueSignificant LevelTreatment1.555.216Anxiety5.381.023*Time3.640.060Treatment x Time.098.755Anxiety x Time6.243.015*Treatment x Anxiety x Time1.314.25514* = p < .05Repeated 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.

15. 15ResultsMeans Table for Mother’s DBDRSPrePostMean (SD)Mean (SD)PMTNo Anxiety5.067 (1.710)2.87 (2.532)Anxiety6.214 (1.369)2.50 (2.653)CPSNo Anxiety5.182 (1.250)3.27 (2.649)Anxiety5.750 (1.485)3.25 (2.563)n = 52

16. EffectF valueSignificant LevelTreatment.469.497Anxiety.486.489Time5.613.022*Treatment x Time.876.354Anxiety x Time2.50.121Treatment x Anxiety x Time1.801.18616ResultsRepeated Measures ANOVA: Disruptive Behavior Disorders Rating Scale

17. 17Exploratory AnalysesMeans Table for Primary Anxiety CSRPrePostMean (SD)Mean (SD)PMT4.68 (1.460)2.41 (1.943)CPS4.47 (1.219)2.21 (1.789)n = 41

18. 18Exploratory AnalysesPrimary Anxiety CSREffectF valueSignificance LevelTreatment.259.614Time.603.442Treatment x Time.042.874

19. ODD CSR ratings significantly reduced for children with an anxiety disorderNumber of symptoms, as reported on the DBDRS, significantly reduced from pre to post treatmentWhile the Anxiety CSRs did reduce, the change was not significant 19Results Summarized

20. Anxiety can contribute to ODD treatment in a positive way howeverAnxiety does not change during an ODD treatmentComorbid children would benefit from combined treatments 20Implications and Future Directions

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

22. 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 PressDrabick, 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. 22References