Single Study on Collaborative and Proactive Solutions

ORIGINAL PAPER

Perceived Parent–Child Relations, Conduct Problems, and Clinical Improvement Following the Treatment of Oppositional Defiant Disorder

Jordan A. Booker1 • Thomas H. Ollendick2 • Julie C. Dunsmore3 •

Ross W. Greene2

Published online: 24 November 2015

� Springer Science+Business Media New York 2015

Abstract Our objective in this study was to examine the

moderating influence of parent–child relationship quality

(as viewed by the child) on associations between conduct

problems and treatment responses for children with oppo-

sitional defiant disorder (ODD). To date, few studies have

considered children’s perceptions of relationship quality

with parents in clinical contexts even though extant studies

show the importance of this factor in children’s behavioral

adjustment in non-clinical settings. In this study, 123

children (ages 7–14 years, 61.8 % male, 83.7 % white)

who fulfilled DSM-IV criteria for ODD received one of

two psychosocial treatments: Parent Management Training

or Collaborative and Proactive Solutions. In an earlier

study, both treatments were found to be effective and

equivalent in treatment outcomes. In the current study, pre-

treatment maternal reports of conduct problems and pre-

treatment child reports of relations with parents were used

to predict outcomes in ODD symptoms and their severity

following treatment. Elevated reports of children’s conduct

problems were associated with attenuated reductions in

both ODD symptoms and their severity. Perceived rela-

tionship quality with parents moderated the ties between

conduct problems and outcomes in ODD severity but not

the number of symptoms. Mother reports of elevated

conduct problems predicted attenuated treatment response

only when children viewed relationship quality with their

parents as poorer. When children viewed the relationship as

higher quality, they did not show an attenuated treatment

response, regardless of reported conduct problems. The

current findings underscore the importance of children’s

perspectives in treatment response and reductions in

externalizing child behaviors.

Keywords Oppositional defiant disorder � Parent–child relationships � Antisocial behavior

Introduction

Children with conduct problems engage in a broad array of

problem behaviors ranging from defiance to physical

aggression and stealing (Murrihy et al. 2010). Taken

together, these behaviors are the most frequent bases for

referrals to mental health clinics and residential treatment

centers for children and are of great concern because they

involve a high degree of impairment, may persist over

time, and are associated with negative life outcomes.

Children with conduct problems typically meet Diagnostic

and Statistical Manual (DSM-IV, DSM-5; American Psy-

chiatric Association 1994, 2013) criteria for Oppositional

Defiant Disorder (ODD) or Conduct Disorder (CD).

Although these disorders are viewed as separate in the

DSM system, it is common for youth meeting diagnostic

criteria for ODD to exhibit some of the behaviors charac-

terizing CD (Rhodes and Dadds 2010). Though the

behaviors comprising ODD (e.g., defiance, argumenta-

tiveness, noncompliance) have been found to predict a

variety of adverse outcomes independently of CD (Greene

et al. 2002), these behaviors are thought to represent the

& Jordan A. Booker [email protected]

1 Family Narratives Lab, Department of Psychology, Emory

University, 36 Eagle Row, Psychology and Interdisciplinary

Sciences Building, Atlanta, GA 30322, USA

2 Child Study Center, Department of Psychology, Virginia

Tech, Blacksburg, VA, USA

3 Social Development Lab, Department of Psychology,

Virginia Tech, Blacksburg, VA, USA

123

J Child Fam Stud (2016) 25:1623–1633

DOI 10.1007/s10826-015-0323-3

less severe end of the conduct problems spectrum com-

pared with the behaviors characterizing CD (e.g., physical

aggression, lying, stealing). In addition, the behaviors

comprising ODD tend to occur earlier in development and,

in some instances, serve as a precursor to the onset of the

more severe behaviors comprising CD (Kimonis and Frick

2010).

Irrespective of the specific diagnosis, conduct problems

in children can negatively impact children’s relationships

with parents and peers, both concurrently (Epstein and

Saltzman-Benaiah 2010; Wolke and Samara 2004) and

predictively (Burt et al. 2005; Dodge et al. 2003). Children

with conduct problems generally display more hostile

relations and negative forms of communication in their

interactions with their parents (Edwards et al. 2001). Fur-

ther, these children are more likely to misperceive social

situations as threatening (Crick and Dodge 1996) and are at

risk for concurrent and long-term peer conflict and rejec-

tion, which may exacerbate later aggression and hostility

(Dodge et al. 2003). In addition, children who display

conduct problems are at greater risk for emotional malad-

justment and poorer well-being, including comorbidity

with other psychological disorders (e.g., anxiety, depres-

sion, substance use; Angold et al. 1999; Greene et al. 2002)

and difficulties with emotional instability and reactivity

(e.g., Stringaris et al. 2010). These behaviors can also

coincide with stunted skills or callous and unemotional

traits (Frick and Ellis 1998) and predict poorer long-term

outcomes (Fergusson et al. 2005; Frick et al. 2003, 2005),

particularly when coupled with ineffective parenting

strategies (Wootton et al. 1997). As such, conduct prob-

lems are often associated with continued and ongoing

externalizing problems over time (Frick and Loney 1999;

Frick et al. 2003, 2005).

Family relationships marked by hostility and conflict

are common for many children with conduct problems

(e.g., Edwards et al. 2001; Wootton et al. 1997), though

some children, to the surprise of their parents and clin-

icians, view the relationship with their parents in a

positive light. Such patterns were found in Edens et al.

(1999) comparisons of referred children’s reports of

relationship quality with reports from close partners

(peers, teachers, parents) with whom the children were

interacting. Although reports of relationship quality by

many of these children matched those of their relation-

ship partner, approximately one-third of children held

discrepant views of relationship quality that were notably

more positive than the views of their interaction partners.

These children were also more aggressive than other

referred youth.

It should be noted that such discrepancies in views of the

self and others are not unique to oppositional children.

Concepts of the self and one’s relationships are partly

grounded in how individuals believe others perceive and

will interact with them (Cooley 1902; Mead 1934) and it is

not uncommon to see moderate-to-large discrepancies

between individuals and observers of varying intimacy

levels (i.e., friends, parents, teachers, strangers, indepen-

dent raters; e.g., Rapee and Lim 1992; Shrauger and

Schoeneman 1979; South et al. 2011). Furthermore, with

typically developing youth, perceptions of positive rela-

tionships with parents are related to self-reports of adjust-

ment, academic competence, and behavioral conduct

(Laursen and Mooney 2008).

Hence, we believe it is valuable to consider children’s

perceptions of relationship quality with their parents to

address an understudied perspective among clinical sam-

ples and further understand implications for treatment.

Although multiple treatments already aim to improve

interaction styles between parents and their children (e.g.,

Barkley 1997; Greene 1998; Reid et al. 2003; Urquiza and

Timmer 2012), these studies frequently examine parental

reports of stress due to children’s dysfunctional behaviors

or perceptions of parenting efficacy (e.g., Nixon et al.

2003), leaving a gap in the views of treated children. We

sought to address this gap by considering the direct and

moderating roles of children’s views regarding the parent–

child relationship on treatment response for treated oppo-

sitional children.

This study aimed to address whether reports of chil-

dren’s conduct problems and perceived parent–child rela-

tionship quality (as reported by youth) predicted

improvements in ODD symptoms and whether the effect of

conduct problems on treatment response was moderated by

children’s perceptions of relationship quality with parents.

To address these aims, we conducted a re-analysis of youth

meeting full DSM-IV (American Psychiatric Association

1994) criteria for ODD (Ollendick et al., in press). These

children did not meet clinical criteria for conduct disorder,

though nearly all showed subclinical CD problems. Youth

received one of two psychosocial treatments: Parent

Management Training (PMT; Barkley 1997) or Collabo-

rative and Proactive Solutions (CPS, Greene 1998). Pre-

vious research has documented the efficacy of PMT (see

Brestan and Eyberg 1998; Eyberg et al. 2008), which

focuses on improved child compliance as the primary

treatment goal. Based on research pointing toward lagging

cognitive skills as a major factor contributing to chal-

lenging behaviors in youth, Greene proposed CPS as an

alternative model to PMT for the treatment of ODD, focusing

on helping parents and children learn to solve problems

collaboratively and proactively (Greene 1998, 2010).

We expected children with elevated initial conduct

problems to show greater stability of ODD symptoms and

an attenuated treatment response. We also expected chil-

dren who had more positive views of the relationship with

1624 J Child Fam Stud (2016) 25:1623–1633

123

their parents to show greater responses to treatment

through decreases in ODD severity and symptom count.

Because both treatment conditions rely heavily on guid-

ance from and cooperation with parents, we expected

children’s positive views of the relationship with their

parents to elevate their receptivity across both treatments.

Lastly, we hypothesized perceived relations with parents

would moderate the effect of reported conduct problems.

We expected that when children saw their relationship with

parents as poorer, higher levels of conduct problems would

negatively impact treatment response, whereas when chil-

dren saw their relationship with parents as more positive,

conduct problems would not be associated with treatment

responses. In other words, children’s perceptions of more

positive relations with parents might buffer them from the

negative impact of conduct problems on treatment

response.

Method

Participants

Participating families included parents and children who

entered a larger study providing treatment for children’s

oppositional problems (Ollendick et al., in press). Families

were referred by school personnel, mental health profes-

sionals, and family physicians. Families were also recruited

through local advertisements in newspapers and television

programs. Parents with children who were likely eligible

for participation based on a phone screen (n = 164)

received additional information regarding the study intent

and procedures. Parents and children then completed an

initial assessment to confirm the ODD diagnosis and

determine secondary and tertiary diagnoses. Parents and

children provided written informed consent and assent, as

approved by the Institutional Review Board at our uni-

versity. Children between 7 and 14 years of age who met

full diagnostic criteria for ODD were included in the study.

Nearly all (99 %) participating children presented with one

secondary disorder, and a majority (83 %) presented with a

tertiary disorder (see below).

Children were excluded from further participation if

they met diagnostic criteria for disorders such as CD,

autism spectrum disorder, a psychotic disorder, intellectual

impairment, or current suicidal or homicidal ideation.

Overall, 134 of the 164 children met criteria for further

participation. However, 11 children were placed on a

waitlist and did not follow the treatment procedures

described below. These children were excluded from cur-

rent considerations, leaving a final sample of 123 treated

children (76 boys, 47 girls, M = 9.56 years, SD = 1.81).

The most common comorbid disorders were ADHD (68 %)

and an anxiety disorder (56 %), as defined by generalized

anxiety disorder, social anxiety, or separation anxiety. No

differences in age, gender, race, family structure, parental

education, family income, or comorbid conditions were

observed between the two treatment conditions (Ollendick

et al., in press).

Procedure

Children and parents initially participated in two pre-

treatment assessment sessions. Due to limited participation

by fathers, only mother and child reports were considered

further. Following pre-treatment assessments, families

were randomly assigned to one of the two treatment groups

described above. Each treatment was designed for 12

weekly 75-min sessions. The two treatment programs are

further detailed by Ollendick et al. (in press).

Children and parents participated in a post-treatment

assessment 1–2 weeks after completion of the final treat-

ment session. Families were reimbursed $50 for partici-

pation in the pre- and post-treatment assessments (for a

total of $100). At each assessment, parents and children

completed questionnaires and clinicians blinded to treat-

ment status provided global assessments of children’s

functioning and adjustment.

Attrition

Following the pre-treatment assessment, 63 participants

were randomly assigned to PMT and 60 to CPS. Over the

course of treatment, 13 participants dropped out of PMT

(20.6 %) and 15 participants dropped out of CPS

(25.0 %). Treatment dropout out was defined as com-

pleting 6 or fewer of the 12 treatment sessions. From the

end of treatment to the post-treatment assessment, an

additional 4 participants from the PMT condition and 4

participants from the CPS condition became unavailable

for post-treatment assessment due to a variety of com-

plications (e.g., time constraints, moved from area, not

interested).

Measures

Child Conduct Problems

Mothers completed the Behavior Assessment System for

Children-2nd Edition (BASC-2; Reynolds and Kamphaus

2000) at pre-treatment. Mothers’ reports on the 17-item

Conduct Problems subscale (sample items, ‘‘Breaks the

rules just to see what will happen’’, ‘‘Lies to get out of

trouble,’’ ‘‘Steals’’) were examined. The items on this

subscale reflect symptoms pertinent to both ODD and CD,

and are completed on a 4-point Likert scale (0 = Never,

J Child Fam Stud (2016) 25:1623–1633 1625

123

3 = Always). While associated with ODD, these conduct

problems differ from the predominantly reactive problem

behaviors frequently associated with ODD in that children

who receive high scores on this subscale tend to use these

behaviors to achieve negative goals, be emotionally cal-

lous, and incorporate lying and manipulation in their

relationships (e.g., White et al. 2013; Wolke et al. 2000;

Woodworth and Waschbusch 2007). The subscale is T-

scored. Within this clinical sample there were minimal

threats to normality [skewness = -.21 (.23); kurto-

sis = -.44 (.45)]. A large proportion of responses

(49.1 %) indicated clinically-significant levels of conduct

problems (C70), whereas smaller portions of responses

indicated at-risk (60–69; 28.2 %) and average (41–59;

22.7 %) levels of conduct problems. BASC rating scales

have been endorsed as evidence-based instruments for

assessment of conduct problems and for monitoring and

evaluation of treatment outcomes (Frick and McMahon

2008; Kamphaus and Frick 2005). Internal consistency of

this scale was acceptable (a = .84) in the current sample.

Child Disruptive Behaviors

Mothers also completed the Disruptive Behavior Disorders

Rating Scale (DBDRS; Pelham et al. 1992) at pre- and

post-treatment assessments. This scale includes the DSM-

IV symptom list for ODD. Items were completed on a

4-point Likert scale ranging from 0 (not at all) to 3 (very

much) for symptom occurrence. For the eight ODD

symptoms, ratings of a ‘‘2’’ (much) or ‘‘3’’ (very much)

were treated as meeting criteria for the symptom (see

Barkley 1997). Total scores for the ODD inventory range

from 0 to 8, and a score of 4 or above indicates clinical

levels of ODD. Internal consistency was acceptable at each

assessment (a C .90) in the current study.

Child Perceived Relationship Quality with Parents

Children completed the child version of the BASC (Rey-

nolds and Kamphaus 2000) at pre-treatment. For the pre-

sent study, we examined the 11-item Relations with

Parents subscale. This subscale considers children’s views

of positive behavior and relationship quality with their

parents (sample items, ‘‘I like to be close with my parents’’,

‘‘I get along well with my parents,’’ ‘‘My parents trust

me’’). Items were completed on a 4-point Likert scale

(0 = Never, 3 = Always). This scale was T-scored. Within

this clinical sample there were minimal threats to normality

[skewness = .32 (.23); kurtosis = -.47 (.46)]. Children

reported a range of responses, with 16.7 % of children

reporting considerably low (B 30) levels of relations with

parents, 29.8 % reporting at-risk (31–40) levels of relations

with parents, 48.2 % reporting average (41–59) levels of

relations with parents, and 5.5 % reporting high (C60)

relations with parents (5.3 %). When children required

assistance in reading/completing items, the assessor read

items aloud and marked child responses. Internal consis-

tency of this scale in the current study was accept-

able (a = .85). The Relations with Parents subscale has been shown to be related to other adaptive reports of well-

being among youth (e.g., Gilman et al. 2000).

Child ODD Severity

The Anxiety Disorders Interview Schedule, Child and Parent

Versions (ADIS-C/P; Silverman and Albano 1996) are semi-

structured diagnostic interviews for a number of psychiatric

disorders that occur in childhood and adolescence. Clini-

cians were trained for administration of the ADIS-C/P

through a 3-h workshop, two practice interviews with a

trainer, and two live observations by supervising adminis-

trators (blinded for review). All clinicians were graduate

students in clinical psychology in an APA-approved clinical

scientist doctoral program or postdoctoral fellows who were

trained to requisite levels of competence to ensure reliability

and validity of collected data. Separate clinicians met with

parents and children to administer appropriate interviews at

pre-treatment and post-treatment assessments. During

interviews, clinicians assessed symptom characteristics of

frequency, intensity, duration, and interference rating.

Assessment clinicians were blinded to treatment condition.

These symptom ratings were used to identify diagnostic

criteria and form a clinician’s severity rating (CSR) with a

CSR of 4 or greater (on a 0–8 scale) indicating clinical

diagnosis. For the ADIS-C/P, CD and ODD are assessed

only in the parent interview. The ADIS-C/P has been found

to be reliable and valid for the diagnosis of ODD, in

addition to the anxiety and affective disorders (Anderson

and Ollendick 2012). Agreement between clinicians

regarding children’s primary, secondary, and tertiary

diagnoses were j = .77, .85, and .86 respectively (j = .89 for diagnoses of ODD).

Following each assessment, consensus diagnoses were

formed based on the outcomes of the ADIS-C and ADIS-P.

These diagnoses were formed during weekly staff meetings

involving the two ADIS clinicians and a supervising doc-

toral-level clinical psychologist. Both the parent and child

clinician provided a report of their assessment observations

and justification for suggested diagnostic codes. Discrep-

ancies were resolved through a dialogue overseen by the

supervising doctoral-level clinical psychologist.

Data Analyses

t tests and Little’s test addressed whether families who

dropped out differed on study variables and whether data

1626 J Child Fam Stud (2016) 25:1623–1633

123

were missing completely at random, respectively. t tests

also addressed whether retained children showed signifi-

cant changes in ODD symptoms from pre- to post-treat-

ment and whether these changes were significantly

different between treatments. Bivariate and partial corre-

lations indicated the direct associations between study

variables before and after accounting for pre-treatment

reports of ODD symptoms. Pre-treatment reports were

controlled to account for the fact that individuals varied in

their ‘‘starting points’’ of ODD symptomatology and the

severity associated with their symptoms. This strategy is

suggested by Vickers and Altman (2001) to control for

pretreatment measures when assessing treatment outcomes.

Stepwise hierarchical regressions tested for two-way

interactions between children’s conduct problems and chil-

dren’s perceived relationship quality with parents, using

both ordinary least squares and then full information maxi-

mum likelihood (FIML) estimation. Regressions were con-

ducted in three steps: demographic factors, pre-treatment

scores, and treatment type (CPS, PMT) were entered on the

first step; main effects of conduct problems and perceived

relationship quality were entered on the second step; and the

interaction term between conduct problems and relationship

quality was entered on the third step. Variables were cen-

tered to control for possible collinearity in forming the

interaction term. FIML was used to address missing data in

regression models and is appropriate when data is missing

completely at random. This approach does not impute

missing data, but provides estimates based on all available

model data (Arbunkle 1996). FIML has been shown to

provide minimally biased results that are comparable to

other popular missing data techniques, such as estimation

maximization and multiple imputation strategies (Enders

and Bandalos 2001; Olinsky et al. 2003). The lavaan latent

variable modeling program was used for FIML-based

regression models (Rosseel 2012). Results between ordinary

least squares and FIML approaches were comparable and

FIML results are shown below. For significant moderation

effects, simple slopes were calculated and a region of sig-

nificance was determined (see Preacher et al. 2006).

Results

See Table 1 for descriptive statistics and the original

counts available for each variable. No differences were

noted between retained families and those who dropped out

before completing treatment (all ps C .097). Using Little’s

test, there was no evidence of study variables being dis-

proportionately associated with missing data (v2(102) = 108.03, p = .322).

In considering mean-level change in treatment out-

comes, both ODD symptom count (M reduction = 2.85,

t(67) = 8.01, p \ .001) and ODD severity (M reduc- tion = 2.15, t(74) = 8.87, p \ .001) significantly and equivalently decreased following both treatments.

See Table 2 for bivariate correlations and for partial

correlations regarding post-treatment outcomes, controlling

for pre-treatment reports of ODD symptoms and severity,

respectively. For child reports of perceived relationship

quality with parents and mother reports of child’s conduct

problems there were small to moderate correlations with

clinical outcomes; all were in the expected directions.

These effect sizes suggest that items such as reported

conduct problems were expectedly related to, but not

heavily overlapping with, other indices of ODD. In partial

correlations, maternal reports of conduct problems were

associated with greater resultant ODD symptoms (r = .37,

p = .002) and severity (r = .27, p = .024), whereas child

reports of perceived relationship quality with parents

showed a trend toward lower ODD symptoms (r = -.23,

p = .071) and was associated with significantly lower

resultant ODD severity (r = -.27, p = .024).

Regressions concerning change in mother-reported

ODD symptoms were tested first. See Table 3. At Step 1,

boys had greater reductions in ODD symptoms than girls

(Beta = -1.37, SE = .64, p = .034) and children who

were initially reported to have more ODD symptoms at

pre-treatment showed greater reductions in symptoms

(Beta = .89, SE = .18, p \ .001). Treatment type did not contribute significantly. At Step 2, conduct problems sig-

nificantly predicted attenuated reductions in ODD

Table 1 Descriptive statistics for study variables

N Mean SD Min Max

Pre-treatment (pre-TX) variables

Child perception of parent–child relationship quality T

114 41.93 11.39 10 62

Mother-reported conduct problems T

110 71.28 12.61 48 103

Mother-reported ODD symptom count 123 5.61 1.90 0 8

Clinician-reported ODD severity 111 5.91 1.04 4 8

Post-treatment (post-TX) variables

Mother-reported ODD symptom count 75 2.72 2.67 0 8

Clinician-reported ODD severity 72 3.64 2.06 0 8

T Indicates the variable is T-scored. Skewness for each variable was B.72

J Child Fam Stud (2016) 25:1623–1633 1627

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symptoms (Beta = -.08, SE = .03, p = .010), whereas

perceived relationship quality with parents showed a near-

significant trend for greater reductions in ODD symptoms

(Beta = .05, SE = .03, p = .052). At Step 3, the interac-

tion term did not account for significant variance

(DR2 = .004, Beta = .002, SE = .002, p = .517). Regressions concerning change in clinician-reported

ODD severity were then tested. See Table 4. At Step 1,

pre-treatment ODD severity significantly predicted greater

reductions in ODD severity (Beta = .72, SE = .24,

p = .003), but the other variables including treatment type

did not. At Step 2, conduct problems significantly predicted

smaller reductions in ODD severity (Beta = -.04,

SE = .02, p = .042) and perceived relationship quality

with parents showed a near-significant trend for greater

reductions in ODD severity (Beta = .04, SE = .02,

p = .068). At Step 3, the interaction between positive

relations with parents and conduct problems accounted for

significant variance (DR2 = .07, Beta = .004, SE = .002, p = .020). When relationships with parents were viewed as

being more positive, children showed greater reductions in

ODD severity, across levels of conduct problems. When

Table 2 Bivariate and partial correlations with treatment outcomes in ODD symptom count and severity

Bivariate correlations

1 2 3 4 5 6 7 8

1. Child age –

2. Child gender .12 –

3. Perception of parent–child relationship quality -.16 .05 –

4. Conduct problems .19* .08 -.04 –

5. Pre-TX ODD symptoms .22* .13 .02 .23* –

6. Pre-TX ODD severity .17 .15 -.02 .40** .43** –

7. Post-TX ODD symptoms .23 .17 -.26* .31* .20 .10 –

8. Post-TX ODD severity .24* .30* -.23 .40** .13 .15 .60** –

Partial correlations controlling for pre-treatment ODD variable

1 2 3 4 5 6 7 8

Post-TX ODD symptoms .22 .28* -.23 .37** – .09 – .58**

Post-TX ODD severity .19 .14 -.27* .27* .02 – .58** –

For child gender, girls are coded as the higher value

* p \ .05; ** p \ .01

Table 3 Mother-reported improvement in ODD symptoms as a function of conduct problems and relations with parents

Ordinary least squares FIML

Step DR2 Beta SE Step DR2 Beta SE

Step 1 .30** .32**

Pre-TX ODD symptoms .93** .20 .89** .18

Child gender -1.53* .18 -1.37* .64

Child age -.16 .18 -.15 .17

Treatment group -.02 .67 .13 .62

Step 2 .13** .17**

Conduct problems -.08* .03 -.08* .03

Perception of parent–child relationship quality .05 �

.03 .05 �

.03

Step 3 .00 .00

Conduct problems 9 relationship quality .002 .002 .002 .002

Relations with parents and conduct problems were mean-centered. For child gender, girls are coded as the higher value. For treatment group, the

PMT treatment group is coded as the higher value. FIML values used full information maximum likelihood to address missing data. Variance

inflation factor for all variables \1.50 * p \ .05; ** p \ .01; � p \ .10

1628 J Child Fam Stud (2016) 25:1623–1633

123

the relationship with parents was viewed as being more

negative, children showed smaller reductions in ODD

severity as conduct problems became more elevated. See

Fig. 1 for the simple slopes of this interaction. Confidence

bands were calculated to determine simple slope regions of

significance across conditional values of perceived rela-

tions with parents when ODD severity was regressed on the

focal predictor of conduct problems (Bauer and Curran

2005; Preacher et al. 2006). The region of significance

indicated that when mean-centered values for perceived

relations with parents were below .62, confidence bands for

simple slopes for associations between conduct problems

and reductions in ODD severity did not include zero and

the simple slopes were significant at the a = .05 level. When mean-centered values for perceived relations with

parents were equal to or above .62, simple slopes for

relations between conduct problems and reductions in

ODD severity were non-significant.

Discussion

Findings partially support our hypotheses regarding the

main effects of conduct problems and children’s percep-

tions of the parent–child relationship on ODD treatment

response, and the moderating role of perceived parent–

child relations on impacts of conduct problems. Consis-

tent with our earlier findings (Ollendick et al., in press),

CPS and PMT were equally effective and did not con-

tribute to the differential prediction of treatment response.

On the other hand, mother reports of conduct problems at

pre-treatment were associated with poorer treatment

response and a smaller decrease in ODD symptoms (as

reported by mothers) and ODD severity (as determined by

blinded clinicians). In addition, child reports of relation-

ship quality with parents showed trends of greater

reductions in ODD symptoms following treatment. An

interaction effect was observed between these variables

on reductions of ODD severity. When children reported

better relations with their parents, conduct problems did

not attenuate treatment response; hence, they showed

similarly robust symptom severity improvement regard-

less of the level of conduct problems. In contrast, when

children reported poorer relations with their parents, they

failed to show improvements in ODD severity when pre-

treatment conduct problems were higher. This moderation

effect was not significant for mother-reported improve-

ments in ODD symptoms.

Table 4 Clinician-reported improvement in ODD severity

as a function of conduct

problems and relations with

parents

Ordinary least squares FIML

Step DR2 Beta SE Step DR2 Beta SE

Step 1 .13 �

.13 �

Pre-TX ODD severity .76** .26 .72** .24

Child gender -.42 .52 -.45 .48

Child age -.20 .14 -.18 .13

Treatment group -.18 .50 .08 .46

Step 2 .11* .14*

Conduct problems -.04* .02 -.04* .02

Perception of parent–child relationship quality .04 �

.02 .04 �

.02

Step 3 .06* .07*

Conduct problems 9 relationship quality .004* .002 .004* .002

Relations with parents and conduct problems were mean-centered. For child gender, girls are coded as the

higher value. For treatment group, the PMT treatment group is coded as the higher value. FIML values used

full information maximum likelihood to address missing data. Variance inflation factor for all variables

\1.50 * p \ .05; ** p \ .01; � p \ .10

0

0.5

1

1.5

2

2.5

3

Low Conduct Problems High Conduct ProblemsR e

d u

ct io

n s

in O

D D

S e

ve ri ty

Low Perceived Relationship Quality

Moderate Perceived Relationship Quality

High Perceived Relationship Quality

Fig. 1 Moderator effect of children’s perceived relationship quality with parents on the association between conduct problems and post-

treatment ODD symptom count. Plotted values were set at 1 SD

below and above the mean for Conduct Problems and Perceived

Relations with Parents

J Child Fam Stud (2016) 25:1623–1633 1629

123

The perception of relationship quality with parents has

been understudied among youth with ODD. Yet, with

community samples, positive behaviors between parents

and children (e.g., warmth and limited instances of conflict)

and children’s perceptions of high-quality relationships

with parents are associated with academic performance and

adjustment (Ingoldsby et al. 2006; Laursen and Mooney

2008). As noted earlier, in our sample, only 16.7 % of

children were in the severe range for poor parent–child

relations on the BASC (T-score of 30 or below) and an

additional 29.8 % (T-score of 31–40) were in the border-

line range. Thus, slightly more than half (53.5 %) of our

children viewed their relationships with parents as average

or of high-quality prior to commencement of treatment.

Thus, a considerable number of children reported positive

relations with their parents even though they were

exhibiting argumentative, negativistic, and oppositional

behaviors. It is possible that at least some children’s per-

ceptions of relations with their parents were inflated, as

some research suggests that boys with ODD report overly

positive self-concept (Hoza et al. 2002) and other findings

have shown discrepancies in how some aggressive youth

and their parents perceive the parent–child relationship

(Edens et al. 1999). Even if this were the case in the current

study, there was a trend for reports of parent–child relations

to predict better treatment response from a third-party, the

clinician. Because children’s perceptions of high-quality

relationships with parents may compensate for other

poorer-quality relationships (e.g., siblings; van Aken and

Asendorpf 1997), improving perceptions of the parent–

child relationship might not only benefit symptom reduc-

tion but might also enhance development of positive social

skills.

In terms of clinical relevance, these findings suggest that

treatment of ODD behaviors is more difficult when the

initial relationship between child and parent is viewed

negatively by oppositional children. This appears to be the

case independent of treatment type, at least for the two

treatments examined in the current study. The impact of

positive relations between oppositional children and their

parents can be explained in various ways, depending on

one’s perspective on oppositional behavior. It is possible

that, in spite of problematic ODD behaviors, some family

members are able to maintain relatively positive relations

with each other. In other words, oppositional behavior does

not define the totality of interactions between children

diagnosed with ODD and their parents, and conflictual

interactions may be confined to certain specific demands

and expectations. Thus, one possible interpretation of the

current findings is that treatment is more difficult when

parent–child conflict has come to color a higher number of

parent–child interactions, or at least when such conflict has

come to color perceptions of the parent–child relationship.

By this reasoning, positive parent–child relations facilitate

children’s compliance with adult directives (as is involved

in PMT) and adult–child collaboration in solving problems

(as is involved in CPS). These are more likely to be fam-

ilies which exhibit warmth and better emotion regulation

across interactions (Beauchaine et al. 2005; Eisenberg et al.

2005).

It is also possible that children’s concepts of their

relationships with parents and other family members are

particularly salient aspects of their self-views which direct

thoughts, feelings, and goals when interacting with the

family, and that these self-views are grounded in more

secure and optimistic outlooks. These views of the rela-

tionship, just as with other concepts of the self and one’s

standing in the social world, may then direct ongoing

interactions with the world and continue to be shaped by

experiences across relationships and settings (Andersen

and Chen 2002; Tesser 2002). For oppositional children in

treatment, viewing the relationship with parents as some-

thing worth maintaining and improving further may

encourage greater cooperation and collaboration during

and after treatment, enhancing investment and willingness

to follow instructions or work with parents when dis-

tressed. For oppositional children who do not initially hold

the relationship with parents in high regard, investment in

treatment may, initially at least, be lower. However, given

the potential malleability of the parent–child relationship

(Scott et al. 2014; Silver et al. 2011; Webster-Stratton et al.

2004), and the emphasis of relationship improvement

among many clinical treatments, it is possible that these

children would continue to see more value and quality in

their relationships over time, and eventually invest more

effort in incorporating treatment techniques. Finally, in

transactional terms, it is possible that ODD behaviors are

the byproduct of pre-existing difficulties that could hinder

relations between parent and child (e.g., biological factors

contributing to reactivity or risk-taking, mean testosterone

levels, neuroanatomical functioning) as well as difficulties

in other social domains that impact routine family

dynamics (e.g., peer rejection; see Burke et al. 2000;

Greene and Ollendick 2000). With each of these possibil-

ities, the parent–child relationship remains an important

consideration, with implications for family cooperation and

treatment response in both PMT and CPS treatment

approaches.

Our findings also emphasize the importance of assessing

broader conduct problems among oppositional youth.

Research has historically linked ODD and CD; moreover,

children who exhibit the behaviors associated with ODD

are at increased risk for the behaviors characterizing CD

(Beiderman et al. 1996; Maughan et al. 2004). For our

sample, although none of the children met full criteria for

CD, mothers typically reported that their children displayed

1630 J Child Fam Stud (2016) 25:1623–1633

123

clinical levels of conduct-related problems on the BASC

(T-score C70). As noted above, these conduct problems

differ from the predominantly reactive problems frequently

associated with ODD, and often reflect forethought and

intentional manipulation of others in the achievement of

relationship goals (e.g., White et al. 2013; Wolke et al.

2000; Woodworth and Waschbusch 2007). Although chil-

dren with oppositional and conduct problems may be par-

ticularly difficult to treat, they may be more engaged in and

responsive to treatments if they value their relationships

with their parents and believe their parents value them as

well (Pasalich et al. 2012).

The current study possesses several weaknesses. First,

the correlational nature of our study precludes making

causal inferences. Second, a major limitation concerns the

extent of family dropout during treatment or before the

post-treatment assessment. Although lower than the

approximately 50 % attrition rates in many treatment

studies of ODD or CD (Kazdin 2005; Murrihy et al. 2010),

our dropout rate was still about 25 %. We used full

information maximum likelihood to incorporate all avail-

able data and reduce the impact of attrition. Other weak-

nesses include our largely middle-class, Caucasian sample

of children and the lack of longer-term follow-up on

intervention effects. In addition, we recognize that con-

sidering only the perspective of the child concerning the

quality of the parent–child relationship is limiting, and fails

to incorporate important (and possibly discrepant) views

from the parent. Parents’ views of the relationship are also

important and could further inform treatment responsive-

ness among families. However, we prioritized children’s

perspectives in the current study given interest in the

understudied role of oppositional children’s viewpoints in

treatment response and the desire to incorporate separate

informants whenever possible.

Importantly, our study also possesses strengths. This is

the first study to examine child perceptions of relationship

quality with parents alongside the level of conduct prob-

lems in children with ODD and to explore their associa-

tions with treatment outcomes. As noted above, we also

used FIML approaches to handle missing data in analyses

and we used multiple informants (child, parent, clinician).

Each of these approaches strengthens the present results.

Further, while ODD was the principal reason of referral for

all youth, nearly all of our youth met criteria for another

disorder, most frequently ADHD or an anxiety disorder,

and over half met criteria for a third disorder. The highly

comorbid sample suggests that our findings have applica-

bility to populations of youth with ODD in the ‘‘real-

world,’’ where non-comorbid ODD is rare.

Our findings suggest important leads for future research

and possible treatment. For example, in future studies it

will be important to assess for conduct problems in

children diagnosed with ODD and to examine pre-treat-

ment levels of positive parent–child relations. Oppositional

children with co-occurring conduct problems—even in the

absence of a clinical diagnosis of CD—may require an

augmented treatment that addresses these additional fea-

tures. Our findings suggest this will be especially important

for youth who are less positive about the support they will

receive from their parents. Indeed, perhaps the most clin-

ically relevant conclusion to be drawn from our findings is

that, in some families, successful treatment of youth with

ODD may benefit from improving the relationships

between these youths and their caregivers to enhance

reduction in ODD symptoms. It is possible that focusing

solely on reduction of ODD symptoms may not address

other factors contributing to dysfunctional interactions

between youth with ODD and their caregivers.

Acknowledgments Funding was provided by R01 MH59308 from NIMH and by the Institute for Society, Culture, and Environment at

Virginia Tech. We wish to express appreciation to the graduate stu-

dents and research scientists who assisted us with various aspects of

this project, including data reduction, assessment, and treatment of

these youth. We also wish to extend thanks to the many undergraduate

students at Virginia Tech who assisted us with data coding, entry, and

verification. Finally, we are grateful to the youth and families who

participated in this clinical research.

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