The Effectiveness of Social Skills Training (SST)
A Pilot Study
Meghan M. Dwyer
social skills training (SST); social skills
I would like to thank all those who have helped
me through my thesis.
First, I would like to thank my supporting family who continued to ask
and encourage me about my thesis. To all of my friends,
Shells, my roommates Kate, Ronnie, and Liz, and my psychology buddies
and Hannah, thanks for your support and
Without the help of my psychology professors, I would never have
the value of research and scientific inquiry. Thank you to
Troisi and Profossor Ossoff, without your help I would not have known
to write a thesis.
A special thank you to Dr. Monarch who gave me the opportunity to work in a clinical setting and to use the children as the participants in this experiment. Dr. Monarch deserves special thanks for helping me through the different stages of the thesis, from the research question to the final editing. My co-workers Lea Lockwood and Colette Salvas deserve recognition for their guidance through the process as well. I have enjoyed each stage of this journey. Thank you for all of your support.
Socially disadvantaged children have higher rates of
maladjustment, including anxiety and mood disorders. However,
skills training (SST) effectiveness studies rarely investigate
adjustment. Prior to participation and following completion of a
SST program, socially disadvantaged children (n=12) and their parents
questionnaires regarding the participants’ psychological adjustment.
SST program included 12 hours of intensive verbal and nonverbal
training. Results indicated significant decreases in
distress including less anxiety and depression. The findings
that SST may improve the psychological well-being of socially-rejected
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Many children and adolescents experience
difficulties throughout development. Those with additional
such as learning, behavioral, or emotional disabilities, or ADHD,
or anxiety are at a particular disadvantage in terms of gaining social
competence. The literature suggests that such children display
positive social behaviors, lower rates of reinforcement and cooperation
with peers, and less initiative interacting with peers. Even in
absence of disabilities, however, some children are socially
Socially disadvantaged children have higher rates of anxiety and mood
loneliness, delinquency, aggression, and academic
Unfortunately, early social problems often endure through the lifespan
and in adulthood can lead to higher rates of job unemployment, more
conflicts and even higher risk of suicide (Bagwell, Molina, Pelham,
Previous research has indicated that social skill deficits are predictive of later maladjustment. Namely, the literature has focused on the association between peer rejection and lack of social skills with externalizing outcomes such as rule breaking behavior, hostility, delinquency, and aggression (Bagwell, Molina, Pelham, & Hoza, 2001). Hymel, Rubin, Rowden, and LeMare (1990) conducted a longitudinal study to investigate whether social skill deficits would predict externalizing and internalizing problems three years later. Prior to this investigation, virtually no studies examined internalizing difficulties such as anxiety, depression, and withdrawn behaviors. The hypothesis of this study was that children who are rejected by peers would recognize their peer status and as a result internalizing problems would become present. The findings of this study were consistent with previous research; that is, a link was found between peer rejection and externalizing difficulties such as aggression. In addition, peers significantly related internalizing problems to early social difficulties, particularly social isolation, social incompetence, and poor acceptance. The current study is an investigation of both internalizing disorders such as anxiety and depression as well as externalizing disorders such as rule breaking and attentional problems. Thus social difficulties may be a risk factor in development. Fortunately, there are methods to assist children with low social competence.
Remediation for children with low social competence has come in the form of individual counseling, psychotropic medications or, more recently, social skills training (SST). Social skills are overt nonverbal (e.g., eye contact) and verbal (e.g., introducing yourself) interpersonal skills that maximize social engagement. They are socially accepted, learned behaviors that enable one to interact with others in ways that elicit positive responses, avoid negative responses and serve as the basis for social competence (Hops, 1983). According to Gresham (2004), who reviewed six meta-analyses, social skills training (SST) programs have a 64% improvement rate. Gresham (2004) noted, however, that, for the most part, SST programs are prototypical commercial programs that do not assess participants prior to treatment. The current study sought to evaluate the treatment effects of a novel SST program that incorporated information gathered from a pre-treatment evaluation. In addition, in contrast to other SST outcome studies, the current study sought to evaluate the relationship between pre-treatment psychological adjustment and post-treatment psychological adjustment with both internalizing and externalizing functioning. In contrast to other studies, the current study examined pre and post parent ratings of specific social skills. Additionally, the current investigation examined overall functioning through parent and child responses before and after treatment. The study also examined pre and posttests on nonverbal cues of participants. Lastly, the study examined satisfaction of the SST program and how well the program met the needs for the individual children.
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Social Skills Comorbidity
In the current study nine of twelve children (75%) possess another disability. Which, according to the literature, may put children at risk for greater social skills difficulties. The literature suggests that children with learning disabilities, both verbal and nonverbal are at a greater risk for social skills deficits (Kavale & Forness, 1996). Additionally Kavale and Forness (1996) found evidence for the trimorbidity hypothesis, that is a relationship among social deficits, learning disabilities, and psychiatric conditions (such as depression). The current study employs this suggestion of assessment of psychiatric conditions, specifically examining depression and anxiety, as well as examing attentional difficulties.
In addition to learning disabilities, children with ADHD are at a higher risk for a number of social deficits and have difficulty interpreting their own social abilities (Deiner & Milich, 1997). Difficulties children with ADHD have with their peers are often such profound problems that investigators have argued that the phenomena of disturbed peer relations itself should be a defining characteristic of the disorder (Landau & Moore, 1991). ADHD is frequently comorbid with other disorders including mood and anxiety disorders. Co-occurring psychiatric conditions are believed to range from 9% to one-third of children with ADHD in a primary care setting. Within a referred population, the prevalence of comorbidity is about 33% (Brown & LaRosa, 2002). As we have seen, SST evaluations rarely account for comorbidity as an important criterion variable. Constructs of anxiety and depression are important and research by Segrin (2000) and Karutis, Power, Rescorla, Eiraldi, and Gallagher (2000) have shown there is a correlation between these constructs and social skills.
Unfortunately, poor social skills are often comorbid with ADHD, LDs, depression, and anxiety. SST programs seek to provide children with social skills that will serve as a buffer against other difficulties they may face. If a child possesses social skills and social competence, the hope is that psychiatric problems, attention problems, and academic problems will decrease. Thus, one of the objectives of current study is to determine if social skills training will have an impact on anxiety and depression. Based on Segrin (2000) and Karutis et al. (2000)’s findings, the hypothesis of the current study states that SST will have an effect on changing children’s levels of depression and anxiety if the social skills treatment is effective.
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Social Skills Training
SST can utilize operant, social learning, and cognitive-behavioral approaches as well as a combination of the approaches. Operant learning procedures focus on overt, observable behavior. The current SST program under investigation focuses on overt observable behaviors. The SST program teaches the kids both verbal and nonverbal behaviors. Included in observable verbal behaviors include introducing oneself, starting a conversation, asking relevant questions to show one is listening, ending a conversation, calling a friend, complimenting, and being assertive. The SST program also includes nonverbal observable behaviors such as eye contact and posture.
Operant intervention is at work when SST instructors give children the opportunity to work together. The current study allows the SST group to form their own identity by establishing a team name, competing with other SST teams, and are given free time to work and play together. Thus, the environment allows the children to practice the skills. In the current study, the SST intervention relies heavily upon operant learning principles of positive reinforcement and constructive feedback (rather then punishment) to shape behavior. In SST both instructors and children are capable of being models. In the SST under investigation, peers and coaches become models and the entire group is encouraged to give feedback to one another.
Problem behaviors may affect social difficulties, yet for the most part social difficulties can stem from performance deficits, not being able to implement the social skills, or skill deficit, that is not recognizing or knowing the skill (Gresham, 2004). Due to the nature and complexity of social difficulties, there is the notion that perhaps it is best not to apply standardized SST programs. In all likelihood, individual children vary in the degree to which skill remediation or performance motivation will be helpful. Therefore, SST must emphasize the need for tailoring intervention to fit the individual (Pfiffner, Calzada, & McBurnett, 2000). Most SST programs do not tailor fit the individual; rather, a one-size fits all approach is used. As Gresham (2004) vividly illustrates the prototypical SST programs “round up the usual suspects” and put them in a social skills group and teach them behaviors whether they need it or not.
The current study evaluates children in an in-depth assessment prior to treatment. In addition, participants are matched according to their needs with similar peers. SST groups are not established unless the group members are similar in their social deficits, strengths, age, and general intellectual functioning. The efficacy of SST programs are equivocal. One begins to wonder if the equivocal results are caused by the universal assumption that all children benefit from the same intervention.
Despite some initially reported positive outcomes (Kendall & Braswell, 1982) some researchers believe SST programs have failed to demonstrate efficacy in remediating social skills deficits in children with ADHD (Abikoff, 1985). However, the most recent article to date (Gresham, 2004) reviewed six meta-analyses of social skills training with over 25,000 children between the ages of 3 and 18. The internal validity of the meta-analyses reveals that there is a 64% improvement rate relative to controls using the binomial effect size display. The 64% success of SST is significant because it is almost identical to the meta-analytic findings of the effects of psychotherapy with children and adolescents. the external validity of Gresham’s large meta-analysis demonstrated that SST is effective across a broad range of behavioral difficulties including aggression, externalizing behaviors, internalizing behaviors, and antisocial behavior.
The objective of the current study is to examine if there is a change in overall functioning for children participating in SST programs. The external validity of Gresham’s large meta-analysis demonstrated that SST is effective across a broad range of behavioral difficulties including aggression, externalizing behaviors, internalizing behaviors, and antisocial behavior. It is predicted that this finding in the large meta-analysis will occur in the current study.
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Participants were drawn from a series of children receiving SST at a private practice. Twelve children (7 girls, 5 boys) aged 8-16 (mean age=12.42, SD=2.50), and their parents completed questionnaires. Seven children declined to participate in the study. The children and parents who agreed to participate were Caucasian middle class (83%)with the exception of one parent and child of Indian (8.3%)and one parent and child of Asian background (8.3%). Half (n= 6) of the children in the current study have been diagnosed with ADHD. Thirty-three percent (n=4) on the children had been diagnosed with LD; sixteen percent (n=2) with a nonverbal learning disability and sixteen percent (n=2) with a verbal learning disability. Twenty five percent (n=3) possess traits of Aspergers. Participants were given the opportunity for free twenty-minute feedback sessions with a clinical psychologist for completing post paperwork. Eleven sent the questionnaires back in the mail (57.9%), eight parents came into the office for feedback (42.1%) and seven parents and children declined to participate (36.8%).
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Child Behavior Checklist (CBCL; Achenbach, 1991) see Appendix A
The Youth Self-Report (YSR; Achenbach, 1991) see Appendix B
Child Depression Inventory (CDI; Kovacs, 1992) see Appendix C
Multidimensional Anxiety Scale for Children (MASC; March, 1998) see Appendix D
Questionnaire see Appendix E
As part of an administered screening, participant’s mood and behavior were evaluated. Participants then engaged in a four-day intensive social skills workshop with approximately four other peers. Patients were then given a cover letter describing the research (see Appendix F). With signed informed consent (see Appendix G), participants were able to mail in posttest surveys. Participants were given free twenty-minute feedback from a licensed clinical psychologist on their child’s progress in SST intervention. Parents were sent a final reminder in the mail (see Appendix H ) that this was the last opportunity to participate in the study and detailing when the last open office hours were available. The Institutional Review Board and the American Psychological Association Code of Ethics have approved this study.
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Children received three-hour sessions consecutively for four days during the summer of 2004. There were five small groups in SST. The same two therapists taught sessions for the small groups for a week. One therapist is an undergraduate, one has a bachelor’s, one has a master’s, and one is a licensed doctoral level psychologist. The therapists engaged in training to ensure standardization. The leaders taught skill modules using didactic instruction, in vivo modeling, role-playing, rehearsal, and feedback.
Each skill was presented to the group through didactic styles. Leaders then reviewed how, when, where, and why to use the skill with peers. Leaders modeled the skill extensively and children then role played the positive use of the skill with another child in the group. Children were then provided with both positive and constructve feedback from leaders and peers. Typically four to five skills were taught to the group in a day and were reinforced throughout all sessions. Two weeks after the sessions, parents were invited to a meeting to review how to generalize the specific skills at home and in school settings.
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In comparison to reports on pre-treatment
on post-treatment questionnaires, the children rated themselves as
less anxious (t(6)=4.26, p<.05), less on the anxiety disorder
(4)=3.23, p<.05), less withdrawn (t (6)=2.63, p<.05), less
(t(6) = 3.10, p<.05), possessing fewer social problems (t (6)= 2.90
, p<.05), less externalizing (behavior) problems (t(6)= 4.733,
and having fewer total problems (t(6)=3.121, p<.05).
Ratings by parents followed a similar pattern with parents rating their
as significantly less withdrawn (t (10)= 2.85, p<. 05), having fewer
internalizing symptoms (t (10)= 2.79, p<.05), and having a
significant improvement in externalizing symptoms (t (10)= 2.18, p=
The change from pre to post measurement for all the subscales of the Children’s Depression Inventory, Multidimensional Anxiety Scale, Youth Self Report, and Child Behavior Checklist was in the predicted direction. The means for all subscales were lower on post measures, although not significant.
The parents reported an increase in their child’s use of social skills as compared to before the program with both friends and parents. Parents reported that their children need reminders and support to implement social skills. This questionnaire also examined generalization; 83.4% of parents reported “somewhat”, “most”, or “full” generalization of the program. Seventy-five percent of parents noticed “somewhat”, “most”, or “full”improvement in their child’s relationships. Eighty three percent of parents said they were “mostly” or “fully” satisfied with the social skills program. Ninety one percent of parents reported that the program “somewhat”, “mostly”, or “fully” met their personal goals for their child.
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The literature identifies a relationship between
social skills and psychiatric factors (Kavale & Forness,
2000; Karutis et al. 2000).The stated hypothesis for the current
was that acquisition of social skills in this SST program would result
in decreased symptoms of anxiety and depression. Results of this
study suggest that SST did have a positive effect on the psychological
adjustment of children with low social competence.Specifically, these
behaviors (anxiety and depression) were significantly decreased on
measures rated by both the children and parents.
Both children and parents reported significant differences in withdrawn behaviors on posttest measures following participation in SST. This is an important finding in current study because not only did the children report feeling significantly less withdrawn the parents reported identical findings. Being less withdrawn enables children to try out new things, engage in novel social interactions, and affords them the opportunity to use their new social skills.Being less withdrawn is a positive sign that children may be ready to use their new social skills and build new friendships.
In addition to internalizing problems (anxiety and depression), Gresham’s large meta-analysis (2004) supported the external validity of SST as effective across a broad range of behavioral difficulties including aggression, externalizing behaviors, and antisocial behavior. It was predicted the current study would replicate these findings. The current study did support this hypothesis with parent responses on the CBCL significantlyindicating children were less withdrawn, had fewer internalizing symptoms (depression and anxiety), and having a marginally significant improvement in externalizing symptoms (rule breaking behavior, attention problems) from posttest to pretest. The children rated themselves as significantly less anxious, less withdrawn, and less aggressive, and as having fewer total problems.It is important that future research continue to investigate and support the external validity of SST programs.If internalizing, externalizing, and total problems are decreased as a result of participation in SST, children are more likely to make and maintain friendships, a factor that is associated with positive long-term consequences.
The significant positive results of this pilot study are encouraging. The study reported significant decrease of internalizing, externalizing, and total problems as reported from both children and parents. Parents also reported satisfaction with the program and that the program did in fact tailor to fit the individual child; specificically, 91% of parents reported the program “somewhat”, “mostly”, or “fully” me their personal goals for their child. These results are especially encouraging considering the SST program was only a 12-hour intervention and in light of the fact the children were experiencing much distress prior to SST (marked distress on pretests and comorbidity).
Methodologically, the length of time between pre and posttest for each individual child varied. Although, on average, only 2 months passed between pre- and post- measurement, the effects of maturation could account for the positive results obtained in this study. The positive results in the study could also be accounted for placebo effect for the children and adults were aware of the purpose of the study and thus could have reported false positive effects. Consent forms and questionnaires were in a packet for the children and parent to complete and mail back to the office.Because these questionnaires were sent home with the parents, there was little control over the environment in which the questionnaires were completed.The current study did not control for such outside influence and thus this is a threat to the internal validity of the current investigation.
A great strength of this study is that both parent and child questionnaires were administered. Thus, enabling children and parent ratings to be examined independently and examined for corroboration. However, this required the use of additional questionnaires. Attrition may have minimized if fewer instruments were used. Yet this would be at the cost of receiving additional and informative data.The attrition of seven children and parents who did not complete posttests measures is also a threat to the internal validity of the study. The attrition affected the sample size.The small sample size did not allow for adequate statistical power; therefore, there may have been differences that were not detected.Shortcomings of this pre-post study include small sample size and lack of a comparison group. Future research should employ a control group of children on a waiting list who do not receive SST treatment. This group would control for the confounding variables of placebo effects and maturation.
Although there were limitations in the current study, there is importance in and implications of the results that were found.There are a number of goals for SST programs.The main goal is for children to acquire social competence.A secondary goal of SST, which effectiveness studies often neglect, is for the individual child to improve in psychological adjustment.Very few studies on the effectiveness of SST have examined the degree to which psychological adjustment (or internalizing problems) may change as a result of participation in a SST program as the present study did. Although the direction of the relationship between social skills deficits and psychological adjustment has not yet been established it has been hypothesized in the literature that acquisition of social skills and competence may increase psychological functioning.The current pilot study is important to increasing considerations for psychological variables in the future. If future studies were to continue to support the comobidity of social skills deficits and difficulty with psychological functioning, SST may assist more children in remediation of both social skills deficits and psychological problems.
An important conclusion can be drawn from this pilot study: some of the suffering these children experience appears to be alleviated.Being significantly less anxious, withdrawn, and posessing fewer internalizing, externalizing and total problems means the child is suffering less. These findings suggest that SST can have positive effects socially and in overall functioning of children.
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