MIAMI – Children with comorbid oppositional-defiant and obsessive-compulsive disorders may be more likely to engage in and benefit from cogni-tive-behavioral therapy if the oppositional defiant disorder is treated first, according to preliminary findings from an ongoing study.
Such comorbid children are at increased risk for early, more severe obsessive-compulsive disorder (OCD).
“Children with oppositional defiant behavior tend to develop OCD more rapidly,” Jennifer Adkins, Ph.D., said at the annual conference of the Anxiety Disorders Association of America.
“They engage in rituals more than other children might be able to, and that allows OCD symptoms to get more severe more rapidly,” she noted. “There is a strong importance to this work in children–80% of adults with OCD exhibited the disorder in childhood,” said Dr. Adkins, of the department of psychiatry at the University of Florida, Gainesville.
Dr. Adkins and her associates studied 40 pediatric patients at the University of Florida in Tallahassee. The goal was to determine whether oppositional defiant disorder and/or family accommodation alter cognitive-behavioral therapy (CBT) outcomes immediately after treatment and/or at follow-up.
All participants actively sought treatment for OCD. An independent evaluator performed a preassessment.
Patients had 15 CBT sessions. Those sessions were followed by an assessment immediately after treatment and at 3 months' follow-up.
Clinicians assessed the participants with a diagnostic clinical interview and the Children's Yale-Brown Obsessive-Compulsive Scale.
Parents provided input using the Child Behavior Checklist and the Family Accommodation Scale.
“We don't expect full clinical remission; we expect alleviation of symptoms,” Dr. Adkins said.
The investigators defined a treatment responder as someone who experienced a 70% or more reduction in total score on the obsessive-compulsive scale, “so we set a higher standard for clinical response than most researchers,” Dr. Adkins said.
Mean age was 13 years (range 8–18 years), most patients were white, and annual family income ranged from $30,000 to $350,000.
Twenty-five of the patients were taking concurrent selective serotonin reuptake inhibitors.
The CBT protocol included exposure and response prevention, psychoeducation, and attempted cognitive restructuring. There is active family involvement, “so parents become the treatment after we are done,” Dr. Adkins said.
Age and onset severity were not predictive of treatment outcome. The presence of oppositional defiant disorder, however, significantly predicted poorer outcome immediately after treatment but not at follow-up.
The disorder correctly predicted outcomes in 58% of the patients. There was excellent specificity with no false positives, although “the false negatives brought down” the accuracy, according to Dr. Adkins.
“Treatment may be more effective if oppositional defiant disorder is addressed before starting CBT for OCD, especially if they are extremely oppositional,” Dr. Adkins said.
“Patients must be agreeable to engage in exposure therapy for it to be effective.”
Dr. Adkins and her colleagues also examined the effect of family accommodation on treatment outcomes.
“Interestingly, family accommodation did not predict outcome at this immediate time measurement,” Dr. Adkins said. At the 3-month follow-up, though, family accommodation proved to be 70% predictive.
Parents may be less stringent about adhering to no-accommodation rules following the end of active treatment, she proposed.
“This is an early study. We only have 40 participants so far,” Dr. Adkins said. “More significant predictors of outcome may be identified as we recruit and assess more patients.”