the effect of comorbidity on treatment outcome in an odd sample
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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. Overview. ODD, Anxiety, and Comorbidity Dual Pathway Model Treatment Approaches Present Study Implications and Future Directions. - PowerPoint PPT PresentationTRANSCRIPT
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)
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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Anxiety
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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Comorbidity
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)
• 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)
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 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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Hypotheses
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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Sample
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ResultsMeans 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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ResultsMeans 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
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 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 Directions
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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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References