Order 818901: Qualitative research evaluation

ORIGINAL PAPER

Tailoring Social Competence Interventions for Children with Learning Disabilities

Karen Milligan1 • Marjory Phillips2 • Ashley S. Morgan2

Published online: 3 September 2015

� Springer Science+Business Media New York 2015

Abstract Challenges in social competence are common

in children with Learning Disabilities (LDs), particularly

those who present with co-occurring mental health chal-

lenges (LD ? MH). Social competence calls upon a com-

plex set of skills, including social skills, perspective-taking

abilities, and an understanding of the social environment.

Successful enactment of these skills necessitates behavioral

and emotion regulation, an area of weakness for many

youth with LD ? MH. Using a mixed-method design, the

present study assessed the efficacy of a social competence

group program for children with LD ? MH (mean

age = 11.4 years) in which group size, content, and

structure are tailored to the child’s level of emotion regu-

lation, information processing abilities, and social compe-

tence goals. Quantitative measures completed by parents

and coded behavioral observations completed pre- and

post-treatment indicated significant gains in initiation and

engagement in positive social interactions, foundational

skills that support improvement in social competence.

Qualitative interviews with parents, children and teachers

suggested improvements in social self-concept, initiation,

and emotion regulation. Tailoring treatment to the child’s

information processing and emotion regulation abilities, as

well as ‘in the moment’ feedback, supported gains made

and contributed to participants having a positive social

experience. Directions for future research are discussed.

Keywords Learning disabilities � Social competence � Group intervention � Emotion regulation � Children and youth

Introduction

Social competence refers to the ability to successfully and

independently engage in social interactions, to establish

and maintain relationships with others, and to have one’s

needs and desires met across diverse contexts (Stichter

et al. 2012). Engaging in meaningful social relationships

plays a foundational role in fostering mental health across

the lifespan. Without supportive social relationships, chil-

dren are more likely to experience low self-esteem (Side-

ridis 2007), loneliness (Valås 1999), social rejection (Bryan

et al. 2004), and bullying and peer victimization (Mishna

2003), and are at greater risk for school failure (Parker and

Asher 1987).

Social competence calls upon a complex set of skills and

competencies, including age-appropriate social skills, reg-

ulation of behaviors and emotions, perspective-taking

abilities, and an understanding of the social environment

(Baumeister et al. 2005; Shechtman and Katz 2007).

Information processes, including attention (Andrade et al.

2009), executive functions (Riggs et al. 2006), language

abilities (McCabe and Meller 2004), and theory of mind

(Fink et al. 2014) have also been associated with social

competence and peer relations.

Information processing weaknesses are common among

children with learning disabilities (LDs). Children with

LDs have average to above average levels of cognitive

ability but do not achieve in reading, writing, and/or math

at a level that would be expected for their age or cognitive

ability (Burke 2008). Given the link between information

& Karen Milligan [email protected]

1 Department of Psychology, Ryerson University, 350 Victoria

Street, Toronto, ON M5B 2K3, Canada

2 The Integra Program, Child Development Institute, Toronto,

ON, Canada

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J Child Fam Stud (2016) 25:856–869

DOI 10.1007/s10826-015-0278-4

processing and social competence, many children with LDs

experience significant challenge with social interactions.

In a meta-analysis of social skills research, Forness and

Kavale (1996) found that 75 % of students with LDs have

lower levels of social competence than typically develop-

ing children, as assessed by teachers, peers, and children

themselves. Approximately 50 % of children with LDs are

rejected, neglected, or victimized by peers (Baumeister

et al. 2008; Mishna 2003), and many have impoverished

and unstable friendships (Wiener and Schneider 2002;

Wiener and Sunohara 1998), putting them at increased risk

for co-occurring mental health challenges in addition to

their LD (LD ? MH).

Information processing challenges may underlie both

learning and social competence difficulties, such as

understanding sarcasm, reading body language, or recalling

information about social situations (Bauminger et al. 2005;

Elksnin and Elksnin 2004). Children with LDs may also

lack the language skills necessary to put voice to their ideas

and desires and to negotiate with peers (McCabe and

Meller 2004). Challenges with attention have been asso-

ciated with behavioral challenges in social interactions

(Andrade et al. 2009). Further, many youth with LDs

present with challenges within the domain of executive

functions, which may impact on their ability to plan social

interactions, execute their plans, monitor the success of

their behavior, and flexibly shift their behavioral approach

based on feedback from peers and the broader environment

(Clark et al. 2002; Nigg et al. 1999).

Group-based social skills intervention has been identi-

fied as the treatment of choice for improving the quality of

peer relationships of children with LD ? MH, given that

the group setting provides the opportunity to create more

naturalistic and experiential peer interaction opportunities

in which to teach and practice social skills (Mishna et al.

2010). While social skills groups for children with LDs

have been associated with positive outcomes (e.g.,

improved social skills and self-esteem, decreased feelings

of isolation), results of meta-analyses indicate an average

effect size of .21 (Forness and Kavale 1996; Kavale and

Mostert 2004), which is considered small in strength (Co-

hen 1988).

Improving the effectiveness of social competence pro-

grams for children with LD ? MH may lie in tailoring

treatment to their specific social competence and infor-

mation processing needs. Gresham et al. (2001) have

suggested that social competence challenges can arise due

to a lack of knowledge of social skills (acquisition deficit),

not being able to perform skills due to cognitive, emotional

or behavioral factors (performance deficit or competing

behaviors), or challenges with not being able to implement

a skill with automaticity or fluency when needed (fluency

deficit). Social competence researchers have further

suggested that intervention effectiveness may be improved

if interventions are tailored to the unique information

processing strengths and needs of the child (Cotugno 2009;

Guli et al. 2013; Maag 2006; Stichter et al. 2012). Tailoring

of social competence interventions may be particularly

important for children with LDs, and in particular, for those

that present with co-occurring mental health challenges

(LD ? MH). A recent study by Margari et al. (2013) found

that almost 50 % of children with a specific learning dis-

ability met criteria for another psychological disorder, such

as anxiety, attention-deficit/hyperactivity disorder

(ADHD), and depression. Behavior problems are also more

common in children with LDs (Lowe et al. 2007). This

comorbidity is important to consider given that challenges

with information processing are common, and may be

magnified, when both LDs and mental health difficulties

are present. For example, executive functioning deficits are

more severe in the LD ? ADHD comorbid population than

in ADHD alone (Seidman et al. 2001).

The impact of information processing challenges on

social competence also needs to be further understood

within the context of emotion regulation, particularly when

intervening with performance and fluency based social

competence challenges. Emotion regulation is defined as

the ‘‘extrinsic and intrinsic processes responsible for

monitoring, evaluating, and modifying emotional reactions,

especially in their intensive and temporal features, to

accomplish one’s goals’’ (Thompson 1994, pp. 27–28). For

children with LDs, the ability to manage and modify

emotional reactivity is a significant contributor to social

information processing (Bauminger and Kimhi-Kind

2008). Emotional reactivity is impacted by information

processing (e.g., language, flexibility, processing speed,

inhibition; Diamond 2013). From a neurobiological per-

spective, the presence of a strong emotional response limits

a child’s ability to fully engage their cognitive abilities

(e.g., impulse control, cognitive flexibility, social knowl-

edge, perspective-taking abilities, social skills; Zelazo and

Lyons 2012), which may already be weakened due to the

presence of information processing challenges associated

with the LD or mental health difficulty. Further, many

children with LDs experience feelings of low self-esteem,

failure, shame, and self-doubt associated with the school

challenges they have experienced (Arthur 2003; Ginieri-

Coccossis et al. 2013; Mishna and Muskat 2004), and as

such may be more likely to interpret academic or social

situations as threatening. To regulate these strong emo-

tions, many children with LDs learn that avoiding activities

and interactions reduces the experience of distress and

discomfort. While effective in the short-term, this pattern

of avoidance precludes children from engaging in skill-

building opportunities (Chawla and Ostafin 2007; Duch-

arme and Harris 2005; Hayes et al. 1996). Social

J Child Fam Stud (2016) 25:856–869 857

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competence interventions that take into account emotion

regulation abilities have the promise of supporting children

in accessing their full range of cognitive capacities which

may in turn set the stage for learning and implementing

social skills, thus promoting adaptive social interactions

(Dollar and Stifter 2012).

Tailoring to the level of social competence challenge,

information processing, and emotion regulation has been

largely absent in intervention studies in the extant literature

(Maag 2006). Further, a framework for tailoring treatment

for children with LD ? MH has not been posited, with

many programs lacking a clear theoretical rationale

(Kavale and Mostert 2004). Finally, norm-referenced

measures with established reliability and validity have

rarely been utilized in the extant literature (Kavale and

Mostert 2004). The present mixed-method cohort (pre-

post) study was undertaken to evaluate the impact of a

social competence program specifically tailored to meet the

unique needs of children with LD ? MH on several social

competence outcomes. We explored the impact of the

program on parent- and teacher-rated social competence

outcomes (e.g., Communication; Cooperation; Assertion;

Responsibility; Empathy; Engagement; and Self-Control)

and changes in social competence observed throughout the

group. Qualitative interviews were completed to explore

outcomes, as well as the processes that support or hinder

social competence gains.

Method

Participants

Thirty-six children enrolled in the Integra Social Compe-

tence (SC) Group program were invited to participate in

this study. Six children were unable to complete the group

due to transportation problems, family issues, or other

unspecified reasons. On this basis, the final sample inclu-

ded 30 children (mean age = 11.4 years, SD = 1.49),

consisting of 22 boys (mean age = 11.6 years, SD = 1.56)

and 8 girls (mean age = 10.9 years, SD = 1.19). The

sample was relatively diverse in terms of ethnicity (60 %

White, 23.3 % Asian, 13.3 % European, and 1 % Latin).

The study was conducted at an urban, community-based

children’s mental health center that is accessible to all

children with diagnosed LDs and co-occurring mental

health challenges. It is located in a middle- to upper-middle

class area of the city, and as such, the population is largely

reflective of this location, but includes some children from

families from a lower socioeconomic (SES) level. Infor-

mation on SES was not available for the participants.

All children had diagnosed LDs on the basis of a psy-

choeducational assessment completed by a registered

psychologist or psychological associate. While access to

the specific scores were not available for research purposes,

to meet criteria for a LD and to gain admittance into the

program, children had to have cognitive scores on the

Verbal or Perceptual Reasoning indices of the Wechsler

Intelligence Scale for Children-III or IV (or other compa-

rable intelligence test) falling within the Average to Above

Average range (25th percentile or greater), have at least

one area of academic achievement (math, reading, or

writing) that is significantly lower than their cognitive

ability, and have significant challenges in at least one area

of information processing (i.e., memory, executive func-

tions, processing speed). Further, to be specifically referred

to the SC Group program, children had to present with

significant emotion regulation challenges (e.g., behavior,

anxiety, depression) that impact on their peer relationships

(assessed as part of the admission criteria to the children’s

mental health center).

Children were divided into ten groups based on a multi-

source assessment of their information processing and

emotion regulation skills as well as their performance

ability of specific social skills. In the SC Group program

model, social competence and emotion regulation are

dimensional constructs, and as the group characteristics

increase or decrease along these dimensions, there is a

corresponding increase or decrease in the level of pro-

cessing that occurs within the group structure. As depicted

in Fig. 1, the assessment process begins with case man-

agers and parents completing a group referral form that

specifies strengths and needs in terms of learning and

information processing, as well as social skills and emotion

regulation (see Table 1 for information processing, social

skills, and emotion regulation areas).

All children have undergone psychoeducational assess-

ment as part of the process by which they received their LD

diagnosis. These assessments typically include information

about their verbal and visual cognitive abilities, as well as

key areas of information processing such as memory,

executive functions, and processing speed. This informa-

tion can be used as a road map to tailor treatment goals,

activities, and accommodations based on how a child learns

best in order to ensure that information is taken in and

encoded in a manner that is meaningful for the child and

promotes later recall and implementation. For example,

visually-based activities, such as cooperative building

games, are used with children who have difficulty

expressing themselves verbally. Instructions for activities

are provided one step at a time and may be repeated,

accommodating for processing speed and memory diffi-

culties. In addition to repetition of instructions, slower

processing speed is accommodated for by slowing down

the pace of the game and ensuring that the child is not

rushed by other group members. Similarly, children who

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have difficulty with transitions and ‘letting go’ may be

engaged in group games that target turn-taking and shifting

from one task to another. Memory and generalization dif-

ficulties are alleviated through use of visuals both in and

out of session, including the use of weekly session sum-

maries with at-home recommendations that are taken home

by parents to help reinforce the skills practiced during the

session. Executive function challenges (e.g., attention,

impulse control, and cognitive flexibility) and perspective-

taking are addressed through use of ‘in the moment’

feedback and scaffolding.

Children are then observed in two group assessment

sessions (with 5–8 children) a week apart. During these

sessions, they play a variety of social skill based games,

including collaborative problem-solving games, games

requiring identification of emotion (e.g., Taxi Driver game

which requires the ‘‘taxi driver’’ to observe and mimic the

emotion of the child who is their ‘‘passenger’’). These

activities create an opportunity for group leaders and case

managers (observing from behind a one-way mirror) to

observe the emotion regulation and social competence

abilities of children (following the categories included on

the group referral form).

The case manager combines information from the

child’s psychological assessment report, parent and teacher

reports, and observations from the assessment groups to

make a clinical judgment about optimal group placement.

Children with difficulties in regulating emotions and

behaviors are flagged for placement in small groups of 2–3

children. Children who are better able to regulate emotions

are assigned to larger groups, which may include up to

eight children. All group placements are further matched

according to level of social skills (high, medium, low),

gender (male or female), and age. The nature of group

activities is determined by the composition of children in

the assigned group and is tailored to their LDs. For

example, with a triad of younger boys with low emotion

regulation and social skills and low language abilities, the

group will consist of a fast pace of group games and

activities to practice basic social competence, such as eye

contact, turn-taking, and improving awareness of others. In

contrast, with a larger group of older, well-regulated boys

Case manager and parent complete a group referral form containing data related to strengths, needs, information processing abilities,

social skills, and level of emotion regulation

Clinical team observes child in two assessment group sessions

Consider child's abilities on two key dimensions: 1. Social Competence Abilities (e.g., openness to others, ability to join, tolerance of others) 2. Emotion Regulation Skills (e.g., self-control, response to adult direction, ability to follow group structure)

Low level of ER/SC Activities themselves foster basic social skills building (e.g. turn-taking, listening, making eye contact, etc.) Need for direct coaching

High level of ER/SC Activities provide ‘in the moment’ teaching followed by processing

Focus on ‘higher order’ social competence skills such as understanding impact on others, perspective-taking, social problem- solving

Social Competence (SC)

E m

ot io

n R

eg ul

at io

n (E

R )

Resulting Groups: 3 low SC/low ER; 1 low SC/medium ER; 1 medium SC/low ER; 5 medium SC/high ER

Fig. 1 Flow chart illustrating the Integra Social Competence

Group Program assessment

process. Participants’

information processing abilities

are considered when planning

the group activities. Group

participants with very low levels

of emotion regulation are often

streamed into dyads and triads

J Child Fam Stud (2016) 25:856–869 859

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with low social skills and high verbal abilities, cooperative

games are accompanied by group discussions to process the

application of the social competence skills used in the

game to real-life challenges, such as conflict resolution

when working on a similar group project at school.

Procedure

The SC Group program ran on a weekly basis for

10 weeks, after the completion of the two group assess-

ment sessions. Each group was planned and run by two

Masters-level therapists with training in providing support

to children and youth with mental health issues compli-

cated by learning disabilities. Co-therapists liaised with the

case manager and, when necessary, the parents to set goals

for each group so that they were tailored to the social

competence level and emotion regulation needs of the

children. In addition to group goals, each child within the

group had individual social competence goals that had been

identified by the case manager in collaboration with the

family and the child. Across all groups (assessment and

treatment), there was a similar structure that included

providing the children with a written agenda, a ‘check in’

discussion at the beginning, followed by games and

activities, and ending with ‘snack and chat.’ For all groups,

each weekly session was supplemented by a handout for

parents/guardians that outlined the session goal and tar-

geted skills and provided suggestions for home and school

practice.

Groups low on both social competence and emotion

regulation were structured in such a way as to limit the

amount of processing that occurred and focused more on

fostering basic social skills such as turn-taking and making

eye contact, for example. Groups characterized by higher

levels of social competence and emotion regulation were

structured to include games and activities that fostered

cooperation, group work, conflict resolution skills, and

higher order social competence skills such as perspective-

taking and social problem-solving. Such groups also

emphasized processing of group dynamics and ‘in the

moment’ teaching opportunities. Group size was also

considered, especially in relation to participants’ levels of

emotion regulation. Thus, participants who were very low

on emotion regulation abilities were often streamed into

dyads and triads to ensure that their emotion regulation

needs were supported. In the current study, groups varied

in size, ranging from 2 to 5 participants each.

Considering social competence and level of emotion

regulation as two key dimensions in the group matching

process (see Fig. 1), there were three low social compe-

tence/low emotion regulation groups (n = 2–3), one low

social competence/medium emotion regulation group

(n = 3), one medium social competence/low emotion

regulation group (n = 5), and five medium social compe-

tence/high emotion regulation groups (n = 3–5).

Previous research on the SC Group program have

examined accommodations related to group process that

are specific to the LD population, such as special tech-

niques to accommodate for the LD and to foster positive

group process factors (Mishna et al. 2010). One long-s-

tanding key process in the SC Group program has been the

use of experiential group activities that allow ‘‘real life’’

peer conflicts, challenges, and cooperation to arise, thereby

providing opportunities for ‘in the moment’ instruction,

cueing, and reinforcement of new skills. Importantly, these

‘teachable moments’ were planned to address the social

and information processing needs of group members within

a safe and supported environment (Mishna et al. 2010).

Activities were selected to target specific skills and areas of

focus, such as turn-taking, initiating conversation, or social

problem-solving (e.g., compromising), depending on the

type of group and the level of social competence and

emotion regulation of the group members.

All children and their parents enrolled in the SC Group

program were invited to participate in the research. Con-

sent to participate in the completion of questionnaires and

to videotape group sessions was received by all child

participants and their parents. Questionnaires were dis-

tributed by a research assistant and completed by parents at

the first and last SC group session. Teacher questionnaires

were given to parents to give to their child’s teacher and

then were returned to the researchers by mail. All SC group

Table 1 Information processing, social, and emotion regulation skills assessed in referral and assessment group process

Behavior

Language ability/verbal cognitive abilities

Processing speed

Memory (i.e., working memory, verbal, visual)

Attention and focus

Self-control of impulses

Copes with own emotions

Compliance with authority

Works well within structure

Transitions between activities

Copes with anxiety

Listens openly to others

Aware of their impact on others

Tolerance of others’ behaviors

Responds on topic

Joins in

Takes turns

Demonstrates flexibility

Asserts wishes and needs

Shows leadership and teamwork

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sessions were videotaped. Data collection was carried out

by the first author of this paper and a team of research

assistants not involved in the delivery of the program but

employed by the children’s mental health center delivering

the group.

Measures

Social Skills Improvement System Rating Scales (SSIS;

Gresham and Elliott 2008)

The SSIS provides a targeted assessment of an individual’s

social skills, problem behaviors, and academic compe-

tence. Teacher and parent forms are included to provide a

comprehensive picture of social competence across school,

home, and community settings. Subscales of interest for

this study included Communication; Cooperation; Asser-

tion; Responsibility; Empathy; Engagement; Self-Control;

and Top Ten, which includes items that were deemed by a

national sample of teachers to be most important for school

success (e.g., following rules, paying attention to instruc-

tions, turn-taking, interacting well with children, showing

concern for others, tolerating annoying behavior, and

managing disagreements). Inter-rater reliability for the

SSIS for total social competence is adequate for parent

(0.62) and teacher (0.70), with subscale reliability coeffi-

cients ranging from 0.35 to 0.71 (Gresham et al. 2010).

Coding of Social Competence Behaviors

All group sessions were video recorded for subsequent

coding of social competence behaviors. To qualitatively

assess changes in children’s social competence within the

context of group sessions, a social competence coding

manual was developed based on an adapted version of the

‘‘Initiative Response Assessment (IRA)’’ coding scheme

(Cummings et al. 2008). See Table 2 for a description of

behaviors coded. Behaviors were coded every 30 s for a

period of 10 min. Coding was completed at the beginning

(e.g., session 1), middle (e.g., session 5), and end (e.g.,

session 10). If a child was absent during the designated

coding session, the next session attended was coded. To

determine inter-coder reliability, 20 % of coded sessions

were independently coded by a second member of the

coding team. The coding team was not involved in the

delivery of the group treatment. There were no significant

differences between coder observations, with agreement

exceeding 90 % for each behavior category.

Qualitative Interviews

To understand the experience of children participating in

the SC Group program and key intervention processes and

outcomes, children and their parents and teachers were

invited to participate in an interview. Given the pilot nature

of this study, we sought to collect detailed information

from a small group of children and to triangulate this

information with data from interviews with parents and

teachers. A poster inviting children and their parents to

participate in interviews about their experience was posted

in the waiting room area outside of the therapy room

2 weeks prior to the end of the group. Case managers who

were not directly involved in the delivery of the group also

provided names of parents and children who they thought

would be able to reflect on their experience in the program

and fully participate in a verbal interview. Teachers of

children who participated in these interviews were also

contacted to better understand any gains seen at school

since participation in the group.

The final sample for the qualitative interviews included

4 children, 5 parents, and 5 teachers. The majority of

children were from the medium social competence, high

emotion regulation groups, with one child representing the

medium social competence, low emotion regulation group.

Parallel forms of the semi-structured interview guide were

developed for parents and children and a brief interview

was developed for teachers. The purpose of the parent and

child interviews was to better understand the process

variables that contributed to the success of the program.

The teacher interview, in contrast, focused on description

of the child’s social interactions and any changes that the

teacher saw in the child’s social competence. Questions

included in the qualitative interview are presented in

Table 3. Given the exploratory nature of this research and

the small sample, an inductive thematic analysis as

described by Braun and Clarke (2006) was used to analyze

interview transcripts. This approach enabled the identifi-

cation of both explicit and implicit or underlying themes to

highlight areas that may be important in fostering social

competence and positive social experience for children

with LD ? MH. Two researchers individually read each of

the transcripts, tabulated responses, and took notes on key

themes. These themes were then discussed to ensure

common interpretation and identification of key themes.

This process allowed for investigator triangulation (i.e., the

use of two or more investigators to examine the same

phenomenon) in interpreting the data, thereby reducing the

risk of biased interpretation. Any discrepancies were

resolved by consensus.

Results

Baseline levels of social competence reported by parents

suggested that 75 % of children were rated as having below

to very below average social competence. Problem

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behaviors were also commonly reported, with above to

well above average levels of problem behaviors noted for

71 % of children. Specific behavioral difficulties included

externalizing behavior (46 %), hyperactivity (54 %),

internalizing behavior (64 %), and behaviors seen in aut-

ism, such as preoccupied with objects, repeating things,

and not making eye contact when talking (78 %).

Children exhibited high levels of engagement

(M = 2.96, with a score of 3 representing the highest level

of engagement) across the three coded sessions (see

Table 4). Repeated Measures Analysis of Variance

(ANOVA) indicated that the most significant gains for

children were made in the area of goal-directed initiations

(Wilks’ k = 0.64, F (2, 25) = 7.02, p = .004), with sig- nificant gains made between session 1 and 5 and then

maintained until the end of treatment (session 10). Results

did not significantly differ based on age, gender, type of

group, number of previous groups attended, number of

children in the group, or parent-rated level of behavioral

difficulties.

Paired sample t tests were conducted to examine chan-

ges in SSIS scores from pre- to post-intervention. Signifi-

cant gains in overall social skills approached significance

(t(22) = -1.9, p = .07), with items considered most

important to school success by a US-sample of teachers

(Top Ten) showing significant gains from pre- to post-

treatment, (t(22) = -2.35, p = .03). SSIS subscales were

examined to better understand these gains. Significant

gains were made in assertion (t(22) = -2.05, p = .05,

d = .43) and engagement (t(22) = -2.8, p = .01,

d = .59), with gains in responsibility approaching signifi-

cance t(22) = -1.91, p = .07, d = .40). Results did not

significantly differ based on age, gender, type of group,

number of previous groups attended, number of children in

Table 2 Description of coding scheme for social competence group observations

Behavior Coding description

Initiation The child makes a verbal or non-verbal attempt to interact with a peer or leader, without being prompted (e.g., talking

to another child, asking questions, making suggestions, taking something from another child, with their verbal or

non-verbal acknowledgement and approval, gesturing to demonstrate it’s another child’s turn)

Positive response The child acknowledges and responds to a verbal or non-verbal prompt, initiated by a peer or leader (e.g., answering

questions, complying with another child’s on-task request, nodding)

Rejection The child responds to a verbal or non-verbal prompt, initiated by a peer or leader, but expresses intolerance of another

individual’s choices, ideas, suggestions, or behaviors (e.g., verbal rejection, sarcasm, non-acquiescence)

Supportive/positive

behaviors

A positive verbal or non-verbal interaction that helps, supports, assists, and/or provides encouragement to a peer or

leader. It may be on or off-topic and does not have to relate to the completion of the task (e.g., providing rule or

game demonstrations, complimenting or encouraging a peer, acquiescence)

Negative behaviors A negative verbal or non-verbal interaction that hinders the group’s progress and/or hurts someone’s feelings

Level of engagement 3 levels coded (occurs in at least half of coding interval)

Actively disengaged

Engaged with some distraction

Actively engaged

Table 3 Qualitative interview questions (parent version)

Do you think the social competence group was a positive social experience for your child? Why? Probe for specific examples

What were the best things about the social competence group?

Do you see any areas where the social competence group experience could be improved?

What was your child’s goal for the social competence group? How successful was he/she in achieving his/her goal? What about the social

competence group program helped him/her to achieve his/her goal?

Has the manner in which your child interacts with other children improved since being in the group?

Have you noticed any changes in your child’s confidence in social interactions?

Have you noticed any changes in your child’s mood (e.g., are they more happy, less anxious, less angry or frustrated)?

Your child attended 1 or 2 sessions before the beginning of group to determine what group would be best for him/her. What was this

experience like for your child? What were the best parts of this experience? What could be improved?

Did you feel that your child was with a group of children that would enable him/her to make gains in their social competence?

What aspects of the group did you and your child like the most? The least?

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the group, or parent-rated level of behavioral difficulties.

No significant differences from pre- to post-treatment were

found for problem behavior (see Table 5).

Paired sample t tests were run to examine changes in

SSIS scores from pre- to post-treatment as reported by

teachers. No significant gains in social skills or decreases in

problem behavior were reported by teachers.

Qualitative Interviews

Three main outcomes were commonly described by chil-

dren and their parents: (1) improved social self-concept; (2)

increased initiation; and (3) enhanced emotion regulation.

A number of parents highlighted that they saw an

improvement in their child’s social self-concept and con-

fidence. Parents made comments such as: ‘‘She definitely is

helpful and a team player so she was able to demonstrate

that in the group, so it made her feel successful and was

good for her self-esteem;’’ ‘‘I think that it just builds his

self-esteem;’’ and ‘‘He has definitely built some self-

confidence.’’

In addition to overall social self-concept and confidence,

parents and children highlighted the ability to initiate

interactions and share ideas more freely. For example, one

parent remarked, ‘‘He’s learned how to find his voice.’’

Another parent discussed how the process supported her

daughter’s ability to ‘‘take on a very positive leadership

role.’’ Children reported similar themes of confidence,

initiation, and being able to share ideas. For example, a

child reported now being able to share his ideas on a school

field trip: ‘‘I’m sharing my ideas. Actually today I shared

my idea about a super villain [with the class] at the

Table 4 Behaviors of participants in Integra Social

Competence Group assessed

through observational coding of

10-min segments from the

beginning, middle, and end of

the series

Subscale M (SD)

Pre-test Mid-test Post-test

Goal directed initiations* 20.56 (13.38) 34.56 (26.96) 32.89 (22.12)

Goal directed responses 13.04 (7.41) 11.67 (5.08) 7.63 (4.58)

Goal directed rejections 0.04 (0.19) 0.56 (1.31) 0.04 (0.19)

Non-goal directed initiations 0.22 (0.58) 0.85 (2.23) 1.48 (3.21)

Non-goal directed responses 0.22 (1.15) 0.07 (0.27) 0.11 (0.32)

Non-goal directed rejections 0.00 (0.00) 0.00 (0.00) 0.00 (0.00)

Positive/supportive behaviors 0.74 (1.95) 1.03 (2.89) 0.22 (0.51)

Negative behaviors 0.07 (0.38) 0.11 (0.32) 0.04 (0.19)

Acquiescence 0.04 (0.19) 0.07 (0.27) 0.04 (0.19)

Level of engagement 2.96 (0.10) 2.94 (0.11) 2.94 (0.11)

n = 27, * p \ .05

Table 5 Parent rated social skills and problem behaviors of

participants in social

competence group

Subscale M (SD)

Pre-test Post-test

Social skills standard score �

77.96 (10.68) 82.57 (12.68)

Social skills—communication raw score 11.35 (2.96) 12.09 (2.92)

Social skills—cooperation raw score 10.39 (2.89) 11.17 (3.07)

Social skills—assertion raw score* 10.87 (3.47) 12.04 (3.16)

Social skills—responsibility raw score �

10.65 (3.10) 11.35 (3.14)

Social skills—empathy raw score 10.52 (3.38) 11.04 (3.50)

Social skills—engagement raw score* 8.00 (4.02) 9.87 (3.48)

Social skills—self control raw score 8.35 (2.90) 8.91 (3.44)

Problem behaviors standard score 119.30 (11.68) 118.48 (13.68)

Problem behaviors—externalizing raw score 11.04 (5.28) 11.09 (5.612)

Problem behaviors—bullying raw score 2.48 (2.00) 2.39 (2.59)

Problem behaviors—hyperactivity/inattention 9.17 (3.56) 9.04 (3.70)

Problem behaviors—internalizing raw score 10.26 (3.68) 10.13 (3.65)

Problem behaviors—autism spectrum score 20.00 (5.72) 18.04 (5.16)

n = 23, � p \ .10, * p \ .05

J Child Fam Stud (2016) 25:856–869 863

123

National Film Board Centre.’’ Another child reported that

before the group she was always ‘‘really shy at first’’ but

noted that ‘‘has all gone away’’ since completing the group.

She remarked that she now feels like things are going to be

ok when she changes schools for Grade 7. A third child

noted while speaking to the interviewer that she is now able

to ‘‘talk to people in the eyes—just like now.’’

Finally, parents and children noted improved emotion

and behavioral regulation. For example, one parent repor-

ted, ‘‘[He’s] not melting down, like frustrated.’’ Two par-

ents reported that their daughters were able to let things go

and that they were able to ‘‘integrate this and let [their

parents] know.’’ Another parent echoed this outcome, but

noted that they ‘‘had to build that over weeks.’’ Consistent

with emotion regulation gains, children remarked, ‘‘I liked

being with the therapist because I was still able to let out

what I need to say and not offend anybody’’ and ‘‘I feel

better when I talk [to other kids] now that I’m breathing in

and out, relaxing, I’m okay.’’ Another child also discussed

this theme, highlighting an activity that had been helpful

for her.

‘‘Well, one of the things we did was role plays and we

had to act out a scene where there were two people

fighting and then the audience had to help negotiate it

out. I realized that I’ve had very similar things hap-

pen to me before and I followed some of the advice

that I got and it seems to have worked.’’

Outcomes were mixed in terms of their generalizability to

other settings, such as school. Two parents noted positive

outcomes. At one extreme, a parent noted ‘‘I’m clearly

hearing at school that he’s become Mr. Popular and every-

body wants to play with him, so there’s a lot more going on in

his social life.’’ More modest gains were made by other

children. For example, a parent reported, ‘‘In grade 2 she

spent a lot of time followingthe popular girls around and they

were bothered by her behavior, whereas this year, she seems

to have more friends.’’ Another parent noted ‘‘she is talking

more in Tae Kwando, playing more with kids at recess.’’ In

contrast, one parent noted that there was ‘‘no improvement in

unstructured settings such as the schoolyard.’’

Children echoed seeing some social improvements out-

side of group. Some children noted that they had better

friendships outside of school after the group. For example,

one child reported ‘‘Playing Tip the Scale and the Friend’s

Scale…where you describe a good friend and a bad friend [was helpful]. Now I just ignore a lot of people who try to

trick me so I have better friends now and I can trust them.

For a while I couldn’t trust my friends because of all the bad

stuff that was happening.’’ Similarly, another child noted:

‘‘I was actually hoping to maybe get along better with

the kids in my class, but unfortunately that didn’t

change. However, I have some girls that I see every

Sunday that I argue with a lot and I’ve actually made

friends with a lot of them now…It helped me to be more positive and showed me ways around our

differences.’’

Mixed results in terms of generalization of social gains

were also found in teachers’ comments. Three of four

teachers noticed significant changes in the children over the

course of the group. For two children, speaking, engaging

in social interactions, and taking social risks was difficult.

Both children were reported by their teachers to have made

gains since participating in the group. Gains reported

included behaviors such as speaking in a voice that could

be heard, responding to questions asked, and playing and

interacting more with peers. Both children were reported to

be happier and more confident, and one child was taking

more of a leadership role and had made more friends at

school. The third child presented with more externalizing

behaviors and greater difficulty with impulse control,

reading social situations, and responding appropriately. Her

teacher also reported significant gains, including being less

disruptive and now more thoughtful and aware of herself.

She noted that she is more relaxed and happy and associ-

ates with peers that are more age-appropriate than before

the group. This child was also reported to be more confi-

dent and to be able to take on a leadership role in helping

teachers with younger students. All of the teachers noted

that, while gains had been made, there was still need for

improvement in a variety of areas, such as initiating con-

versations, reading social behaviors, and developing closer

friendships. It is interesting to note that each of the three

children described as making positive gains were in a small

class educational placement that provided them with high

levels of support and encouragement rather than a regular

stream classroom. It is possible that these class settings

may have similar characteristics to the group therapeutic

environment and may have supported the generalization of

these skills. In contrast, the parent of the child who was not

reported to make significant gains reported that her

daughter has struggled in her school placement and

reported that her child needed more support at school than

she was receiving. Future research is needed that explores

continuity of gains and environmental factors that may

foster generalization and maintenance of social compe-

tence skills.

Processes that support or hinder gains in social compe-

tence were also explored. The results of the qualitative

interviews with parents and children reflected three pri-

mary therapeutic process variables: (1) positive social

experience, (2) assessment process, and (3) ‘in the

moment’ feedback from therapists to encourage risk-taking

and support learning.

864 J Child Fam Stud (2016) 25:856–869

123

Parents and children reported that the social competence

groups were fun and enjoyable, and this helped children

who may have had negative social experiences in the past

to take the risk to come to group. They were engaged and

were able to participate in new activities.

All children and parents reported that they would return

to the group for another session if it was offered and would

recommend it to other children. One parent noted, ‘‘She

seemed happy every time she came out of the room. You

know, a big smile on her face.’’ Similarly, another parent

stated, ‘‘She had a good time. She enjoyed coming. There

was no resistance.’’ Another reported, ‘‘Well, every time

that she would come out she would be bouncing and pos-

itive.’’ The perspective shared by children in the groups

also emphasized the positive and fun nature of group. For

example, comments included ‘‘The girls were nice and we

played fun games’’ and ‘‘the games made it fun.’’ ‘‘Can’t

wait [to attend another SC group series].’’

Having the opportunity to make friends was important to

many of the children with whom we spoke. For example,

one child reported ‘‘Well, I made some new friends and I

hadn’t made friends in a while because I’ve had a couple of

bullying problems at school. I tend to be the one who is

picked on the most out of my class.’’ Parents reported that

being with children with similar challenges in a supportive

environment was important to their child’s success. For

example, one parent noted, ‘‘[Children’s mental health

center] has been good for [my daughter] to understand that

she’s not the only one and that we all have something to

work on.’’ Another parent emphasized the importance of

comfort with other children for engaging in social risk-

taking. ‘‘He has to feel very comfortable and confident with

whomever he’s with to put himself out on that limb

because it is a risk for him.’’

Overall, parents and children liked the pre-group

assessment process and referred to it as ‘‘good practice’’

before the actual group. Parents reported that leaders were

responsive, knowledgeable, and realistic about LDs. It

seemed to be ‘‘grounded in the reality’’ of LD ? MH. One

parent noted about the assessment process ‘‘You can’t just

say it’s a social competency group and here are five girls.

Not everyone needs the same social competencies. And so

while one person needs to learn to [be quiet], another

person may need to learn to talk.’’ Similarly, another parent

noted being pleased that it was ‘‘Ok if it takes a while to

find the words to express yourself.’’

Scaffolding children so that they had to be present with

challenges and not avoid by withdrawing or acting out was

also noted as being an important process. Providing ‘in the

moment feedback’ when challenges arose in the context of

naturally occurring social dynamics allowed group leaders

to create ‘‘teachable moments’’ and gently correct mis-

perceptions or scaffold the child in trying out new ways of

interacting. For example, one parent commented: ‘‘I think

it was great for her to, in a very supportive environment, go

through struggles and learn from those and then be able to

try again, and to do all of those things in that very safe

environment and structure. There’s lots of help there… Here’s a teachable moment and we’re going to do this.’’

Another parent noted, ‘‘She was able to do things like step

up to be the leader, step back to let others lead and then to

get the very quick positive feedback, like very quick bio

feedback from the group, and that’s what she needs.’’

Children similarly reported that experiencing challenges in

the group was helpful. For example, ‘‘now that I faced

some challenges with the group, it’s easier to ignore people

for some reason. I’ve gotten better at doing it with my

brother.’’

Parents and children also provided recommendations for

future groups. They noted that change takes time and that

longer and a greater number of sessions would be helpful.

For example, one parent reported, ‘‘I think she was just

kind of getting into it and then it was done.’’ Parents also

requested more feedback about the groups so that they

know about progress being made and how to help their

child outside of group. For example, ‘‘If there’s something

they [the leaders] noticed in a session, maybe they could

talk to the parent about it.’’

Discussion

Children with LD ? MH are at increased risk for chal-

lenges in social functioning. The present study evaluated

the effectiveness of the Integra Social Competence Group

program, an intervention aimed at ameliorating social

competence in youth with LD ? MH using activities tai-

lored to their specific information processing and emotion

regulation deficits. Using mixed methods, this study

examined social competence both within the group context

(using observational methods) and outside of the group

process to examine gains made and the generalization of

outcomes to home and school settings. Overall, findings

suggest that participating youth and their families benefit-

ted from the program, as evidenced by both group obser-

vations and parent- and child-report.

From a group process perspective, levels of engagement

in the group sessions was observed to be high throughout

treatment, suggesting that the program was acceptable,

engaging, and implemented at a level that supported chil-

dren. Relatedly, the level of social competence challenge in

the context of the assessment was also lower than parent

report levels. Specifically, while 75 % of parents reported

significant social competence challenges, only 30 % of

children were assessed to be of low social competence,

with the remaining 70 % exhibiting medium levels of

J Child Fam Stud (2016) 25:856–869 865

123

social competence. This difference may reflect character-

istics of the group environment (e.g., structure, support,

safety) that allow children to engage more fully and to

exhibit their social strengths that may be less prevalent in

school or community settings.

Further, children were observed to improve their goal-

directed (or on-task) initiation from the beginning to the

end of treatment. For example, children made more

attempts to interact positively with a peer or leader without

being prompted, such as asking questions or making sug-

gestions for the group. Importantly, increases in initiation

were not limited to the group context, but were observed by

parents in contexts outside of the group, in the form of

increased parent-rated social assertion and engagement in

social interactions. Importantly, effect sizes associated with

these outcomes were in the upper end of the small or

moderate range in terms of strength and larger than pre-

vious outcomes which have been small in strength (Forness

and Kavale 1996; Kavale and Mostert 2004). Similarly,

qualitative interviews with both parents and children

highlighted that children improved in their abilities to share

thoughts and feelings, initiate conversation, engage in peer

interaction, and appropriately engage in solving problems

in relationships. Such changes in engagement and initiation

are noteworthy given that children with LD ? MH show a

greater tendency to withdraw from social interactions and

report greater feelings of sadness related to social interac-

tions (Semrud-Clikeman et al. 2010). Remaining present

rather than engaging in patterns of avoidance (fight or

flight) sets an essential foundation that enables children to

practice social skills and develop a sense of competence.

Qualitative interviews with parents and children sug-

gested that the high rates of engagement, improved prob-

lem-solving, and initiation were supported by ‘in the

moment’ coaching and feedback from therapists. Children

and parents noted that they had to engage in skills that were

hard for them but were able to do this with the support of

the group leader and then generalize this to social inter-

actions outside of the group with peers and siblings.

‘In the moment’ feedback served to help children to

become aware of their behavior and to correctly interpret

social-emotional information, which are considered key

skills associated with social competence (McKown et al.

2009). Parents, however, noted that they would benefit

from more session-by-session feedback so that they were

able to provide ‘in the moment’ feedback to their children

and support their social skills. This recommendation has

now been incorporated into the SC Group program.

Interestingly, despite above average levels of internal-

izing and externalizing behavior problems at baseline in

75 % of the participants, the occurrence of negative

behaviors during the SC groups was low throughout

treatment, regardless of initial level of emotion regulation.

This is an important finding because it highlights that

taking emotion regulation into consideration when deter-

mining child placement, group composition, and size can

support emotional and behavioral regulation, enhancing

opportunities for skill- and relationship-building within the

group setting. Further, results suggest that while the SC

Group program does not directly target emotion regulation

as an outcome, there is indirect benefit in fostering higher

levels of regulation, at least within the SC group process. It

may be that children who are in SC groups that are tailored

to their emotion regulation needs may be able to focus

more on skills development and less on behavior man-

agement of group dynamics. Having a safe foundation that

supports emotion regulation may set the stage for learning

and implementing social skills, thus promoting adaptive

social interactions (Dollar and Stifter 2012). These results

are also consistent with previous research that underscores

the contribution of emotion regulation to social compe-

tence (Bauminger et al. 2005; Rydell et al. 2007) and the

potential role of emotion regulation in mediating negative

social behaviors (Dollar and Stifter 2012).

Similar to other intervention studies of social compe-

tence, the current study showed mixed results with regard

to generalizability (Forness and Kavale 1996; Greenberg

et al. 2001; Maag 2006; Schneider et al. 1992). Parents

reported significant gains in social competence from pre- to

post-treatment, with significant gains in overall social skills

and in social skills that are considered to have the highest

association with school success (i.e., Top Ten on SSIS

including following rules, paying attention to instructions,

turn-taking, interacting well with children, showing con-

cern for others, tolerating annoying behavior, and manag-

ing disagreements). Gains were also noted in engagement

and assertion from pre- to post-intervention, results that

mirror the observational outcomes observed in the context

of the SC groups. Qualitative responses of parents, chil-

dren, and some teachers also supported the effectiveness of

the group, suggesting gains in child social self-concept and

initiation in and outside of the group.

In contrast, while positive gains were noted by teachers

in the qualitative interviews, there were no significant

changes in scores on teacher ratings of the SSIS. In part,

this may reflect situational context for the observation of

gains in pro-social behaviors. Teachers may be more likely

to notice aggressive, disruptive, and distractible behaviors

with peers, particularly when the behaviors compete with

attention to instruction and school tasks (Blandon et al.

2010). Moreover, the classroom setting in particular has

been described as ‘‘multifaceted and multi-situational’’

(Goodwin 1999). Lack of social competence can be exac-

erbated by situational factors in the classroom that may not

exist in other situations, such as home (Musser et al. 2001;

Wight and Chapparo 2008) or the SC group setting. Given

866 J Child Fam Stud (2016) 25:856–869

123

the mixed nature of the results reported by teachers, further

investigation of the generalizability of the skills learned in

the SC Group program is warranted. Similarly, it may be

fruitful for future research to study social competence in

children with LDs across a variety of settings (e.g., school,

community) to better understand the processes that support

or hinder the development of social competence across

contexts.

It is interesting to note that teacher interviews suggested

that when the classroom setting was most similar to the

group setting and embodied some of the characteristics

described by children and parents as important (e.g.,

structured, safe, ‘in the moment’ feedback, small class

size), more positive gains were seen. In particular, the

children whose teachers reported social competence gains

during interviews were all enrolled in specialized class-

rooms, with a smaller class size, increased structure and

predictability, and accommodation for the processing and

academic challenges associated with the child’s specific

LD. This finding is consistent with research by Kiuru et al.

(2012) who found that smaller class size offered a pro-

tective factor against peer rejection. Results suggest that

supportive and safe classrooms may function as a moder-

ator for the promotion of generalization of social compe-

tence from the treatment setting to the school setting. This

is an area for future research and may be an important

avenue for enhancing generalization of skills to the school

setting.

Another factor that may impact on outcomes as well as

the potential for generalizability is time in treatment. Par-

ents and children noted that they had made gains, but that

more treatment was needed to reach their social compe-

tence goals. This is consistent with Kavale and Mostert’s

(2004) critical review of social competence programs for

children with LD that suggests that 10 weeks of treatment

may not be enough to improve social skills challenges that

have been longstanding. Similar to learning, more practice

and repetition across different setting characteristics and

partners may be needed to better internalize and generalize

skills.

The current study provides preliminary within-partici-

pant support for the effectiveness of the SC Group pro-

gram. However, further controlled research by independent

researchers is needed to better understand the impact of the

program and child characteristics that may moderate out-

comes. More specifically, research using a randomized

group design is needed that compares the SC Group pro-

gram and its tailoring process to a social competence group

program that does not employ this tailoring approach. A

larger sample is also required to increase statistical power

and to more fully explore moderators of change, such as

gender, presence of internalizing and externalizing behav-

ior challenges, emotion regulation ability, type of LD, level

of cognitive ability, and type of group. Finally, follow-up

assessment to explore the sustainability of gains made, as

well as behavioral observation to examine generalization to

settings such as the classroom or home would increase our

understanding of the impact of the intervention on the

child’s daily living. Further qualitative research with a

larger sample of parents, children, and teachers is also

warranted, given the small sample included in this study

and that those included may have been biased due to self-

selection or case manager selection. This would provide a

more balanced representation of the different types of

social competence groups.

Social competence is an important predictor of future

well-being (Holopainen et al. 2012). Children with LDs

and impairments in emotion regulation have more diffi-

culty than typically-developing youth in acquiring social

competence. Results of this study suggest that improve-

ments in initiating, taking social risks, and engaging suc-

cessfully in conversations can be achieved by applying a

multi-dimensional view of social competence that addres-

ses three key areas: skills (i.e., behavioral, social-cognitive,

and social emotional depending on the specific needs of the

child and group as a whole); emotion regulation abilities

(provision of ‘in the moment’ feedback); and environ-

mental factors (e.g., by adapting amount of structure, group

size and composition based on skills and emotion regula-

tion abilities). These elements are all critical components

of socially competent behavior. Providing children with

LD ? MH with a positive and engaging structured social

experience may change their trajectory of social compe-

tence development from a negative spiral of withdrawal

and social isolation into empowerment and engagement.

This may enable children to more effectively stand up for

themselves or others, ask for help, and express their feel-

ings when wronged, thereby decreasing risk of victimiza-

tion and placing them on more positive trajectories of

social functioning and mental health.

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