1. 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.

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

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) 3

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) 4

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 relations ◦ poor academic performance ◦ information processing deficits  Directionality ◦ Anxiety or ODD? 5

6.  Multiple problem hypothesis ◦ Anxiety exacerbates ODD  Buffer hypothesis ◦ Anxiety mitigates ODD 6

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 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 skills 8

9. 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

10. 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

11.  H 1 : Presence of anxiety disorder will enhance treatment outcome ◦ Dual Pathway Model  H 2 : Children with comorbid anxiety will do better in the CPS condition than the PMT condition ◦ Emphasis on child regulation skills 11

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 PMT  37 (47.4%) in CPS 12

13. 13 Means Table for ODD CSRs PrePost Mean (SD) PMTNo Anxiety 5.84 (1.068)4.58 (1.924) Anxiety 6.09 (1.019)3.27 (2.097) CPSNo Anxiety 5.88 (1.054)4.00 (1.837) Anxiety 5.50 (1.00)2.95 (1.986) n = 78

14. EffectF valueSignificant Level Treatment1.555.216 Anxiety5.381.023* Time3.640.060 Treatment x Time.098.755 Anxiety x Time6.243.015* Treatment x Anxiety x Time1.314.255 14 * = 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, χ 2 = 5.333, p =.021.

15. 15 ResultsResults Means Table for Mother’s DBDRS PrePost Mean (SD) PMTNo Anxiety 5.067 (1.710)2.87 (2.532) Anxiety 6.214 (1.369)2.50 (2.653) CPSNo Anxiety 5.182 (1.250)3.27 (2.649) Anxiety 5.750 (1.485)3.25 (2.563) n = 52

16. EffectF valueSignificant 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 16 Repeated Measures ANOVA: Disruptive Behavior Disorders Rating Scale

17. 17 Exploratory Analyses Means Table for Primary Anxiety CSR PrePost Mean (SD) PMT 4.68 (1.460)2.41 (1.943) CPS 4.47 (1.219)2.21 (1.789) n = 41

18. 18 Primary Anxiety CSR EffectF valueSignificance Level Treatment.259.614 Time.603.442 Treatment x Time.042.874

19.  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

20.  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 20

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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, 2 nd 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