Elsevier

Clinical Psychology Review

Volume 28, Issue 8, December 2008, Pages 1447-1471
Clinical Psychology Review

Comorbidity as a predictor and moderator of treatment outcome in youth with anxiety, affective, attention deficit/hyperactivity disorder, and oppositional/conduct disorders

https://doi.org/10.1016/j.cpr.2008.09.003Get rights and content

Abstract

In the present review, we examine one of the critical issues that have been raised about evidence-based treatments and their portability to real-world clinical settings: namely, the presence of comorbidity in the participants who have been treated in these studies and whether the presence of comorbidity predicts or moderates treatment outcomes. In doing so, we examine treatment outcomes for the four most commonly occurring childhood psychiatric disorders: Anxiety disorders, affective disorders, attention deficit/hyperactivity disorder (ADHD), and oppositional defiant disorder (ODD)/conduct disorder (CD). For each of these disorders, we first review briefly the prevalence of comorbidity in epidemiological and clinical samples and then highlight the evidence-based treatments for these disorders. We next determine the effects of comorbidity on treatment outcomes for these disorders. For the most part, comorbidity in the treated samples is the rule, not the exception. However, the majority of studies have not explored whether comorbidity predicts or moderates treatment outcomes. For the not insignificant number of studies that have examined this issue, comorbidity has not been found to affect treatment outcomes. Notable exceptions are highlighted and recommendations for future research are presented.

Section snippets

Procedure

Standard computerized databases (PsycInfo and MEDLINE) were searched. For each of the four substantive areas (anxiety, depression, ADHD, and conduct problems), search terms included psychotherapy, counseling, treatment, clinical trial, child, adolescent, and comorbidity. Only articles written in English and published between 1980 and 2007 were sought. This timeframe was selected because it coincided with the advent of DSM-III and progressed through DSM-III-R and DSM-IV and up to the present

Anxiety disorders

Anxiety disorders are among the most common mental health problems in children and adolescents, with prevalence rates approximating 12% in community samples and 36% in clinical samples (cf, Kessler, Berglund, Demler, Jin, & Walters, 2005). DSM-IV specifies that all of the anxiety disorders of adulthood are recognized in childhood (i.e., generalized anxiety disorder — GAD, specific phobia — SP, social phobia — SOC, panic disorder — PD, agoraphobia — AG, obsessive–compulsive disorder — OCD, and

Affective disorders

Affective disorders evidenced by children and adolescents include major depressive disorder (MDD) and dysthymia. Epidemiological studies suggest the prevalence of unipolar affective disorders in youth to be between 1.5% and 8.0% (Angold et al., 1999, Costello et al., 1996). The diagnostic criteria for MDD and dysthymia in youth are similar to those specified for adults, except that children may experience irritability instead of depressed mood. In addition, weight and appetite disturbances may

Attention-deficit/hyperactivity disorder (ADHD)

ADHD is also a prevalent psychological disorder in childhood with studies typically showing prevalence rates ranging from 3%–7% (APA, 2000). In addition, the DSM-IV delineates three subtypes of the disorder based on the two symptom dimensions of inattention and hyperactivity-impulsivity: ADHD, predominantly inattentive type (ADHD-I), ADHD, combined type (ADHD-C), and ADHD, predominantly hyperactive/impulsive type (ADHD-H/I; APA, 2000). ADHD is often associated with significant short-term and

ODD/CD

Children with oppositional and conduct problems comprise a heterogeneous group of youth who engage in a broad array of problem behaviors ranging from relatively minor defiance and temper tantrums to more serious violations such as physical aggression, destructiveness, and stealing. ODD refers to a recurrent pattern of developmentally inappropriate levels of negativistic, defiant, disobedient, and hostile behavior toward authority figures. CD consists of more severe antisocial and aggressive

Discussion

Findings from our qualitative review inform us about the current state of comorbidity and its potential effects on treatment outcomes of EBTs. First, contrary to the assertions of many (e.g., Dulcan, 2005, Westen et al., 2004), the vast majority of RCTs examined in this review included participants who had comorbid disorders. Although the majority of the studies excluded participants with psychosis, pervasive developmental disorders, and mental retardation, other more frequently occurring

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