Evaluation of a School-Based Social Skills Program for Children With Attention-Deficit/Hyperactivity Disorder

Abstract

Attention-Deficit/Hyperactivity Disorder (ADHD) is prevalent among school-aged children. An associated feature of the disorder is a deficit in social functioning, which can be detrimental in terms of long-term outcomes. Therefore, it is crucial to identify evidence-based interventions which can improve the social skills of children with ADHD. The current study was an evaluation of a school-based social skills training program, called Working Together: Building Children's Social Skills Through Folk Literature. The modified version of the program with generalization enhancers was delivered in three schools to 16 children over a 10-week period. Results indicated that this program was effective for improving social skills in children with ADHD, particularly for children with poor pragmatic language skills.

KEYWORDS:

• ADHD
• group intervention
• pragmatic language
• social skills

Positive social interactions play a vital role in a child's development. Many studies have demonstrated that children who fail to develop adequate social skills are more likely to have problems with long-term adjustment, mental health, and delinquency (e.g., Asher & Wheeler, 1985; Nijmeijer et al., 2008). Children with Attention-Deficit/Hyperactivity Disorder (ADHD), which is characterized by severe, persistent, and developmentally inappropriate levels of inattention, and/or hyperactivity and impulsivity, often evidence deficits in social functioning (DuPaul & Weyandt, 2006; Stormont, 2001).

Although social problems in children with ADHD have been considered a result of a performance deficit (i.e., not applying the skills that they have; Barkley, 2004; Nijmeijer et al., 2008), there is some evidence that these children may also have some specific skill deficits in their knowledge of appropriate social behavior (Grenell, Glass, & Katz, 1987). Also, children with ADHD have been shown to have emotional recognition deficits (Kats-Gold, Besser, & Priel, 2007), overestimate their social abilities (Diener & Milich, 1997), and have an exaggerated perception of how well they are liked by others (Hoza et al., 2004).

Several authors have noted that children with ADHD have problems specifically with their pragmatic (i.e., conversational) language abilities (Bruce, Thernlund, & Nettelbladt, 2006; Guerts et al., 2004; Kim & Kaiser, 2000). Camarata and Gibson (1999) theorized that poor pragmatic language skills may be one of the reasons children with ADHD experience such a high rate of social problems. The symptoms of ADHD are thought to interfere with pragmatic language ability in several ways. For example, inattentiveness may cause a failure to stay on topic, an inability to follow appropriate turn-taking in conversation, and can cause the child to miss nonverbal cues; whereas hyperactive and impulsive symptoms may cause excessive talking, interrupting conversations, and blurting out answers (Bruce et al., 2006; Camarata & Gibson, 1999). This relationship, although clinically intuitive, has not received much research attention.

Given the high prevalence of children with ADHD and the growing awareness of the lasting detrimental effects that social problems can have on a child, it is not surprising that a large number of Social Skills Training (SST) programs have been designed to improve the social functioning of children with ADHD. Empirical support for the effectiveness of these programs, however, has been mixed (Antshel & Barkley, 2008). The main concern with SST is a lack of generalization to natural settings and difficulty with maintenance of the results (DuPaul & Weyandt, 2006; Pfiffner, Calzada, & McBurnett, 2000). However, a recent review by de Boo and Prins (2007) highlights the potential of SST to be effective in treating social skills deficits in children with ADHD. For example, when Pfiffner and McBurnett (1997) included parents who provided reinforcement outside the training session and across contexts, they found that SST was successful in achieving significant and lasting improvements in parent reports of social interaction and home behavior problems for children with ADHD.

Other issues that potentially interfere with the generalizability of SST are the location of treatment and the group composition. Specifically, many of these studies have been clinic based and delivered to groups of children who had not been previously acquainted with each other. This setup might not have allowed them to apply learned skills in their daily interactions. Administering SST in a more natural setting—such as school, where children are learning new social skills with their classmates—may increase the likelihood that these skills will be practiced and reinforced outside of the treatment setting (DuPaul & Weyandt, 2006).

A program which we thought had potential for this purpose was Working Together: Building Children's Social Skills Through Folk Literature (Cartledge & Kleefeld, 1994). This program has been used clinically, and although there is little empirical research support for the program's effectiveness, there are numerous teacher and parent anecdotal reports which have attested to the perceived benefits children experienced as a result of this intervention. Although the effectiveness of this program for children with ADHD has not yet been established, the program has been found to reduce antisocial behaviors in students at risk for emotional and behavioral disorders (Ya-Yu, Loe, & Cartledge, 2002). Furthermore, an earlier version of the program (Taking Part: Introducing Social Skills) was found to be effective in reducing students' aggressive behaviors (Middleton & Cartledge, 1995).

The Working Together program was thought to be an ideal intervention for children with ADHD, as it is deliverable in a natural setting (school), focuses on both skill development and performance of the skills, and is a flexible program in terms of the selection of skills that are taught and practiced (e.g., pragmatic language). Since the generalization of social skills across settings has been repeatedly highlighted as a challenge to the effectiveness of SST, the current study modified the Working Together program so that parents and teachers were included to help reinforce the skills across contexts.

The goals of the current study were to determine: (a) if the program Working Together: Building Children's Social Skills Through Folk Literature was feasible and effective for increasing the social skills of children with ADHD; and (b) whether pragmatic language skills were predictive of change in social skills above and beyond the other known predictors including oppositional behavior, hyperactivity-impulsivity symptoms, and inattentive symptoms.

METHODS

Participants

Sixteen children (10 males and 6 females) with ADHD participated in this study. They were selected from three suburban schools in a mid-sized Canadian city. All children were Caucasian and ranged in age from 97 months to 141 months (M = 119.56; SD = 14.49). Socioeconomic status (SES) was estimated using Hollingshead's Two-Factor Index of Social Position (Hollingshead & Redlich, 1958). SES scores were categorized into five levels ranging from I (highest level of SES) to V (lowest). Using this estimate, the participant's mean SES fell within the lower parameter of Level II.

School personnel were asked to nominate students who had a diagnosis of ADHD and social difficulties. Exclusionary criteria included any other diagnosis that is known to have social or cognitive deficits (e.g., Autistic Disorder, Asperger's Disorder, Mental Retardation) and severe behavior difficulties (e.g., physical aggression toward peers, major destruction of others' property, frequent threatening or intimidation of peers).

Measures

CONNERS' PARENT AND TEACHER RATING SCALES-REVISED: SHORT FORM (CPRS-R:S/CTRS-R:S; CONNERS, 1997)

The CPRS-R:S is a 27-item questionnaire that screens for ADHD (ADHD Index) and helps to determine the presence of oppositional behaviors, cognitive problems/inattention, and hyperactivity. The CTRS-R:S is a 28-item questionnaire, which evaluates behaviors in the same areas as those on the CPRS-R:S. Sattler (2002) reported that the CPRS-R:S and CTRS-R:S have good reliability and adequate validity.

KAUFMAN BRIEF INTELLIGENCE TEST (K-BIT; KAUFMAN & KAUFMAN, 1990)

The K-BIT is a standardized intelligence test that is used for screening cognitive abilities in children. The K-BIT produces three scores: Vocabulary score, Matrices score, and a Composite score. The K-BIT has been shown to be a reliable and valid measure with test-retest reliability coefficients ranging from .86 to .97 for the Vocabulary subtest and from .80 to .92 for the Matrices subtest (Kaufman & Kaufman, 1990).

SOCIAL SKILLS RATING SYSTEM (SSRS; GRESHAM & ELLIOTT, 1990)

The SSRS is a standardized questionnaire that consists of three forms designed to gather information about a child's social skills from parents, teachers, and the child. The SSRS parent form consists of 55 items and is divided into two scales—Social Skills and Problem Behaviors. The teacher form of the SSRS consists of 57 items and is divided into three scales—Social Skills, Problem Behaviors, and Academic Competence. The student form of the SSRS contains 34 items that evaluate children's perceptions of their own social skills. Both the parent and teacher forms of this questionnaire have been shown to be valid and reliable measures of social skills, as demonstrated by test-retest correlation coefficients of .65 to .87 and .84 to .93, respectively. The test-retest reliability is .68 for the student form (Gresham & Elliott, 1990). Van der Oord, Van der Meulen, and Prins (2005) found support in an ADHD sample for the factor structure and internal consistency of the parent and teacher versions of the SSRS but this was not as reliable in the child version.

CHILDREN'S COMMUNICATION CHECKLIST (CCC; BISHOP, 1998)

The CCC consists of 70 items that help to determine children's communication abilities, and is divided into nine domains. The pragmatic composite of the CCC consists of five of the nine domains (i.e., inappropriate initiation, coherence, stereotyped conversation, use of context, and rapport). Each item is rated on a scale of 0 “does not apply,” 1 “applies somewhat,” or 2 “definitely applies.” Items are summed together to arrive at an overall score. Low scores on this measure are indicative of adequate communicative abilities, whereas high scores are indicative of language difficulties. Research conducted on the CCC found that teachers and speech/language pathologists demonstrated good interrater reliability in completing the checklist (.61 to .83; Bishop, 1998). Guerts et al. (2004) found that the CCC was useful in obtaining information about the pragmatic language abilities of children with ADHD.

WORKING TOGETHER: BUILDING CHILDREN'S SOCIAL SKILLS THROUGH FOLK LITERATURE (CARTLEDGE & KLEEFELD, 1994)

This manualized program was designed to teach social skills within the context of folk stories. This program is administered in a group setting, with one skill being taught per session. A typical session involves a review of the previous skill learned, the presentation of a new folktale, discussion of the new folktale and its relationship to a new skill, a practice activity, and a maintenance activity. The manual includes five units which covers 31 social skills. For the current study, 10 specific social skills were chosen from this program based on the relevance of the skill in addressing typical problems in social skills and social communication of children with ADHD. The skills selected included: (a) making conversation, (b) introducing yourself, (c) making positive statements to others, (d) speaking assertively, (e) using courtesy words, (f) asking for help, (g) offering and giving help, (h) giving and accepting criticism, (i) joining a play activity, and (j) negotiating conflict. Skill steps were taught through direct instruction and related to the folk literature and real life situations. Children practiced and received performance feedback on new skills through role-plays and skill activities.

In addition to using the Working Together program, a generalization component that involved parents and teachers was implemented in this study. At the end of each session, parents and teachers were provided with skill information and “way to go” slips that were to be used in the following week to positively reinforce the children for performing the specific skill taught in the session. The “way to go” slips were collected each week and were exchanged for a celebration party when the sessions were completed.

Procedure

Baseline measures were obtained from the parents, teachers, and participants. The parents completed a demographic questionnaire, CPRS-R:S, and SSRS; and the teachers completed the CTRS-R:S, SSRS, and the CCC. The children completed the K-BIT and SSRS. The social skills program was delivered to three groups (one group in each of three schools). The groups were made up of four to seven students. The sessions were conducted during regular school hours and each group was led by one graduate student in school psychology, who had no previous experience with this program. Students participated in a total of 10 weekly 1-hour sessions. At the end of each weekly session, teachers and parents were provided with the specific skill steps involved in the new skill learned and “way to go” slips. Students were instructed that over the 10 weeks they collectively needed to earn a total of 50 “way to go” slips which then could be exchanged for a small celebration party. At the end of the social skills groups, posttreatment measures were completed. The parents, teachers, and children completed the SSRS.

RESULTS

Sample Characteristics

Chi-square tests and one-way ANOVAs were completed to compare group composition between schools. Results showed that the groups did not differ in terms of age, gender, estimated IQ, or severity of ADHD symptoms; therefore, data were collapsed across the three groups for all analyses (see Table 1).

TABLE 1 Comparison of Student Characteristics by Group

	School 1	School 2	School 3	Combined sample
	(n = 7)	(n = 5)	(n = 4)	(n = 16)	χ^2	p
Gender: Number of males (%)	4 (57%)	4 (80%)	2 (50%)	10 (62.5%)	1.01	.61
	M (SD)	M (SD)	M (SD)	M (SD)	f	p
Age in months	124.42 (15.46)	117.20 (14.97)	114.00 (14.49)	119.56 (14.49)	.73	.50
SSRS Academic Performance (Standard Score)	79.29 (4.89)	85.4 (12.78)	88.75 (17.65)	83.56 (11.50)	.95	.41
Kaufman Brief Intelligence Test (Standard Score)
Composite	96.57 (11.46)	95.80 (15.66)	102.00 (11.57)	97.69 (11.57)	.34	.71
Vocabulary	97.14 (12.02)	95.80 (23.60)	103.25 (5.31)	98.25 (14.88)	.28	.76
Matrices	96.71 (18.78)	98.80 (12.75)	100.25 (9.88)	98.25 (14.36)	.07	.93
Conners' Rating Scales (T-score)
Parent
ADHD Index	70.48 (11.00)	71.60 (6.99)	64.00 (10.42)	69.19 (9.64)	.77	.48
Inattention	70.57 (16.19)	73.40 (10.31)	66.50 (8.81)	70.44 (12.48)	.31	.74
Hyperactivity	73.43 (12.11)	69.40 (10.21)	66.00 (22.45)	70.31 (14.04)	.34	.72
Teacher
ADHD Index	71.14 (13.51)	77.60 (7.60)	65.00 (18.60)	71.63 (13.47)	.98	.41
Inattention	71.29 (11.44)	59.80 (7.12)	66.50 (17.37)	66.50 (12.32)	1.32	.30
Hyperactivity	66.57 (13.26)	78.20 (6.26)	60.25 (19.62)	68.63 (14.46)	2.11	.16

The sample of 16 Caucasian children was comprised of 10 males and 6 females ranging from 97 months to 141 months with a mean age of 119.56 months. All the children's estimated IQ scores fell within 1.5 SD of the mean on the K-BIT, with the mean falling in the average range at 97.69. Based on teacher reports on the SSRS of the children's academic functioning, the sample's average score fell in the 1.5 SD below the mean. Of the 16 participants, 9 were taking stimulant medication for their ADHD symptoms. One student had multiple diagnoses (ADHD, Tourette's Disorder, and Obsessive Compulsive Disorder) and was taking Paxil and Risperdal. Based on parent report, none of the children had a comorbid diagnosis of Oppositional Defiant Disorder and/or Conduct Disorder. Two children had been diagnosed with a Specific Learning Disability. Mean ADHD symptoms ratings based on the CPRS-R:S and CTRS-R:S were above the clinical cut-off (see Table 1).

Treatment Feasibility

The feasibility of the program was subjectively evaluated on attendance rates, participation of the parents and teachers in the program through using the “way to go” slips, and the facilitators' field notes regarding the ease of implementation. Of the 16 children who participated in the 10 sessions offered, 8 students did not miss any sessions, 6 missed only 1 session, 1 student missed 2 sessions, and 1 student missed 3 sessions. For each of the three groups, “way to go” slips were completed by parents and teachers such that each group reached their target goal of 50 slips over the 10 sessions. Finally, both facilitators anecdotally noted the ease of conducting the Working Together program in a school setting. There was minimal preparation time needed (less that 30 minutes per session) and all activities used from the manual appeared appropriate to the context and the children appeared to enjoy the sessions.

Treatment Effectiveness

The effectiveness of the social skills program, Working Together, was evaluated by conducting paired sample t tests on the pre- and post-skills training measures completed by the parents, teachers, and students (see Table 2). We used a one-tailed test, as we were interested in only one end of the distribution (i.e., improvement). Therefore, p values below .10 were considered significant. Both parents and teachers rated the children's social skills on the SSRS as significantly higher posttreatment compared to pretreatment [parents: t(11) = −2.37, p = .04; teachers: t(15) = −2.11, p = .05]. The mean ratings were at least one standard deviation below the mean prior to treatment and within the average range after treatment (see Table 2). The children's SSRS data also indicated a significant improvement between the pretreatment and posttreatment standard scores [t(15) = −1.88, p = .08]. Interestingly, the mean rating for the children pretreatment was in the average range, whereas the mean rating after treatment was at the high end of the average range.

TABLE 2 Treatment Effectiveness: Social Skills Scale of the SSRS

	Pre	Post
Measure	M (SD)	M (SD)	df	t	p
Social Skills Scale (SSRS ^a ; Standard scores)
Teacher	81.37 (8.40)	86.50 (8.52)	15	−2.11	.05
Parent	83.67 (12.81)	92.42 (12.50)	11	−2.37	.04
Student	101.94 (13.10)	107.56 (16.72)	15	−1.88	.08

Prediction of Improvement

Hierarchical regression analyses were conducted to determine the predictors of change. The first model included age and gender. The second model included CTRS-R:S scales of oppositional, hyperactive-impulsive, and inattention. The final model included the above noted variables as well as the pragmatic composite score of the CCC. The regression analysis was only conducted with the teacher data, given that the CCC was only completed by teachers. The results indicated that the third model was significant (see Table 3), with only gender and the pragmatic language composite being significant predictor variables (see Table 4). Of interest, the pragmatic language composite was also highly related to baseline teacher ratings of social skills (r = −.63, p = .009), indicating that better developed pragmatic skills was associated with better developed social skills.

TABLE 3 Hierarchical Regression Analysis of the Predictors of Change in Social Skills Rating (Teacher)

	Change in teacher SSRS rating
Block	R	R ^2	F/t	p value
1 Age & gender	.59	.35	3.44	.06
2 CTRS indexes	.63	.39	1.30	.34
3 CCC pragmatic	.86	.74	4.33	.03

TABLE 4 Individual Predictors in Model 3

	Change in teacher SSRS rating
Model 3	Beta	t score	p value
Variable
1 Sex	−.94	3.50	.007
2 Age	−.35	−1.76	.11
3 CTRS Opp	.46	1.51	.17
4 CTRS InA	.39	1.50	.17
5 CTRS HI	.30	1.32	.22
6 CCC Pragmatic	−.99	3.50	.007

DISCUSSION

Given the high prevalence of children with ADHD and the serious effects of the social problems associated with this disorder, there is a pressing need to identify effective interventions. The study found that the Working Together: Building Children's Social Skills Through Folk Literature was feasible to implement in the school setting and was effective for increasing social skills in students with ADHD.

In the current study, the Working Together program was judged to be smoothly carried out in the school setting; there were high rates of attendance at the skill training sessions as well as teacher and parent participation evidenced by the return rate of the “way to go” slips. The program includes a user-friendly manual which presents each skill in a structured format of activities for the session, but which is flexible and can be adapted to suit the number of children, to address specific concerns, and to adapt to time limitations. This allowed for ease of administration of the program by the facilitators, who had no previous experience with this specific program. There is a minimum amount of preparation time required for each skill session and there are numerous activities to choose from; both important features for programs to be administered in schools.

Previous research on the effectiveness of SST has been mixed. It has been suggested that the reason for limited effectiveness of SST is a result of the fact that most interventions are delivered in clinical settings (e.g., mental health clinics), are comprised of children who do not interact together outside of the group sessions, and that the skills are not reinforced across a range of settings to allow for generalization to the child's home and school environment (DuPaul & Weyandt, 2006). In our study, we conducted the groups in a natural setting (schools), thus ensuring that the children knew each other and could potentially interact outside of group time. The “way to go” slips allowed for generalization and maintenance of the learned skills. Similar to findings of previous studies which included generalization enhancers (Frankel, Myatt, Cantwell, & Feinberg, 1997; Pfiffner & McBurnett, 1997), the program we used also resulted in improvements in social skills.

The mean parent and teacher ratings before treatment were 1.5 SD below the mean, but at posttreatment fell within 1 SD of the norm mean, indicating that on average children's social skills were rated to fall in the average range. Interestingly, children rated their social skills well within the average range at pretreatment and posttreatment. This is consistent with previous research which has found that children with ADHD tend to overestimate their social abilities (Diener & Milich, 1997; Hoza et al., 2004).

The second goal of this study was to determine if pragmatic language skill was related to change in social skills above and beyond the known predictors (i.e., oppositionality, hyperactivity-impulsivity, and inattention). Prior to treatment, a strong relationship was found between students' pragmatic language skills (as rated by teachers using the CCC) and the quality of their social skills, providing preliminary support for a relationship between weak pragmatic language abilities and social difficulties in children with ADHD. Also, change in social skills as rated by teachers from preintervention to postintervention was found to be related to gender and pragmatic language skills, but not the previously identified factors such as core ADHD symptoms and oppositional behavior.

The results of the current study are promising, but there are several limitations which should be noted. Most important is the fact that there was no control group, a small sample size, lack of a direct observational measure of social skills, and the raters were not blind to the fact that the children had attended the group. Overall, the study results indicate that the Working Together program is a promising social skill intervention for children with ADHD and social skill deficits that can be efficiently carried out in the child's own school with their own peers. These findings suggest that delivering social skills training programs in the school system, focusing on pragmatic language skills, and involving the child's teachers, parents, and pre-existing peer groups may increase the effectiveness of SST programs.

Notes

^a Higher standard scores on the Social Skills Scale indicate improved social skills.

Note. Model 1 = age (in months) and gender; Model 2 = Conners' Teacher Rating Scale (CTRS) Oppositional, Hyperactive-Impulsive, and Inattention Scales (T scores); Model 3 = Pragmatic Composite score of the Children's Communication Checklist (CCC).

Note. CTRS = Conners' Teacher Rating Scale; Opp = Oppositional Scale; InA = Inattentive Scale, HI = Hyperactivity Scale, CCC = Children's Communication Checklist, Pragmatic = Pragmatic Composite score.