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.
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ODD, Anxiety, and Comorbidity
Dual Pathway Model
Treatment Approaches
Present Study
Implications and Future Directions
2
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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)
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Increased risk for another psychiatric
disorder, including conduct disorder,
substance abuse and depression (Loeber et al.,
2000)
3
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Excessive worries or fears
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Prevalence rates for at least 1 anxiety
disorder: 6-20% (Costello et al., 2004)

(APA, 2000)
No significant gender differences in
childhood, but adolescence shows an
increase in anxiety for girls (Van Oort, GreavesLord, Verhulst, Ormel & Huizink, 2009)

Risk for another anxiety disorder,
depression, and substance abuse
(American Academy of Child and Adolescent Psychology, 2007)
4
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About 40% of those with ODD have
comorbid anxiety
(Drabick, Ollendick, & Bubier, 2010)
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High risk for negative outcomes
(Brunnekreef et al., 2007, Franco, Saavedra, & Silverman, 2007)
◦ peer relations
◦ poor academic performance
◦ information processing deficits
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Directionality
◦ Anxiety or ODD?
5
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Multiple problem hypothesis
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Buffer hypothesis
◦ Anxiety exacerbates ODD
◦ Anxiety mitigates ODD
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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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• 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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1.
2.
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?
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H1: Presence of anxiety disorder
will enhance treatment outcome
◦ Dual Pathway Model
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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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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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Means Table for ODD CSRs
PMT
CPS
Pre
Post
Mean (SD)
Mean (SD)
No Anxiety
5.84 (1.068)
4.58 (1.924)
Anxiety
6.09 (1.019)
3.27 (2.097)
No Anxiety
5.88 (1.054)
4.00 (1.837)
Anxiety
5.50 (1.00)
2.95 (1.986)
n = 78
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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, χ2 = 5.333,
p = .021.
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Means Table for Mother’s DBDRS
PMT
CPS
Pre
Post
Mean (SD)
Mean (SD)
No Anxiety
5.067 (1.710)
2.87 (2.532)
Anxiety
6.214 (1.369)
2.50 (2.653)
No Anxiety
5.182 (1.250)
3.27 (2.649)
Anxiety
5.750 (1.485)
3.25 (2.563)
n = 52
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Repeated Measures ANOVA: Disruptive Behavior Disorders Rating Scale
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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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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Primary Anxiety CSR
Effect
F value
Significance Level
Treatment
.259
.614
Time
.603
.442
Treatment x Time
.042
.874
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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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
Anxiety can contribute to ODD treatment in
a positive way
however
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Anxiety does not change during an ODD
treatment
Comorbid children would benefit from
combined treatments
20
21
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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