Small Group Experience for Socially Withdrawn Girls

Social Competence

Broadly, social competence refers to the effectiveness of social interactive behavior (Rose-Krasnor, 1997). This adaptive competency is thought to reflect a balance between the autonomous processes of self-assertion and self-regulation (Houck & Spegman, 1999). As such, social competence is a multidimensional construct and includes the effective use of social skills, the absence of maladaptive behaviors, accurate and age-appropriate social cognition, and positive relations with others (Vaughn, Hogan, Kouzekanani, & Shapiro, 1990).

The development of social competence is derived, in part, from the child’s early experiences of connectedness and relatedness (Cassidy, 1990; Connell, 1990). The emotional quality of early relationships carries over to later relationships, an idea that has a fair amount of supporting evidence (Klinnert & Bingham, 1994). There is a sequence for how expectations for social behavior are learned through repeated social interactions: familiarity develops first and the familiar interactive behavior becomes predictable; eventually, preference is developed for what is familiar and predictable (Klinnert & Bingham, 1994). Thus, children learn social behavior, the expected quality of relations, and how to think about social relations (social cognition) from these early repeated social interactions and come to prefer them.

A review of the literature on social competence revealed consensus among researchers that children’s difficulties with peers are typically manifested in either externalizing or internalizing behavior patterns (Rose-Krasnor, 1997). Externalizing behaviors include aggressive and disruptive behaviors; these are “acting out” behaviors directed toward others. Externalizing behavior problems are more likely to come to the attention of educators because of their disruptiveness in the classroom that interferes with teaching. However, children with externalizing problems may be managed through disciplinary measures rather than through interventions to strengthen their social competence.

On the other hand, internalizing behaviors are internally experienced or directed inward, toward the self. Children with internalizing behavior problems usually are not disruptive and are typically quiet or withdrawn from social interactions. In the classroom, these children have not been problematic (Rubin, 1993) and therefore are more likely to be ignored by students and educators.

Social withdrawal is a pattern of behavior characterized by a low social interaction with peers. Initially, socially withdrawn children may appear shy with a stable inhibited temperament. Unlike shy children, however, socially withdrawn children do not warm up to social situations and have a lower rate of social initiation (Rubin, Hastings, Stewart, Henderson, & Chen, 1997). Socially withdrawn children tend to be isolated in solitary play; in group activities they are less communicative and may be deferential, submissive, or immature (Harrist, Zaia, Bates, Dodge, & Petit, 1997). Peer rejection is typical, and social problem solving develops poorly. Socially withdrawn children are at risk for repeated negative social outcomes and the social anxiety that attends them.

It is not uncommon for socially withdrawn children to have somatic symptoms not accounted for by pathological findings. They frequently seek help from the school nurse and are often absent from school (Garralda, 1996). The characteristics of social withdrawal are also those signs that may be associated with depression in children: lack of interest in playing with friends; social isolation, poor communication; difficulty with relationships; frequent vague, nonspecific physical complaints such as headaches, muscle aches, stomachaches, or tiredness; and frequent absences from school or poor performance in school (National Institute of Mental Health, 2000). These characteristics alone constitute the minimum five symptoms that, if persistent for 2 or more weeks, can warrant a diagnosis of depression.

According to Kovacs and Devlin (1998), children at risk for the internalizing disorders of anxiety and depression are more likely to exhibit anxiety disorder first, behavior problems in middle childhood, and depressive disorder in late childhood due to certain developmental constraints. This sequence is consistent with the findings that 6-year-olds’ self-reported symptoms of anxiety were related to poorer social functioning at school and were rather stable to the 5th grade (Ialongo, Edelsohn, Werthamer-Larsson, Crockett & Kellam, 1995). Furthermore, both social competence and depression were found remarkably stable in elementary school students, and social competence was found to be predictive of depression among 6th-graders (Cole, Martin, Powers, & Truglio, 1996). By middle school, social anxiety and low self-esteem become prominent, and depressive symptoms are even more evident (Garralda, 1996). Finally, there are high rates of comorbidity between anxiety and depression, and to a lesser extent among these disorders and externalizing behavior problems (Kovacs & Devlin, 1998).

Interventions

Interventions to enhance social competence can be thought of as strategies for influencing children’s developmental trajectories (Consortium, 1994). Accordingly, most effective social competence promotion interventions were designed in developmentally sensitive ways to improve problem solving, to promote prosocial relationship skills, and to provide the basic skills for interpersonal effectiveness and sound psychosocial growth (Consortium, 1994). One model used to guide change is the social development model, a theory of prevention that integrates control theory, social learning theory, and social disorganization theory (Hawkins, Von Cleve, & Catalano, 1991; Hawkins & Weis, 1985).

According to the social development model, social bonding to family, school, positive peers, and neighborhood serves as a key protective factor. Bonding is thought to have an important role in self-regulation of behavior because it provides the motivation to live according to the standards and norms held by those to whom one has bonded. The elements of the social bond include attachment or emotional closeness, commitment or personal investment, and belief in the values of the social unit.

This perspective was most useful in guiding the intervention developed for elementary school students who were socially withdrawn. Broadly, the goal was to enhance the social competence of socially withdrawn girls and thereby reduce the risk of later negative social and mental health outcomes. Through a weekly group experience facilitated by the school nurse, the purpose of the intervention was to strengthen (if not establish) a social bond to the school and to strengthen the social bond with positive peers. The weekly group experience made possible the three protective developmental processes in the social development model that were determined to be necessary to build social bonding: (a) providing opportunities for the students to be involved in school and with a peer group, (b) stimulating the development of social skills for effective participation in the classroom and a peer group, and (c) recognizing students for their efforts and performance.

In other words, through such an intervention, experiences that enhance a socially withdrawn child’s sense of connectedness and provide successful interactions can be offered (Houck, 2000). The relationship experience provides the opportunity to facilitate connectedness or bonding and the necessary learning about relationship skills. Essentially, learning about social relationships needs to occur in the context of a relationship; only then can social skills be generalized and carried forward to other relationships. The objectives of the practice improvement were to (a) enhance a sense of belonging and connectedness to peers and the school community, (b) improve social interactive behavior, and (c) reduce somatic complaints and visits to the school nurse.

Intervention

Before beginning the project, a process for obtaining permission from parents was determined. It was most helpful for the school nurse to contact the parents by telephone. The purpose of the group was described as an opportunity to strengthen the child’s school bonding. Verbal consent to send the permission form home with the child was obtained. The written permission form, on the Education Service District Department of School Nursing letterhead (to communicate from the nurse rather than the school), and a stamped, addressed return envelope was then sent home with each child, whose parent(s) gave verbal consent. Follow-up contacts, by telephone, were made one time as needed to remind the parents that the written permission form was essential for their child to participate. Once the written permissions were returned, the group meetings began.

The group met with the school nurse once a week for 30 minutes over a 20-week period, from December through April. The meetings were held in a room separate from the health office to discourage interruptions. The intended milieu was a supportive, ego-strengthening atmosphere in which the students’ sense of belonging and connectedness could be nurtured.

This small group experience represented a social situation in which conversations and a shared snack and craft project provided the opportunities for self-assertion and the expression of prosocial behavior in a socially safe (nonrejecting) environment. The underlying intent was to permit the participants as much control over the activity and the conversation as possible. The craft projects provided an opportunity to discuss an issue or to engage in problem solving. These developmentally appropriate projects included beadwork, collages, Popsicle-stick creations, snowflakes, and valentines.

Topics for discussion emerged from the social discourse—often around the craft project—and were facilitated by the school nurse. For example, making valentines provided the opportunity to discuss friendships and feeling “left out.” When making collages with magazine photos, a question about “looking fat” made possible a discussion about body images portrayed in the media and how to evaluate the messages today’s culture gives young girls.

When appropriate to the topic, strategies for problem solving and coping in social situations were introduced. For example, when one student was having a difficult interpersonal problem with her teacher, she and the school nurse role-played the interaction (with the nurse playing the part of the teacher). The other girls observed the role-play and provided the student with suggestions about how she could change her behavior in ways that would change the interaction. She practiced the suggestions with the other participants coaching her. This process was popular among the participants for solving social difficulties.

The school nurse also facilitated collaborative problem solving when appropriate. The girls increasingly showed evidence of constructive collaboration. For example, when the meeting time for the group conflicted with a group participant’s other learning activities, the group explored alternatives and arrived at a solution: to meet during the lunch period and recess. In that way, no participant missed other school activities, and all were able to continue to belong to the group. Most important, they had appropriately collaborated in the social problem solving.

Evaluation of Outcomes

Enlisting the support of school personnel was a challenge for implementing this intervention. Conducting the practice improvement project involved a dimension of the school nurse role with which most school personnel had little familiarity—the psychosocial or mental health dimension of school nursing. Furthermore, given the current expectations for educators and the attendant time constraints, negotiating a time period for the group meeting was difficult. In the future, education of the school administrators, faculty, and staff to the multidimensional role of school nurses and their part in the prevention of and early intervention with mental health problems is necessary. The fundamental assumption that mental health is irrelevant to optimizing children’s cognitive and academic outcomes requires education. Future efforts may benefit from a formal introduction of the project to the school administrators. School principals can subsequently introduce the project, if not the school nurse, to the faculty.

A difficulty encountered in the evaluation of this practice project was getting teachers to complete an evaluation form pre- and postintervention. Initially, teachers were asked to complete the Teacher Rating Form (TRF; Achenbach, 1991) for school-age children, a 112-item behavioral checklist that addresses behavior in the school setting. The length of this form was simply unrealistic given the demands on teachers’ time and impeded any compliance with this request. Therefore, no evaluation was obtained of the students’ social behavior and peer relationships before the intervention. The only objective data were the criteria for participation.

However, to facilitate measuring outcomes of practice with socially withdrawn girls in the future, a 13-item scale was drawn from the larger TRF checklist using the 10 items from the social withdrawal subscale and 3 items from the unpopular subscale (Achenbach, 1991). The length of this scale will expedite future efforts to measure practice outcomes. In addition, the items are more pertinent to an assessment of social withdrawal, such as “likes to be alone,” “refuses to talk,” “shy or timid,” “doesn’t get involved with others,” “poor peer relations,” and “not liked by other pupils.” This shorter checklist yields scores ranging from 0 to 26, with higher scores reflecting social difficulty. The TRF has norms established for gender and age, and the scores can be evaluated for clinical status on the social withdrawal subscale.

Scores on this modified scale were obtained at the conclusion of the group experience. In the absence of scores obtained before the intervention, it is difficult to consider the measure as an evaluation of outcomes. However, none of the girls was identified in the clinical range of social withdrawal as determined by the 10-item scale at the end of the intervention.

The criteria for participation included sad affect and withdrawn behavior. The girls did not have friends, made few social initiations, and had a low rate of social interaction. However, interim observations and feedback indicated the students preferred the group meetings to other activities and identified with group membership. By the end of the intervention, the students identified each other as “good friends,” and they related stories about how they supported each other if teased at school. They were observed by their teachers to spend recess and other free time involved with peers, especially each other, instead of alone. “Sad and withdrawn” were no longer descriptors.

Within the group, the girls demonstrated social skills that involved empathy and responsiveness. They became increasingly self-assertive and more actively participated in conversation. They were able to collaborate and compromise appropriately. Problem-solving skills were enhanced. With skills emerging that are likely to contribute to social competence, it is not surprising that teachers also reported decreased somatic complaints from these students. There were no further visits to the school nurse with somatic complaints, although visits to greet the nurse and to “check in” continued.

Student satisfaction with the group experience was obtained at the conclusion of the intervention. The participants were asked to write what they liked about the group. One student responded:

I like the program because it teaches me a lot of things that I never knew. It also helps me with friendship. It also gives me a hint on how to keep friends. It also tells me how to not get in an attitude and how to not get in trouble often. We also get to do arts and crafts.

Another student echoed this theme of learning about friendship: “I like being with people I know and like. This group helped me with my friendship. By helping me with friendship I can get along.”