DESCRIPTION OF THE STRATEGY

Interpersonal difficulties are considered one of the hallmark qualities of children with
attention-deficit/hyperactivity disorder (ADHD), oppositional defiant disorder (ODD), and
conduct disorder (CD). Children with these disorders, collectively referred to as externalizing
disorders, are rated more negatively by peers on sociometric measures and are more likely to
experience peer rejection. Thus, peer relationships are an important target of comprehensive
treatment for externalizing disorders. For over 30 years, researchers have investigated and
disseminated treatment packages targeting the social competence of children with
externalizing disorders. Social competence treatments (SCT) for these children focus on
teaching and reinforcing the use of adaptive social skills and social problem-solving strategies
during interactions with peers and adults across settings. Two broad classes of SCT for
children with externalizing disorders include social skills training (SST) and social problemsolving training (SPST).
SST interventions aim to remediate the basic social skills knowledge and performance deficits
of children with externalizing disorders by teaching and reinforcing the use of appropriate
social skills (e.g., communication, cooperation, participation, validation) during interactions
with peers and adults. The rationale for this approach is based on literature suggesting that (a)
deficits in social skill knowledge and application underlie the social incompetence of children
with externalizing disorders and (b) social skills can be learned through instruction and
practice.
In contrast with SST, SPST focuses on modifying deficits in social cognitive processes (e.g.,
encoding and interpreting social cues, social problem solving) that have been shown to
mediate the inappropriate social behavior of children with externalizing disorders. SPST
interventions teach children with externalizing disorders to (a) recognize errors in their social
information processing, (b) cope with stressful interactions using self-talk and perspective
taking strategies, and (c) utilize more appropriate problem-solving strategies when conflicts
arise with others. For example, anger coping programs were developed from the theory that
anger-eliciting stimuli are not the cause or sole determinant of aggressive responses. Rather,
children may respond aggressively to perceived provocation by peers because they
misperceive the stimuli (e.g., inaccurately attributing hostile intent to others) and utilize
immature coping strategies (e.g., aggression) to control their responses to the stimuli. Taking
an alternative approach, problem-solving skills programs focus on deficits in social problem
solving and teach children to identify the problem, generate multiple solutions, evaluate
alternatives, and select adaptive solutions. In sum, anger coping and problem-solving
interventions focus on teaching children with externalizing problems to recognize their
cognitive biases and to utilize coping and problem-solving strategies that facilitate more
appropriate responses to others.
SST and SPST programs for children with externalizing disorders tend to include most, if not
all, of the following instructional components to develop and reinforce knowledge and use of
proper social skills and social problem-solving strategies: didactic instruction, group
discussion, role play, modeling, in vivo play experience, coaching, social reinforcement,
contingency management, and homework. Teachers or therapists implementing SST or SPST
programs use didactic instruction to introduce a social skill or problem-solving strategy by
describing the skill and providing multiple examples. To illustrate, a typical SST session
might begin with the therapist defining cooperation and providing examples of how children
can cooperate with others at home, school, and on the playground. The therapist also engages

the children in a discussion regarding the importance of the skill and further elicits examples
from the children about how the skill can be used in interactions with others.
Role play is used to model both positive and negative examples of the social skill or social
problemsolving strategy. For example, the therapist might role-play with a coleader or a child
an example of participation by describing and acting out a scenario in which children actively
and appropriately participate in a board game. Role play is a useful technique for describing
visually what is meant by a particular skill, demonstrating how to use a particular skill in a
reallife context, and to further elicit discussion among the children.
Social skills and social problem-solving strategies are also taught to the children via
modeling. For example, group leaders model proper use of social skills during all of their
interactions with one another and the children. By modeling skills taught during the session
(e.g., cooperating with children by following the rules of a board game), therapists provide the
children with multiple opportunities to learn by watching others apply the skills. In addition to
therapist modeling, skills taught in SPST programs are often modeled in videotaped vignettes
or through the use of puppets. The videotaped vignettes depict several positive and negative
examples of children using each of the social skills and social problem-solving strategies
taught during treatment sessions. The vignettes are used to generate discussion among the
children regarding how the skills presented in the videotapes may generalize to situations in
their own lives. Puppets are particularly effective to teach skills, generate group discussion,
and reinforce the use of skills during sessions of SPST programs with younger children.
Two important components of SCT programs, particularly SST, are coaching and social
reinforcement. Following a brief group discussion, therapists may utilize the majority of time
coaching each child or groups of children on the use of appropriate social skills during
ecologically valid, in vivo play activities (e.g., board games, sports). Coaching is used to
prompt children to use the social skills presented during the initial group discussion. Coaching
allows group leaders to tailor SST to address the individual needs of each child in a group.
Social reinforcement and contingency management are used in conjunction with coaching to
provide immediate feedback to children regarding their social behavior in the context in
which it occurs. For example, therapists may provide praise, privileges, and/or tangible prizes
to children who use social skills and give neutral feedback and/or remove privileges or
rewards from children who exhibit negative social behaviors. Many researchers believe that
social reinforcement and contingency management are essential components of SST,
suggesting that without it, children would not otherwise be motivated to change their social
behavior. Moreover, gains in social competence may only generalize beyond the treatment
setting if important adults (e.g., parents, teachers) in the child's environment model and
consistently reinforce socially appropriate behavior.
In addition, homework assignments are given to children in both SST and SPST programs to
encourage using the social skills and social problem-solving strategies at home, school, and
other social settings. Both programs place an emphasis on assigning and reviewing homework
because these assignments encourage children to practice the skills taught through experience
in situations beyond the treatment session. SCT homework assignments sometimes require
parents and teachers to track the frequency of positive and negative social behaviors and to
provide reinforcement for the children's use of adaptive social and social problem-solving
skills at home and at school. Tracking is used to monitor the children's progress toward

reaching attainable goals for social behavior across settings and to encourage parental and
teacher involvement in the treatment.
Aside from the differences in theory and treatment focus between SST and SPST, the methods
used by SST and SPST programs to treat the social impairments of children with externalizing
disorders largely overlap. The only significant difference between SST and SPST programs
used to treat children with externalizing disorders is the length of treatment. Although both
programs typically include 1 weekly session lasting from 60 to 120 minutes, SPST programs
generally range in length from 12 to 24 sessions, while SST programs typically include 8 to
12 sessions.

RESEARCH BASIS
A recent meta-analytic review assessing the overall efficacy of SCT for children with social
impairments found the effects of SCT on posttreatment parent and teacher ratings of child
social impairment to be small in magnitude (d = 0.199). Similarly, an earlier metaanalysis of
SCT interventions concluded that children viewed as most needing the treatment (i.e.,
children with externalizing disorders) were the least likely to respond favorably, based on
parent and teacher ratings of social behavior. Moreover, studies suggesting significant postSCT improvement in social skills or social problem solving often do not assess for longterm
maintenance of gains in social functioning. Thus, evidence supporting the use of SCT for
children with social impairment, particularly children with externalizing behavior disorders, is
mixed at best.
Two newly developed, multimodal SST interventions for children with ADHD and ODD have
demonstrated stronger treatment effects across home and school settings than those reported
in the meta-analyses referred to previously. For both of these SST interventions, a parent
group met concurrently to discuss ways to reinforce their child's use of appropriate social
skills in order to maintain treatment gains over time and across settings. Relative to a SSTonly group and a waitlist control group, both studies reported that children with ADHD and
ODD in the SST + parental involvement condition demonstrated moderate to very large
effects on parent and teacher reports of social skills knowledge, social skills performance, and
overall behavior. Thus, teaching and encouraging parents to reinforce their child's use of
appropriate social skills appears to result in larger improvements in the social behavior of
children with externalizing disorders than those achieved with SST-only interventions.
Similarly, research has also examined the incremental benefit of adding parent involvement to
SPST interventions for children with externalizing disorders. One well-controlled study
suggests that children with ODD and CD randomly assigned to an SPST intervention with
concurrent behavioral parent training exhibited significantly greater improvements in social
skill performance, social problem solving, and overall behavior as rated by parents and
teachers at postintervention and 1-year follow-up compared to children who received SPST
alone or children whose parents received BPT only. In sum, results of these studies support
the utility of combining SST or SPST with parental involvement and reinforcement to
enhance the effects of these interventions on the social behavior of children with ADHD,
ODD, and/or CD.
Intensive, multimodal programs such as the summer treatment program (STP) were developed
specifically to address the peer difficulties experienced by children with externalizing
disorders, particularly ADHD. The STP includes both SST and SPST components that are

practiced, modeled, and reinforced in the context of ecologically valid activities, including
academic classrooms and recreational settings. Parents and community school teachers are
also instructed to provide instruction and reinforcement for use of appropriate social and
social problem-solving skills in the home and school settings in order to enhance maintenance
and generalization of the intensive 8-week program. Many studies have demonstrated very
large effects of the STP on measures of the social functioning of children with externalizing
disorders. The magnitude of these effects far exceeds those that have been documented using
traditional clinic-based approaches. However, to date, no study has specifically dismantled
this program to evaluate the incremental benefit of SST and SPST components.

RELEVANT TARGET POPULATIONS AND

EXCEPTIONS
The behavioral excesses of children diagnosed with ADHD, ODD, and CD are often
associated with profound impairments in their social functioning. Research suggests that
school-age children presenting with problems of inattention, hyperactivity, impulsivity, adultdirected defiance, aggression, and other conduct problems often have pervasive social skills
knowledge and performance deficits and are likely to be disliked and rejected by their peers.
Knowledge of the degree and pervasiveness of the social problems for children with ADHD,
ODD, and CD is concerning, because research has shown that children with poor peer
relations, especially those with externalizing behavior problems, are at a significant risk for
continued interpersonal difficulties and other social problems as adolescents (e.g., dropping
out of school, juvenile delinquency) and adults (e.g., being laid off from work, imprisonment).

COMPLICATIONS
Although intervening at an early age appears crucial, equally as important, if not more
important, is choosing an SCT program that is developmentally appropriate for the child. In
order for children to demonstrate improved social behavior as a result of SCT, skills must be
transmitted to children in a manner that is easily comprehendible and affords them the
opportunity to practice the skills in relevant social contexts. Thus, considering the multitude
of SCT programs available, it is important to choose one that best fits the developmental level
and presenting problems of the child.
Moreover, because social impairment is chronic, treatment should also be chronic. Owing to
the prevailing thought in the SCT literature that insufficient positive reinforcement across
settings contributes to the chronic social impairment of children with ADHD, ODD, and CD,
current research emphasizes the need to incorporate parents and teachers as reinforcing agents
for social behavior at home and school in order to facilitate generalized effects across these
settings. Current and future research in this area is exploring the benefit of using siblings and
peers at school as agents of change for social behavior of children with externalizing
disorders.

CASE ILLUSTRATION
Ten children were referred by their mothers to participate in an SST program conducted at a
university ADHD clinic in the spring of 2002. The children were largely comprised of
Caucasian (60%) males (80%) between the ages of 6 and 12 (M = 9) from middle-class

households (M family income = $31,500). Each of the children presented with social behavior
problems across settings with peers and adults. A multiinformant (e.g., parent and teacher),
multimethod (e.g., questionnaires, semistructured interview) assessment was used to examine
whether children met criteria for ADHD, ODD, and CD and the degree to which their
behavioral excesses resulted in social impairment across multiple settings. Based on this
assessment, all children met DSM-IV criteria for ADHD; 60% were diagnosed with comorbid
ODD and 20% were diagnosed with CD.Fifty percent of the children were prescribed
stimulant medication to help manage their ADHD symptoms.
The SST program in which these children were enrolled met weekly for eight 2-hour sessions.
Each session included 15 to 20 minutes of didactic instruction by a therapist, group
discussion, and instructor-led role play to improve the children's knowledge of how to listen
to others, compliment others, help, share, follow directions, ignore provocation, and make
appropriate complaints. During the next 60 minutes of each session, children were coached by
the therapist to use skills taught during interactions with children while playing board games.
Social reinforcement (i.e., praise) was used to reward children for actively participating in
group discussions and for using good social skills with children during the board game
activities. A response-cost contingency management system was used to manage the rate of
negative behaviors (e.g., disrespect toward others, disobedience) exhibited by children during
the sessions. Children exhibiting negative behaviors lost points for each negative behavior.
Children who lost fewer than a predetermined number of points were rewarded with 15
minutes of computer time at the end of each session. Children who exceeded the set number
of points were not permitted to use the computer and instead spent the time writing down
ways they could use good social skills at home and at school during the upcoming week.
Consistent with literature supporting the incremental benefit of parent involvement in social
skills programs, mothers participated in a concurrent group that focused on reinforcing their
children's use of social skills at home and school.
Changes in social skill knowledge and performance were assessed using (a) child-reports of
their use of social skills in hypothetical situations in which they were asked to solve a
problem with peers, siblings, and adults and (b) parent-report questionnaires assessing rates of
social skill performance at home and with peers. In addition, mothers were asked to report
posttreatment changes in social impairment with peers and rates of being ignored and rejected
by peers. Mothers reported improvements in child cooperation at home and social impairment
with peers. Moreover, children demonstrated improvement in using positive social behaviors
to solve problems with siblings, peers, and adults. To enhance generalization of these gains to
other settings in which these children experience social impairment, it is recommended that
teachers, coaches, scout leaders, and other adults be trained in behavioral principles so that
they may also reinforce appropriate social behavior.
Brian T. Wymbs and Andrea M. Chronis
Further Reading

Entry Citation:
Wymbs, Brian T., and Andrea M. Chronis. "Social Competence Treatment." Encyclopedia of
Behavior Modification and Cognitive Behavior Therapy. 2007. SAGE Publications. 15 Apr.
2008. <http://sage-ereference.com/cbt/Article_n2120.html>.