Peer problems are an issue that cut across diagnostic categories and childhood conditions. Peer problems are a critical target of treatment, as they are a strong predictor of negative long-term outcomes. Currently, there are a number of interventions for peer problems that are supported by research evidence. Notably, these treatments involve working directly with the child in peer settings (e.g., recreational settings, classrooms). Basic competencies for clinicians working to treat peer problems include effective assessment strategies and working with the child in the settings of interest. Advanced strategies include effective supervision of individuals working on peer problems with children and ensuring intervention fidelity, individualizing and tailoring intervention components to address peer problems, and working within systems such as schools or summer treatment programs.
57.1 15.1 Overview
The manner in which one interacts and forms relationships with others through early childhood, middle childhood, and adolescence is a cornerstone of most major developmental theories (e.g., Erikson, 1968; Parker, Rubin, Erath, Wojslawowicz, & Buskirk, 2006). The formation of social skills that permit effective negotiation of peer-related interactions and interpersonal relationships is arguably one of the most important developmental tasks. As such, peer relationships make a strong contribution to many aspects of normal and abnormal development (Bukowski & Adams, 2005).
Social acceptance by peers, presence of positive friendships, and using good social skills within the context of friendships predict a host of positive long-term outcomes (e.g., Hartup, 1996; Risi, Gerhardstein, & Kistner, 2003). Conversely, being rejected or neglected by peers, lacking in friendships, and exhibiting behaviors characteristic of poor social skills predict a number of negative long-term outcomes (e.g., Coie, Lochman, Terry, & Hyman, 1992; Ollendick, Weist, Borden, & Greene, 1992; Parker & Asher, 1987). Thus, children not only have to avoid poor peer relationships, but must also develop positive peer relationships to be on a trajectory for positive long-term outcomes.
Peer interactions are reciprocal and recursive in nature. Owing to their complexity, they are vulnerable to breakdowns or impairments across many potential phases of the peer-interaction process, spanning from initiation of social interaction, communication or social skills used during an interaction, to behaviors related to the maintenance or fostering of continued interactions/friendships. Thus, it is not surprising that peer-relationship problems are often impaired in children and adolescents who exhibit impaired functioning owing to externalizing or internalizing behaviors (e.g., Bukowski & Adams, 2005). For example, researchers have long known that children with ADHD (e.g., Pelham & Bender, 1982) or conduct problems (Coie & Dodge, 1998) have problems in peer relationships. Problems may range from simply being ignored by other children (e.g., not being picked to play in recess activities, being the only child not invited to a classmate’s birthday party) to being actively rejected by other children (e.g., being bullied during recess). A child with ADHD or CD may also tease and be teased by peers, get into fights with other children, and exhibit inappropriate social skills (e.g., is a poor sport during games). Likewise, children with internalizing problems may have problems exacerbated by peer victimization or poor peer interactions (e.g., Greco & Morris, 2001; Prinstein, Cheah, & Guyer, 2005).
It is also important to acknowledge that peer relationships are interwoven into most domains of functioning for children and adolescents. Thus, the individual’s neighborhood, school, recreational activities, and home will all contribute to the context of the development of adaptive and/or maladaptive peer interactions. Although this point about the context of peer relationships may seem obvious, it is worth noting that many contexts do not have a primary focus on peer relationships as part of formal or informal intervention efforts. For example, Farmer and Farmer (1999) note how schools may not adequately support interventions related to development of appropriate peer relationships through the current standard of care. A practical example of this comes from the work of researchers (Bradshaw, Sawyer, & O’Brennan, 2007; Craig & Pepler, 1997; Craig, Pepler, & Atlas, 2000; Pepler & Craig, 1995) who highlighted a fundamental difficulty in targeting peer interventions in school settings: adults are generally unaware of the negative interactions between peers, such as aggression or bullying. Therefore, while adults are present in these situations, as they are unaware of the majority of negative interactions, it is difficult to institute effective adult-directed intervention efforts to target these behaviors. The situation can only be worse in instances when adults are not present, presenting a real challenge for the treatment of peer problems (e.g., in school cafeterias or on the bus; in unstructured peer interactions in the neighborhood). Thus, it is critical for adults and children to have open lines of communication with respect to information on occurrence of peer problems.
Given the importance of the development of positive peer relationships through childhood and adolescence, it is notable that the Diagnostic and Statistical Manual of Mental Disorders (DSM; American Psychiatric Association [APA], 2000) does not have any category for impaired peer relationships. A few categories include impairment in peer relationships as a hallmark feature of the disorder (e.g., autism, Asperger’s disorder). In most cases, however, the DSM integrates a consideration of functioning in the domain of peer relationships into most childhood and adolescent disorders through the diagnostic qualifier stating: “The disturbance in behavior causes clinically significant impairment in social … functioning” (APA, 2000). Thus, regardless of a child’s or adolescent’s primary diagnosis or reason for referral, a careful focus on peer relationships is necessary during initial and ongoing assessments, as well as in treatment planning and implementation.
As outlined briefly earlier, establishing peer relationships is a critical developmental task, and peer problems are an important target for intervention and treatment. In the rest of the chapter, we will discuss the assessment of peer problems, maintenance factors related to the problem, evidence-based treatment approaches, what is known (and not known) about the mechanisms underlying change in the intervention, and the basic and expert competencies of clinicians charged with treating peer problems.
57.2 15.2 Recognition and Assessment
Symptoms exhibited by children who experience peer problems vary greatly due to the complex nature of peer interactions. Much of the information on the topography, variation, and extent of peer problems comes from sociometric studies. Sociometric measures generally ask children in a group to nominate children who are liked and disliked within a group (Coie & Dodge, 1988; Coie, Dodge, & Kupesmidt, 1990; Masten, Morison, & Pellegrini, 1985; Newcomb, Bukowski, & Pattee, 1993; Pekarik, Prinz, Liebert, Weintraub, & Neale, 1976; Pope, Bierman, & Mumma, 1991). Based on data from sociometric peer nominations, researchers have identified five types of sociometric status that children are classified as per the peer ratings: popular, rejected, neglected, controversial, and average (Newcomb et al., 1993). In developmental research, four behavioral patterns have been linked with peer rejection. These include low rates of prosocial behavior, high rates of aggressive/disruptive behavior, high rates of inattentive/immature behavior, and high rates of socially anxious/avoidant behavior (e.g. Coie et al., 1990; Parker, Rubin, Price, & DeRosier, 1995).
Children of different sociometric status can be described as varying across three broad behavioral domains: sociability, aggression, and withdrawal (Newcomb et al., 1993). Based on the results of a meta-analysis of sociometric status, Newcomb et al. describe distinct behavioral patterns that discriminate the five sociometric status groups from one another. Compared with children of popular and average status, children who fall into the rejected sociometric status have lower cognitive abilities, are less sociable, and more aggressive and withdrawn. Within the broad domain of aggression, rejected children have increased disruptive and negative behaviors, along with higher levels of physical aggression. In addition to elevated levels of inappropriate behaviors, rejected children also exhibit low levels of positive behaviors, such as prosocial actions and friendship skills, and have higher than average levels of social withdrawal. In contrast to rejected children, those who fall into the controversial status exhibit higher levels of sociability than do average children. However, controversial children also show higher than average levels of aggression and disruptive/negative behaviors. Controversial children also have higher cognitive abilities than rejected children, and their positive, prosocial actions are equal to those of children in the popular status. The behavior of neglected children, on the other hand, appears to deviate the least from that of average children. In the domains of aggression and sociability, neglected children show lower levels than do average children, while having higher levels in the domain of social withdrawal. Coie, Dodge, and Coppotelli (1982) describe neglected children as being ignored and receiving little notice from their peers, but they are not actively disliked.
Prosocial behavior has been shown to be a stable predictor of peer acceptance, while aggressive and disruptive behaviors are related to peer rejection. Children who show low levels of prosocial behaviors have difficulty in the areas of positive behavior and communication skills, emotion regulation, and social awareness and sensitivity. Children who exhibit high levels of physical and verbal aggression are at high risk for peer rejection due to their frequent exhibition of disruptive behavior. Difficulties in emotional regulation are often reflected in disruptive and oppositional behaviors that are also linked to peer rejection, such as irritability, insecurity, children who are overly sensitive and quick to blame others, highly reactive to frustration, resentful, easily annoyed, and generally unhappy.
High rates of inattentive/immature behavior are also associated with peer rejection. This includes behaviors, such as high levels of distractibility, difficulty staying on task and concentrating, and socially immature and insensitive behaviors. When children exhibit socially aversive behaviors, such as failing to follow social protocols, joint activities and play become unpleasant and unpredictable (Barkley, 1996; Pope & Bierman, 1999). Children who have low levels of self-control, such as deficits in following rules and understanding principles of fairness and reciprocity, also tend to experience peer rejection (Landau & Milich, 1988; Saunders & Chambers, 1996). Notably, the negative effects of these behaviors on peer perceptions of a child are almost immediate (e.g., Pelham & Bender, 1982).
An additional behavior that has received recent attention from researchers is relational aggression. Relational aggression involves directing harm at a relationship or friendship. For example, a child may spread gossip or rumors about another, threaten to end the friendship, or shun a child or group of children (Crick, 1996; Ostrov & Crick, 2007). There are measures that can be completed by teachers to investigate the extent of relational aggression (i.e., Children’s Social Behavior Scale, Crick, 1996; Preschool Social Behavior Scale, Crick, Casas, & Mosher, 1997), and sociometric measures completed by peers can query the extent to which children exhibit this behavior. In addition to physical aggression, relational aggression is an important construct to assess as well because of its potential impact on aggressors and victims.
The fourth behavior pattern that is associated with peer rejection is with regard to a child who exhibits high rates of socially anxious/avoidant behavior. Children who are fearful, anxious, and appear uncomfortable around other children are at risk of experiencing peer rejection (Rubin & Stewart, 1996). Children who are isolated or ostracized from their peers are restricted in their ability to develop social skills and self-confidence, which can lead to a cycle of negative socialization. Children may also be rejected by their peers because of atypical characteristics, such as a handicap or minority status.
The complexity of peer problems necessitates that assessment be comprehensive and idiographic, and integrate information from multiple informants. Bierman (2004) notes that assessment of peer problems must include consideration of behavioral, affective, and cognitive features of the child, as well as the characteristics of the child’s peers. Behavioral characteristics include aggressive, immature, and inattentive behaviors, as well as deficits in prosocial behaviors. There are a number of well-developed and valid measures for documenting the presence of these characteristics (e.g., Child Behavior Checklist and Teacher Report Form, Achenbach & Rescorla, 2004; Behavioral Assessment System for Children, Reynolds & Kamphaus, 1998; Social Skills Rating System, Gresham & Elliott, 1990). Affective characteristics include negative expectations, being easily aroused emotionally, or ambivalence in social situations, which can also be measured with standardized methods (e.g., Asher, Hymel, & Renshaw, 1984; Cassidy & Asher, 1992; Harter, 1982; LaGreca, Dandes, Wick, Shaw, & Stone, 1988). Cognitive characteristics include negatively biased evaluations of social situations, lack of problem-solving skills, or inaccurate perceptions of social situations (Bierman, 2004). Finally, quality of the peer relationship itself might be evaluated using the child’s self-report or other measures (Bukowski, Hoza, & Boivin, 1994; Coie & Dodge, 1988; Crick & Bigbee, 1998; Parker & Asher, 1993; Ried et al., 1989; Wheeler & Ladd, 1982).
The purpose of assessment is to inform intervention and treatment efforts; therefore, assessment must be individualized so that each child’s unique behavioral, affective, and cognitive characteristics, as well as the context in which problems occur, can be appropriately considered. In each assessment, a functional analysis of the peer problems a child is experiencing should be included. A functional analysis involves isolating and clearly defining the specific peer problems the child is experiencing (e.g., become physically aggressive when peers do not follow his lead during group activities). Next, antecedents or events that occur immediately before the specific behavior(s) are examined. All aspects of the context in which the specific behavior occurs should be considered when identifying antecedents. Consequences of the specific behavior or what happens immediately following the behavior(s) should be examined to determine what function the behavior is serving for the child. This functional analysis allows for the identification of both the immediate peer problems the child is experiencing, as well as the hypothesizing of long-term correlates such as the child’s reputation among peers.
Assessment of peer problems should include information from multiple sources, including peer ratings, teacher ratings, self-ratings or interviews with the child, and direct observation (Bierman, 2004; Coie & Dodge, 1988; Pepler & Craig, 1998). Information from these multiple sources can be integrated to form a more comprehensive picture of the child’s peer problems, as gathering information from each source has advantages and limitations, and varies in three important ways: access to information about the child, cognitive biases and limitations, and the nature of the relationship with the child (Newcomb et al., 1993). Newcomb et al. note that adult (parent and teacher) ratings may be limited due to lack of direct contact with the child during salient social situations, as they are more likely to interact with children in structured settings where less peer interaction takes place. Adults also may have limited knowledge about the child’s feelings, values, and beliefs. Additionally, adults interact with children as part of a non-equal relationship, which is different from the interaction children have with their peers. Although adults may be poor reporters regarding the nature of children’s peer relationships and the specific strengths and weaknesses, there is some evidence that parents and teachers are accurate in their identification of rating whether peer relationships are impaired (Fabiano et al., 2006).
Regarding peers, Newcomb et al. (1993) outline that they have access to information about the child’s behavior in terms of the norms of the peer group, and within the structure of interactions among equals. However, utility of peer reports varies with cognitive and developmental levels. Peers may also be biased by past information about the child such as reputation. Children’s self-reports are also subject to their cognitive and developmental levels, but are more accurate for identifying the child’s beliefs, feelings, and values related to social situations. However, children’s accuracy in reporting their self-perceptions can vary greatly (Newcomb et al.; Owens, Goldfine, Evangelista, Hoza, & Kaiser, 2007). Similarly, direct observations of children’s behavior are impacted by the pre-existing biases of the observers, the observers’ training, the coding scheme used, and the influence that an observer’s presence has on the social situation (Newcomb et al.).
57.3 15.3 Maintenance Factors
Social competence and cognition, peer response, as well as other external factors may contribute to the maintenance of poor peer relations, if not addressed. Consideration of such socially constructed factors suggests that while discrete behavioral skills may be developed through individual therapy, the key to improving peer relationships relies on interventions beyond the clinician’s office.
The foundation of social competency relies on executive functioning within social contexts (Cavell, 1990; Dodge & Murphy, 1984). Several discrete behaviors and social skills have been identified as essential for enabling effective social functioning. Specific behaviors include: encoding skills, considered as the ability to perceive and interpret the situation; decision skills, eliciting and evaluating possible responses; and enactment skills, which include enacting and evaluating the selected response (Dodge & Murphy, 1984; McFall, 1982). Additionally, social skills include prosocial behavior, adaptive problem-solving skills, and emotional regulation (Bierman & Welsh, 1997).
When considered within a developmental framework, social competence moves beyond a set of discrete social behaviors to include a child’s ability to manage her/his own behavior in various social contexts, which elicit a positive response while avoiding a negative response from others participating in the interaction (Bierman, 2004; Bierman & Welsh, 1997; Dodge & Murphy, 1984). The possession of socially appropriate behaviors is necessary, but is not sufficient for one to be considered socially competent (Biernman, 2004). Social competence also requires social-cognitive ability, allowing the individual to utilize such behaviors to accommodate the ongoing social interaction (Beirman, 2004; Bierman & Welsh, 1997). Clearly, this is a quite complex combination of behaviors that have both reciprocal and recursive feedback effects on social interactions.
The foundation of social-information-processing models asserts that children’s understanding and interpretation of social situations influences their related behavior, which is, in turn, the basis for other’s evaluation. Crick and Dodge (1994) present a complex yet very well-defined model of social-information-processing. The empirically supported cognitive distortions of maladjusted/rejected children within the framework of the social information processing model of children’s social adjustment is a useful way to think about the complexity of social interactions, as well as the multiple areas where intervention may be necessary (Crick & Dodge, 1994). In brief, children need to create a mental representation of the social situation, identify their own social goals, access their own memory of social history to generate potential behavioral responses, and select a behavioral response. Maintaining factors in a child with peer problems could occur at any one or more of these steps, and problems could be present at different steps across different social situations. One of the challenges in identifying maintaining factors is to conduct an assessment that comprehensively identifies all antecedents and consequences of peer interaction behaviors (both positive and negative).
Furthermore, while deficits in social competence may maintain difficulty in peer relationships, subjective peer expectations may maintain social difficulties, especially for children with acknowledged learning and behavioral problems. Such children with diagnostic labels (e.g., learning or behavioral disordered) were perceived more negatively by their peers, who were less friendly and less involved in the interaction, which in turn, contributes to the maintenance of social difficulties (Milich, McAninch, & Harris, 1992). These problems are compounded by a lack of awareness of how these negative behaviors contribute to negative peer outcomes, compounding the problem over time (e.g., Hoza, Waschbusch, Pelham, Molina, & Milich, 2000).
As some maintenance factors may involve cognitions (e.g., a hostile attributional bias), emotions (low feelings of self-worth or feelings of social anxiety), or the behaviors of other children (e.g., teasing/name-calling; Scambler, Harris, & Milich, 1998), clinicians have a tall order to meet in their evaluation and intervention efforts.
After enacting the response decision behavior, children are subjected to evaluation by their peers. Peer rejection has been found to be relatively stable in childhood. Over the course of a 5-year period, rejected children remained rejected, suggesting stability of the status (Coie & Dodge, 1983). Perceptions of rejected children suggest that peers utilize negative or biased stereotypes and expectations, which results in adverse treatment or victimization of the rejected child in comparison with an accepted peer (Bierman, 2004; Perry, Kusel, & Perry, 1988). Consequently, for aggressive children, persistent adverse treatment may elicit and reinforce further aggressive behavior (Bierman & Welsh, 1997).
Finally, maintenance of peer difficulties may result from additional factors, which are considered to be external from the individual’s unique social skills and deficits. These include deviant peer-group acceptance, as well as family factors and other community/neighborhood influences. Aggressive or antisocial preadolescents and early adolescents may establish friendships with other deviant peers. This, in turn, supports and reinforces deviant behavior, as it is highly probable that when one member of a deviant peer group engages in problem behavior, other peer group members will also engage in the deviant behavior (Brendgen, Viaro, & Bukowski, 2000; Dishion, Andrews, & Crosby, 1995; Wasserman et al., 2003). Furthermore, exposure to deviant peers is associated with drug use, antisocial behavior, violent offenses, and is a stronger predictor of delinquent behavior than family, school, and community factors (Elliott & Menard, 1996; Thornberry & Krohn, 1997). Neighborhood socioeconomic status may also contribute to peer relationships; however, neighborhood effects may be mediated by parental behavior, especially for young children (Tietjen, 2006). Additional external factors that have been empirically associated with poor peer relationships include an authoritarian parenting style, parental psychopathology, divorce and marital conflict, exposure to neighborhood violence, and no or low quality child-care experience, particularly for children from lower socioeconomic families (Dishion et al., 1995; Tietjen, 2006).
57.3.1 15.3.1 Evidence-Based Treatment Approaches
Given the significant and sustained impairment experienced by children with peer problems, and the impact of this impairment on long-term outcomes, effective treatments are clearly needed. Most task forces or work groups that establish criteria for and evaluate evidence-based practice, aim to evaluate treatments for a particular DSM disorder. Thus, there is a challenge in identifying evidence-based treatment approaches for addressing peer problems, which cut across diagnostic categories. In the present review, evidence-based approaches that primarily focus on the development of appropriate social skills and adaptive peer-related behaviors as well as the reduction of negative behaviors that impact peer interactions will be reviewed.
However, before reviewing evidence-based interventions, interventions that are not evidence-based will be briefly discussed. Simply enrolling a child with peer problems in a community activity such as sports or scouting is not an effective intervention – without adequate structure and support, it is unlikely that by simply increasing the frequency of peer interactions there would be an improvement in the existing problems. Further, a commonly used, but not evidence-based, intervention for peer problems is individual counseling or social-skills training conducted by a therapist. In this intervention, individual meetings with a psychologist or other professional and “lunch bunch” meetings facilitated by school psychologists or counselors are included. With notable exceptions (see the discussion of Webster-Stratton’s social skills program, below), the preponderance of available evidence does not support this inter-vention for children with peer problems (e.g., Fox & Boulton, 2003; Pelham & Fabiano, 2008; Rao, Beidel, & Murray, 2008), and clinicians report it as being less effective than other interventions (Miller, DuPaul, & Lutz, 2002). Indeed, in a comprehensive review and meta-analysis of social-skills training programs for children with disruptive behavior disorders conducted by Kavale, Forness, and Walker (1999), a modest effect size was generated (mean = 0.20), with 27% of studies yielding a negative effect size (i.e., treated children fared worse in these studies).
Upon closer review, these results are not surprising. Given the complexity of peer interactions, it is folly to believe that an adult (i.e., not a peer) can meet individually with a child and instruct the child in the best manner for negotiating a variety of evolving and frequently subtle social situations (that are impaired to the point of needing clinical intervention) involving one or more peers. For this reason, peer problems cannot be treated in an office or outside the presence of peers – it is necessary for interventions to be implemented within the settings where peer problems occur. It is clear from the discussion that follows that evidence-based interventions are those that work directly with the targeted child in the problematic settings to teach skills and competencies in important functional domains and implement contingencies or modify setting events to reduce the occurrence of problematic behaviors.
Subsequently, we will briefly provide an overview of evidence-based peer interventions for common childhood disorders. For the most part, peer interventions have focused on children with externalizing disorders, such as ADHD, Oppositional Defiant Disorder, and Conduct Disorder. Interventions for children with internalizing disorders and the prevention of bullying or aggression will also be reviewed. Importantly, this is not intended to be an exhaustive list of evidence-based interventions for peer problems. Rather, the focus is on a brief description of treatments that have a core component that addresses peer problems. Many other evidence-based interventions for childhood disorders address peer problems in addition to other targeted behaviors (see the first issue of the 37th volume of the Journal of Clinical Child and Adolescent Psychology for a comprehensive review of evidence-based interventions for child and adolescent disorders).
ADHD. The summer treatment program (STP) for children with ADHD is an evidence-based intervention for peer interactions (Pelham & Fabiano, 2008; Pelham, Fabiano, Gnagy, Greiner, & Hoza, 2005; Pelham, Greiner, & Gnagy, 1997; Pelham & Hoza, 1996). The STP is structured to be comparable with a typical 8-week summer camp; children participate in structured recreational activities, such as baseketball, baseball, soccer, and swimming, attend an art class and an academic classroom, eat lunch and participate in recess together, and they transition between activities together. Across activities, 12–15 children with ADHD are grouped together for the entire summer. Thus, in addition to providing ample opportunity to observe peer interactions in ecologically valid settings, the ongoing functioning and interactions can also be evaluated. A unique aspect of the STP is that an intensive contingency management behavior modification program is interwoven into every activity throughout the program day. Children earn points for positive behaviors (e.g., sharing) and lose points for negative behaviors (e.g., teasing a peer), and points may be exchanged for camp privileges or rewards. Additional interventions such as public recognition for appropriate peer-related activities (i.e., a social skills “button” awarded to a child who best exemplified positive social skills the day before), brief social-skills training discussions (i.e., a 15-min discussion of social skills at the beginning of the program day that includes role-plays and modeling), and praise statements directed toward children exhibiting positive social skills are also liberally used in the program.
While the contingency management token economy generally aims to reduce the occurrence of negative peer-related behaviors, one of the goals of the STP is also to teach children skills and competencies in key domains related to peer relationships (Pelham & Hoza, 1996). For example, many children with ADHD are excluded from or struggle during community activities such as sports or other recreational activities (e.g., Pelham & Bender, 1982). To the extent that these activities are an important forum for learning social skills and interacting with peers, children with ADHD, who already struggle in peer interactions, are placed at a further disadvantage. Therefore, children in the STP receive intense instruction on the rules and applied practice in necessary skills for sports and other group activities. The purpose of these activities is to increase the competencies and skills of the children, so that when they return to their neighborhoods, schools, and playgrounds, they are effective and proficient members of the group or team. Moreover, the progress made and success experienced in the sports domain during the STP possibly contributes to the large parent- and child-reported increases in self-concept at the end of the STP (Pelham & Hoza, 1996).
A recent review of evidence-based treatments for ADHD (Pelham & Fabiano, 2008) evaluated those who had research support for peer interventions. Results of the review indicated that the STP met criteria for a well-established treatment based on a number of group design, cross-over, and single subject studies. What is presently unknown is which components of the STP (e.g., token economy, sports training, staff monitoring of peer-related behaviors) are responsible for the significant effects. Future studies that work to dismantle the intensive intervention to elucidate the active ingredients of the effective peer intervention are needed. In addition, these positive findings in the STP setting for children with ADHD are tempered by a lack of effective treatments outside the intensive programs (see Hoza, 2007 for a review).
Internalizing disorders. There is relatively less research available on explicit peer-problem interventions for children with internalizing disorders related to anxiety or mood. Greco and Morris (2001) reviewed the literature on improving the behavior of children who were shy, and they concluded that there is evidence for cognitive-behavioral interventions aimed at improving social interactions. However, most studies were conducted in clinics or specialized settings, and it is unclear how the results might be generalized to naturalistic peer groups. For example, Beidel, Turner, and Morris (2000) treated children with social anxiety in a 12-session program that included social-skills training, exposure sessions, and generalization activities, such as participating in a recreational activity. When compared with an attention control condition at post-treatment and follow-up, children in the intervention group exhibited improved social skills, and two-thirds no longer met the diagnostic criteria for social anxiety disorder. Importantly, treatment gains owing to the cognitive-behavioral treatment were maintained as long as 5 years post intervention (Beidel, Turner, & Young, 2006). These results are promising, and suggest that increased attention to the treatment of peer problems in children with internalizing disorders is needed.
Conduct problems and aggression. The Coping Power program is a 34-session intervention designed for children with anger- or conduct-related problems, and impaired peer relationships (Lochman, Coie, Underwood, & Terry, 1993; Lochman, Wells, & Lenhart, 2008). The program focuses on skill development related to problem-solving and anger management skills, social skills such as dealing with peer pressure or negotiating peer interactions, and also supports the development of positive school-related skills. The Coping Power program is conducted in group settings with other same-age children. It also includes a parent management training component to facilitate the generalization of child social skills into the home setting. As currently constructed, the Coping Power program can be implemented over the course of a year and a half. A recent review categorized the child social-skills training component of the Coping Power program as probably efficacious (Eyberg, Nelson, & Boggs, 2008).
Another intervention specifically tailored to address peer problems for children with conduct problems is the Incredible Years Dina Dinosaur social-skills training curriculum (Webster-Stratton & Hammond, 1997; Webster-Stratton, Reid, & Hammond, 2001, 2004) for young children with conduct problems. In this program, children attend weekly groups that target the development of appropriate social skills. Children engage in a number of activities during the session including watching videos of children in a number of different social situations, role-plays, participating in activities and problem solving, and interacting with child-sized puppets used to introduce concepts or promote engagement in activities. Teachers and parents monitor children’s behaviors during the week, and are instructed to reinforce children when they exhibit appropriate social skills. The program is highly structured and manualized. A recent review categorized the Incredible Years child training program as probably efficacious (Eyberg et al., 2008).
Another social-skills training curriculum is the Promoting Alternative Thinking Strategies (PATHS) curriculum that is implemented universally by teachers in schools. PATHS is administered within the context of classroom activities, and it aims to reduce the occurrence of aggressive and negative behavior, and also teaches adaptive social skills and behaviors. The PATHS program was part of the multi-component peer treatment in the Fast Track intervention study for young children with conduct problems (Conduct Problems Prevention Research Group, 1999). A recent randomized controlled trial adapting the PATHS program for a preschool setting has also indicated positive results of the intervention (Domitrovich, Cortes, & Greenberg, 2007).
Bullying/aggression prevention. Bullying behavior is clearly related to the emergence, maintenance, and severity of peer problems, as it has consequences for both the bullies and victims. There is now a collection of approaches supported by outcome data to target and reduce the negative effects of bullying in schools (Olweus, 1993; Pepler, Craig, Ziegler, & Charach, 1994; Ross, Horner, & Stiller, 2008). Most approaches are implemented in school settings, and these approaches share some common characteristics. First, there is a universal prevention and intervention component that involves the creation of school-wide expectations and rules, as well as procedures for monitoring and enforcing the rules across all school settings. Programs also involve strong efforts toward increasing awareness of bullying and its consequences throughout the school. In addition, mechanisms for reporting bullying without fear of retaliation are instituted (e.g., an anonymous reporting system). Finally, most programs utilize a tiered system of universal and targeted interventions. In a recent review that included a consideration of bullying prevention interventions, McMahon, Wells, and Kotler (2006) comprehensively reviewed the bullying prevention and intervention literature and concluded such treatments were an effective intervention, in general. This conclusion was qualified in that the interventions appeared to be more effective for younger children than older children in middle schools.
Peer mediation approaches are also widely used in school settings (Gottfredson & Gottfredson, 2002). These universal interventions to address aggression or conflict in school settings involve training peer “mediators” to intervene in problematic social situations between children. Typically, they use a problem-solving approach to resolve the situation. Cunningham et al. have reported on the outcomes of a peer mediation program (Cunningham et al., 1998). In the study, mediation teams were fifth-grade students, trained for 15 hours. The results suggested that peer mediators resolved 90% of the playground conflicts, and direct observation indicated a reduction in physically aggressive behavior by 51–65%, with sustained effects at 1-year follow-up. This study suggests that peer mediation interventions, like the one implemented by Cunningham et al. are promising interventions. One of the innovative aspects of this approach is the reliance on peers as the change agents (i.e., mediators).
There are also targeted treatments for children who are aggressive or bully others. For example, the Reprogramming Environmental Contingencies for Effective Social Skills Training (RECESS) is a well-developed program that aims to improve the social skills of young children who exhibit aggression or are at-risk for antisocial behaviors (Walker, Hops, & Greenwood, 1993). The program is very carefully manualized and structured, and it involves a number of hierarchical components. First, individual social-skills training that includes discussion and role-play with the targeted student and the entire classroom is conducted. Second, a response cost token economy is implemented where the child loses points for inappropriate social behavior (e.g., aggression) and rule violations (Hops & Walker, 1988). Praise and rewards (classwide and home-based) are contingent on appropriate social behaviors exhibited by the child. The program implements the contingency management approach using four phases. The first phase focuses only on behavior in the recess setting and contingency management is implemented by a para-professional. Once the child exhibits improved behavior, similar interventions are implemented in the classroom. After documented progress in the child’s behavior, the para-professional’s support is faded, and procedures are turned over to the teacher and other school staff to maintain. Developers of the RECESS program have extensively field-tested and evaluated the program (Walker, Ramsey, & Gresham, 2003), making this an effective intervention for children at-risk for peer problems in elementary school.
57.4 15.4 Mechanisms of Change
There is currently no consensus across studies regarding the specific mechanisms that promote change in peer problems from intervention. However, there are some commonalities amongst effective interventions that can be discussed, and these are potential contributors to the change seen due to peer interventions. Each of these components will be briefly discussed.
First, as is clearly apparent from an overall review of effective interventions for peer problems, the use of contingency management strategies based on the principles of social learning theory are a component of all effective interventions. That is, establishing clear expectations, rules, and goals for peer-related behaviors, monitoring the exhibition of appropriate and inappropriate behaviors, and following these behaviors with logical consequences for positive and negative behaviors is an approach that appears to be a necessary ingredient of effective interventions. For example, one might argue that the intensive contingency management approach is what makes participation in an STP an evidence-based treatment for ADHD, whereas simply participating in group recreational activities is not (Pelham et al., 2008). Other programs that address peer problems related to anger or conduct problems (e.g., Lochman et al., 2008) and bullying (e.g., Olweus, 1993) also contain contingency management components. It is likely that contingency management helps to support and correct peer-related behaviors that had not been addressed by naturally occurring contingencies for one reason or another. Of course, one drawback of contingency management approaches is that there appears to be only modest evidence of generalization of treatment effects (e.g., Pelham et al., 2005), suggesting that while these interventions improve peer interactions while implemented, they do not appear to result in sustained change in functioning, necessitating long-standing intervention.
A second commonality across the effective treatments outlined earlier is the emphasis on implementing treatment procedures and facilitating social-skills training in naturalistic peer settings, such as during recreational or school-based activities (e.g., Beidel et al., 2000; Pelham et al., 2005). The exact mechanism for change related to this approach is not well-studied. However, it is reasonable to presume that a child who practices a new behavior in a context similar to that of the situation where treatment effects are aimed to generalize may be more successful in maintaining appropriate peer-related behaviors. It is clear that substantial treatment effects can be generated by having a child practice targeted social skills in a peer setting immediately prior to participating in a peer-group interaction (O’Callaghan, Reitman, Northup, Hupp, & Murphy, 2003). What is unknown is the extent to which other treatment approaches can be generalized, whether treatment effects are maintained, if effects do not maintain with what speed they decrease, and whether additional supports or interventions (i.e., including a parent-related treatment in parallel) promotes generalization (see Pfiffner & McBurnett, 1997 for an example of this approach).
Although, generally an unaddressed parameter in the treatment literature, all the effective interventions reviewed earlier include intervention within a peer group. One potential mechanism for change therefore relates to implementation of treatment procedures with same-age peers. Although the precise mechanism of how this peer-group interaction supports the alleviation of peer problems is unknown, it is likely that the peer group provides an ecologically valid setting for intervention, provides a number of models (both positive and negative) for the child to observe, and may reduce feelings of isolation. Further, one important aspect of treatment in the peer group is that it permits peer interactions to occur in a structured and monitored setting. Deficits in social cognitive strategies are one possible reason for peer problems. The structured setting may permit a buffered situation where mistakes or ill-advised peer-related behaviors may be identified, corrected, and retried so that the child can experience different consequences for peer-related behaviors. An additional area that is in need of further study is whether the peer intervention context can serve as a catalyst for the beginning of a friendship that may be maintained after the treatment has ended (e.g., Hoza, Mrug, Pelham, Greiner, & Gnagy, 2003).
A discussion of the mechanisms for change would also be remiss without an examination of potential mechanisms for negative change that may happen within the context of interventions for peer problems. Recent research has highlighted a potential for iatrogenic negative effects of peer interventions in group settings. Dishion et al. (Dishion, McCord, & Poulin, 1999) define this process as deviancy training – the shaping of negative behavior when in the company of other children who reinforce the negative behavior. In a study on conduct problem faced by youth, it was demonstrated that teens reinforced rule-breaking behavior and negative comments through their responses (e.g., laughing, smiling), and as Dishion et al. (1999) reported, the participation in group treatment resulted in more negative outcomes for treated youth (e.g., on measures of smoking during follow-up assessments).
These results spurred an immediate reaction in the professional community, and caused concern regarding the potential harm of group interventions for children. However, further research and analysis has suggested that the original conclusions need to be qualified. First, it is clear that in unstructured treatment settings with poor adult supervision or control, children will engage in considerable deviancy training (Onyango et al., 2003). Importantly, rates of deviancy training (and negative behaviors that can be reinforced through peer attention) decrease dramatically with the use of well-defined structure, rules, expectations, and consequences in the peer-treatment setting. Second, in a comprehensive review and meta-analysis, Weiss et al. (2005) examined the child-treatment literature and found that a child intervention with a peer component was actually less likely to have a negative effect size (i.e., a negative effect of treatment). Thus, although deviancy training may occur, it is less likely to occur in situations where treatment facilitators implement contingency management and monitoring strategies, and across multiple studies on research synthesis, there was little indication that peer affiliation during group treatment was a procedure resulting in a negative outcome.
It is clear that like most mechanisms of treatment effects in child-based interventions, the precise mechanisms of treatment for peer problems (i.e., the mediators of treatment effects) are not well-defined. Certainly, additional work in this area is warranted.
57.5 15.5 Basic Competencies of the Clinician
A conceptualization of basic competencies for the clinician should begin in the early training stages for professionals. Given the prominence of peer relationships in development, prediction of long-term outcome, and as a marker of adaptive or impaired functioning, peer relationships are relatively under-represented in clinical and professional training programs. This may be partly due to the lack of a DSM category for peer relationships, as discussed earlier, as well as the heterogeneous nature of peer problems. Regardless, there should be an increased emphasis in training programs on evidence-based approaches to assessing and intervening peer problems. For example, it is now well-documented that child report may be a valid approach for assessing the presence of peer problems in some situations (e.g., whether a child is being bullied; feelings of social anxiety), but not for other situations (e.g., a child with ADHD’s self report of friendship quality; Owens et al., 2007). An effective training program would review and evaluate assessment approaches specific to peer problems with regard to instruction related to basic principles of assessment. Furthermore, there is a growing literature of evidence-based interventions for children with peer problems. Training programs should educate future clinicians and professionals on how to implement these treatments that are backed by evidence. In addition, there appears to be no viable justification for the provision of practical experience or training in non-evidence-based approaches (e.g., individual counseling with a child). Thus, programs should actively and critically vet potential sites for students, and have procedures in place for the quality control of clinical training experiences, to ensure that training will be consistent with evidence-based approaches.
Basic competencies of a clinician during assessment activities should be grounded within the principles of functional and applied behavior analysis (e.g., Repp & Horner, 1999) as well as social learning theory. Assessments for peer-related competencies and deficits can start with a clinician clearly defining targeted behaviors to increase or decrease (e.g., teasing), obtaining information regarding the antecedents of the targeted behavior (e.g., being provoked or teased by a peer; the child feeling “left out”), as well as the consequences (e.g., obtaining peer attention, albeit for a negative behavior; reinforcement of a maladaptive peer-related behavior; development of a negative reputation with peers). Because of the complexity of peer-related interactions and the concurrent issues of the questionable veracity of child report in some cases, as well as the possibility of parental or teacher ignorance of the antecedents or consequences of some peer-related behaviors (e.g., Hinshaw & Melnick, 1995; Pepler & Craig, 1995), multiple methods and informants are needed to conduct an effective assessment.
Assessment of peer problems may also require assessment strategies that are different from the standard interview and checklists available for most childhood problems. For example, as was discussed in the assessment section earlier, sociometric measures that ask children in a classroom to nominate their friends as well as children whom they dislike may be needed for a clinician to understand the topography of peer relationships in a group (see Bierman & Welsh for a review, 1997). Such measures may also be re-administered and can be sensitive to changes due to intervention. Drawbacks of this approach include the difficulty in obtaining consent from schools and non-treatment-related families to permit the collection of sociometric information. The difficulty may be worth negotiating, however, given the modest relationship between parent ratings and child self-report and peer ratings of social standing (especially from children with externalizing disorders; Hinshaw & Melnick, 1995).
Observations of child or adolescent behavior in peer-related situations may also be a required part of an assessment if a clinician is to completely understand the nature of antecedents and consequences of peer-related behaviors (Bierman & Welsh, 1997). Observations may be necessary due to the limitations of the child’s self-report and adult report noted earlier. Non-obtrusive observations of child behavior may also be helpful for identifying targets of treatment or maintaining factors (e.g., school records of attendance, tardiness, and school nurse visits for a child with social phobia or who is being bullied; discipline referrals for aggression during recess periods).
One additional comment on assessment is that diagnosis or problem identification is but one among many purposes of assessment. Additional purposes include treatment planning, treatment and progress monitoring, and evaluating outcome (Mash & Hunsley, 2005). By using an applied behavioral analytic framework that identifies areas of competencies and strengths, the operational defines the behaviors in these domains and also works to crystallize the specific antecedents and consequences of each behavior should help to promote continuity across the different purposes of assessments related to peer problems. This approach should also help a clinician to focus on impaired areas of peer functioning, which are the socially valid and clinically meaningful targets of intervention (Fabiano & Pelham, 2009). Further, these areas of impaired functioning lend themselves to meaningful measures of progress monitoring. For instance, many children with impaired social behaviors in school receive special education services to facilitate the remediation of these deficits. Services are defined and target behaviors are operationalized in the child’s Individualized Education Program (IEP). These targeted behaviors can be easily modified for use in a daily report card or school-home note, so that a child receives frequent feedback on behavior and importantly, the clinician has a consistent way to monitor progress and evaluate treatment effects. This approach is relatively easy to use (see http://ccf.buffalo.edu for instructions) and preliminary evidence suggests that it may be psychometrically sound (Fabiano, Vujnovic, Naylor, Pariseau, & Robins, 2009; Pelham, Fabiano, & Massetti, 2005). Of course, this approach can be used for a child without an IEP with school-based peer problems as well. Progress monitoring is important for school-wide interventions as well. A good example of this is the peer mediation paper by Cunningham et al. (1998) – follow-up observations of the implementation of the program revealed that one school experienced an increase in aggressive behavior. Upon closer review, it was determined that the school had reduced the number of mediators on the recess playground, resulting in a reduction in the effectiveness of the program. Clear procedures for monitoring progress should help to identify and provide the opportunity to remediate these types of situations.
The preceding discussion of a school-based, progress-monitoring measure of social behavior presumes another basic competency. That is, clinicians must be proficient in working with individuals in the child’s natural environment. Progress monitoring, identification and monitoring of targeted behaviors, intervention strategies, and generalization activities must all occur outside the clinic within the context of peer interactions. For this reason, a basic competency involves coordination of care across agents (e.g., parents, teachers, coaches, child care workers) in all settings where peer problems are observed. This presents a practical barrier for professionals accustomed to working in office settings directly with the child only, but it is notable that none of the evidence-based interventions reviewed earlier included solely clinical contact with the child in the clinic. All included some aspect of school intervention, parent training, or generalization activities in the peer group. Clinics working with children with peer problems must therefore engineer staff schedules and responsibilities to permit time for meeting with teachers at the child’s school throughout the duration of assessment and treatment, and have staffing patterns that permit children and parents to receive treatment in parallel to reduce family burden related to treatment. This approach also supposes that a clinician is competent in child-focused, parent-focused, and family-focused evidence-based treatment approaches.
As is clear from the sampling of evidence-based interventions described earlier, clinicians must also be competent in their ability to manage a therapeutic group. For instance, clinicians must be adept at setting clear limits and boundaries during group activities. This would include explaining the concept and consequences of confidentiality for issues discussed in the group, the management of disruptive or off-task behaviors, and ensuring that all participants have an opportunity to contribute during discussions. Effective group facilitators during discussion or instruction activities are also effective in asking open-ended questions and in using reflective listening skills. It is also clearly apparent that a basic competency necessary for clinicians working on peer problems in groups is the ability to integrate intervention components into the context of recreational or other peer-related activities. This requires a clinician to maintain the ongoing activity at a level that is interesting and engaging, while also being sure that treatment ingredients specified in manuals, such as modeling, practice, and contingency management are implemented according to the treatment plan.
A final basic competency for all clinicians working to address peer problems relates to their being proficient in contingency management strategies. If it were as easy as simply telling a child that they should not tease, or should really join the group activity at school, or to just ask the school bully to stop bullying, most clinicians would be out of a job. Evidence-based interventions include contingencies for meeting treatment goals or expectations, as well as for missing treatment targets because children with peer problems are not successfully negotiating interactions within the context of naturally occurring contingencies or instructions. For instance, contingency management strategies may include the intensive, comprehensive STP token economy (Pelham, Fabiano, et al., 2005) or the more clinically based contingency management included in the parent management training component of the Coping Power program (Lochman et al., 2008).
57.6 15.6 Expert Competencies for the Clinician
As a clinician becomes proficient in basic competencies, skill development also shifts to a consideration of how one increases the depth, breadth, and complexity of clinical skills related to the treatment of peer problems in applied clinical work. Most of the expert competencies relate to enhancing the skills included in the basic competency section to meet additional treatment needs or goals. Some of these competencies are reviewed, and examples of how these expert competencies might be used clinically are described.
One expert competency relates to developing supervision skills. The evidence-based treatments for child and adolescent peer-problems are well-manualized and contain multiple components. Notably, most of these components can be effectively implemented by para-professional providers without advanced degrees (i.e., college undergraduates, individuals with bachelor’s degrees). In fact, it has been long known that there are few differences in treatment outcome owing to the degree of the professionals implementing the intervention (Kent & O’Leary, 1977). In contrast, what is important is the degree of integrity and fidelity incorporated into the treatment implementation (see expanded discussion later). Thus, as professionals master basic skills in treatment implementation for peer problems, and concurrently advance in the field, it is likely that part of their role will be the supervision of others conducting the interventions for peer problems (i.e., student trainees, interns, other professionals). Although there is a growing realization regarding the need for effective supervision (e.g., Neill, 2006), there is also currently substantial variability in the availability, quality, and frequency of supervision available to clinicians working with children who have problems in peer relationships. An expert competency therefore relates to being an effective supervisor. This involves not only using effective supervision skills, but also strategies. For example, research indicates that supervisors typically spent the least amount of time in activities that are the most effective for supervision (e.g., reviewing audio or videotapes; Ward, 1999). Most peer-problem interventions require multiple staff members (i.e., monitor of the child component, facilitator for the parent portion of treatment, etc.). Given the highly manualized and structured nature of the evidence-based peer-problem interventions reviewed, effective supervision that uses procedures known to be effective is needed.
In addition, expert application of evidence-based treatment is a skill that develops with experience and good supervision. Many excellent manualized programs that are evidence-based for peer problems were reviewed earlier. As a clinician masters the basic skills required to implement a manualized treatment, the focus shifts to expert competencies. This includes the ability to work fluidly within the prescribed treatment, while at the same time, applying the treatment procedures with clinical skill, integrity, and fidelity. As Kendall, Chu, Gifford, Hayes, and Nauta (1998) conceptualized, the manual provides a guide for the parameters of treatment, but it is up to the individual to tailor and individualize the treatment to be clinically meaningful for the client. Expert clinicians can use the strategies outlined in a manualized intervention protocol in an individualized manner, to be maximally effective for a referred client. Many treatment manuals provide explicit information on how to individualize treatment in this way, but it is up to the clinician to do this effectively.
An example of individualizing treatment within the context of a highly structured treatment program comes from the STP (Pelham, Fabiano, et al., 2005; Pelham, Greiner, & Gnagy, 1998). The standard program components include a token economy, individualized daily report card, time-out procedures, and additional contingency management strategies (e.g., contingent praise for appropriate peer-related behaviors). However, there are additional treatment components that can be added as needed. These include group contingency procedures wherein the consequences for an entire group are dependent on the behavior of a child or subset of children in the group, or the group as a whole (Litow & Pumroy, 1975). Group contingencies have been successfully employed in the STP to manage the peer attention directed toward negative behaviors. For instance, some children engage in “class clown” behaviors during the classroom activities in the STP. These behaviors are disruptive, yet yield an incredible amount of reinforcing peer attention for a child. In these cases, the target child’s behavior needs to be treated, but it is also necessary to treat the response of the group as a whole to the child’s behavior. In these cases, the class can be informed that a group reward (extra free time; picking a piece of candy from a grab-bag) is made contingent on the target child meeting behavioral goals during the class period. In most cases, peer attention for the child’s “clowning” behavior decreases immediately, effectively changing the positive consequence for the negative behavior. When the child meets the goal, it is also very effective to see he/she beam with delight as the class cheers and claps for the successful attainment of the reward. Group contingencies can also be applied to entire groups of children to reduce the occurrence of negative peer behaviors such as tattling, or even disruptive or aggressive behavior in schools (Fabiano et al., 2008; Hops & Walker, 1988).
A more specific expert competency for a clinician targeting peer problems is to work to engage fathers in treatment efforts. Fathers are considerably under-represented in intervention studies (Fabiano, 2007; Phares, 1996). However, fathers contribute to many aspects of their child’s development, including the development of emotion regulation, social cognition, and focused attention, and probably because of these factors, appropriate peer relationships (Parke et al., 2002). Further, fathers are most likely to be interacting with or supervising a child during activities where peer interactions are likely to occur (e.g., play, outdoors time; Russell & Russell, 1987). Thus, when targeting the treatment of peer problems, fathers may be a critical agent to include in intervention efforts.
Clinicians can also work to focus evidence-based peer interventions on specific contexts or situations where peer problems are present. For instance, behavioral parent training and the intensive peer-focused STP are evidence-based ADHD treatments (Pelham & Fabiano, 2008). The Coaching Our Acting-Out Children: Heightening Essential Skills (COACHES) program combines these two interventions, and it is an approach intended to promote effective parenting by fathers and improved peer relationships for children with disruptive behavior disorders. The COACHES program is an 8-week behavioral parent-training program held for 2 hours each week that includes an evidence-based behavioral parent-training program for fathers (Cunningham, Bremner, & Secord, 1998) and STP soccer skill-building activities and game activities (Pelham, Fabiano, et al., 2005). The COACHES program was created based on the premise that, including a recreational, sports activity within the context of BPT for fathers would increase the palatability of the intervention for fathers as well as provide a forum for improving peer-related behaviors and athletic skills for children, and these two factors together were hypothesized to result in a synergistic treatment effect.
During the first hour, fathers review how to implement effective parenting strategies in a group setting (e.g., using praise, using time out). Concurrently, children practice soccer skill drills with para-professional counselors, to increase competencies in the sports domain (Hupp & Reitman, 1999; Pelham, Fabiano, et al., 2005; Pelham, Greiner, & Gnagy, 1998; Pelham & Hoza, 1996; Pelham et al., 1990). Then, during the second hour, the parent and child groups join together for a soccer game. The soccer game provides a context for the fathers to interact with their children and practice the parenting strategies taught in the classroom (e.g., praise, using effective commands), for the children to practice good social and soccer skills, and for clinicians to provide immediate feedback to the fathers (e.g., Pelham et al., 1998; Reitman, O’Callaghan, & Mitchell, 2005). After each quarter of the game, fathers meet with the COACHES group facilitator, and the group has a brief, 5-min meeting on the playing field. During the meeting, the facilitator asks the parents to report on observations of the use of the weekly parenting strategy employed successfully during the game (either their own use or use by others), asks them to answer attributional questions similar to those described in the COPE program (Cunningham et al., 1998), and offers a chance for fathers to ask each other for advice on how to handle situations that arose during the game.
The COACHES program compares favorably with the standard parent-training program approaches, but offers some specific benefits. First, children were significantly more likely to drop out of treatment if they were in a typical social-skills group and did not experience father–child interactions in the context of the soccer game (Fabiano et al., 2009). As child and parent satisfaction with treatment are important predictors of persistence with treatment (Kazdin, Holland, & Crowley, 1997), this is an important outcome. Fathers are also highly satisfied with the program, and anecdotally report on treatment evaluation ratings that the COACHES program was the first successful community activity they participated in with their child. This suggests that participation in a highly structured and supported recreational activity with other children and the father may be a good beginning approach to working on improving children’s peer problems. Similar approaches of combining evidence-based approaches for a problematic behavior have also yielded promising results (e.g., parent training, teacher training, and a peer-intervention; Webster-Stratton et al., 2001).
Expert clinicians will not only be adept at working with an individual family or groups of children, but will also be able to consult effectively to enact change in systems. Peer relationships, and potential problems, typically occur within the context of a system such as a school, neighborhood, or a recreational activity. In some cases, to effectively change problems in peer relationships, the entire system will have to change. Cunningham et al. (1998) emphasize on the importance of a school-wide embracement of the peer-mediation program that includes endorsement by all individuals in the school from administration to teachers to students, school assemblies to emphasize and kick-off the program, and clear support for the mediators from teachers and other school personnel. The Positive Behavioral Intervention and Support approach (e.g., Sugai & Horner, 2008) as well as anti-bullying programs (e.g., Olweus, 1993; Ross et al., 2008) also require consulting with schools to ensure that a whole-school approach is implemented. Thus, clinicians must be able to successfully attain the support of school personnel across levels of a district (i.e., superintendent, principals, teachers, parents, students), often requiring the time, persistence, and ingenuity to negotiate bureaucratic red tape, a knowledge of the history of past programs targeting social development that failed to maintain, and the need to fit an intervention into existing district priorities. Truly partnering with consumers of interventions is therefore necessary, and an ability to listen and integrate consumer-provided feedback or needs into the framework of an evidence-based intervention is an essential component of effective consulting (see Leff, Costigan, & Power, 2004 for a practical example of this approach for targeting peer-related behaviors on a school playground). Clearly, this is not a simple task, and it is one that will require expert experience as well as adherence to the principles of evidence-based treatment, which can be diverted or can experience drift if not continually monitored (e.g., Gottfredson & Gottfredson, 1998).
A final expert competency worthy of discussion relates to the need to maintain treatment as long as is needed. It is notable that most of the evidence-based treatments discussed are not brief interventions. This makes sense when one considers the complexity of peer interactions – children with peer problems have had possibly years of practice with poor interaction skills, and it is reasonable to presume they may need just as long to master new skills that are adaptive. This may require clinicians to utilize strategies to maintain motivation and engagement over time. For instance, motivational interviewing strategies (Miller & Rollnick, 2002) may be useful for adolescents with peer problems related to affiliating with negative peers or engaging in behaviors where they do not see the benefits of changing (e.g., using alcohol; Monti et al., 1999). Clinicians should also be cognizant of critical periods throughout development where peer interventions may be particularly important. The Incredible Years Dina Dinosaur program is a good example of an intervention that facilitates the transition to interacting with others in a structured school setting, and the Coping Power program targets the transition to middle school. In addition to maintaining treatment as long as is necessary, experienced clinicians will also build-in expectations for families that peer interventions may need to increase in intensity during critical periods of development.
57.7 15.7 Transition from Basic Competence to Expert Competence
Because of the multiple strategies that can be used for treating peer relationships, it is best to think of the development of clinical skills along a continuum of expertise. A conceptualization of skills in this way leads to a discussion of how a clinician may transition from fundamental skills or strategies to more advanced approaches to working with children with peer problems. Strategies that facilitate a therapist’s increasing competence will be discussed in the following paragraph.
One straightforward way to obtain increased levels of skill in the area of treating peer problems is through participation in trainings and continuing education opportunities that include instruction on how to implement evidence-based strategies. Professional associations, such as the American Psychological Association, Division 53 Society of Clinical Child and Adolescent Psychology (http://www.clinicalchildpsychology.org), offer conferences aimed toward clinicians which provide expert instruction on evidence-based treatments, including those mentioned in this paper. Similar offerings are conducted by the National Association for School Psychologists (http://nasponline.org) as well as the developers of the interventions reviewed in this paper. These trainings are excellent starting points for learning about effective strategies and making contacts with program developers. It is important to point out that attendance at a single conference or training, however, is unlikely to substantially modify a clinician’s practice. Therefore, to truly move from basic to expert competence, it is likely that a clinician will need to view these trainings as an ongoing professional development enterprise. Further, trainings may need to be supplemented by on-site training or supervision on a regular basis to ensure successful implementation of procedures, and integrity and fidelity to intervention components.
Related to training is the issue of treatment adherence, integrity, and fidelity. According to Waltz, Addis, Koerner, and Jacobson (1993), the terms adherence and competence distinguish between degree of implementation by the treatment agent and the care in which the agent implemented the intervention. As such, adherence is referred to as “the extent to which a therapist used interventions and approaches prescribed by the treatment manual” (Waltz et al., 1993, p. 620). Competence is referred to as the “level of skill shown by the therapist in delivering the treatment” (Waltz et al., p. 620). Considering the distinction between adherence and competence is especially important when an intervention is implemented by a secondary treatment agent, such as a para-professional or teacher. For clarity in the current discussion, adherence is considered as the degree to which the parent/teacher implements the intervention as intended, while competence is considered as the care and skill shown by the parent/teacher in delivering the treatment. Hereafter, the term treatment integrity refers to the combination of the essential components, adherence and competence.
Gresham (1989) identified several factors related to treatment integrity. They include: (1) the complexity of the treatment, (2) time required to implement the intervention, (3) resources required for treatment implementation, (4) number of treatment agents required, (5) perceived and actual effectiveness of the intervention, and (6) motivation of the treatment agents. The degree of treatment integrity has been directly related to the complexity of treatment, such that greater complexity results in lower treatment integrity (Yeaton & Sechrest, 1981). For instance, treatments considered more complex usually required more time to implement and resulted in lower integrity, with lack of time being the most cited reason for failure to implement an intervention (Gresham, 1989). Lower levels of treatment integrity were found amongst treatments that required additional materials or resources, beyond what was found in a typical classroom or clinic. Treatments requiring more than one treatment agent were likely to have greater complexity, and were often implemented with less integrity. Treatments perceived to be more effective were implemented with greater integrity than those lacking perceived effectiveness.
Notably, these contributors to lowered treatment integrity (e.g., complexity, intensity, etc.) noted by Gresham (1989) are typical of evidence-based peer interventions. Therefore, clinicians need to have procedures for ensuring treatment integrity and fidelity built-in to intervention efforts as a standard part of the intervention. This may make interventions more costly because they become more staff- and time-intensive, yet, if that is what is necessary to promote effective intervention, the additional cost is warranted. As clinicians transition from basic competencies, where they are likely being evaluated for the integrity of the interventions they implement, to expert competencies, it is probable that they will begin to be in the position to evaluate the integrity of others’ interventions aimed at reducing problems in peer relationships.
Perhaps, the clearest distinction between novice and expert clinicians relates to the fidelity of the intervention. Fidelity relates to the genuineness, interpersonal style, and ability to form a therapeutic alliance with a client and family. This is much harder to do if a clinician is preoccupied with implementing the “nuts and bolts” of an intervention correctly. Only after the basic strategies of an intervention are mastered can a clinician focus carefully on the fidelity of the intervention. Importantly, it does not appear that the opposite direction of focus makes clinical sense – a clinician who is warm, genuine, and has a strong therapeutic alliance, but does not implement treatment procedures that work, would not be helping the child and family, even if the therapy experience was pleasant for both parties. Therefore, after careful training and experience with an intervention, the clinician should maintain focus on the integrity of the treatment while also expanding focus to their interactional style and engagement strategies.
An additional consideration in the transition from novice to expert relates to the ability to construct idiographic treatment plans that are relevant to the child and family. For instance, an expert clinician would use initial assessment information to gather data on the antecedents, consequences, and setting events of peer problems, use this information to define treatment targets, and tailor the initial intervention to these targets. Expert clinicians would also institute relevant progress-monitoring measures (i.e., daily report card, peer sociometrics) that can be administered throughout the duration of treatment to inform data-based decision-making. Finally, an expert clinician would coordinate care across agents of change in the home, school, and community settings to ensure a comprehensive approach. With experience, good supervision, adherence to protocols, and integrating consumer feedback into future interventions, clinicians should be successful at refining their clinical approach for treating peer-related behaviors.
57.8 15.8 Summary
In this chapter, we have outlined the impact of peer problems across a host of functional domains, described the symptoms and impairments related to peer problems, and provided a brief overview of the assessment methods supported by research. In addition, potential maintenance factors related to peer problems were discussed. Fortunately, given the considerable impairment experienced by children with peer problems in the short and long term, there are evidence-based interventions available for clinicians to implement. Notably, these are often intensive and complicated treatments that need to be implemented with good integrity and fidelity to be effective. Clinicians must work to develop clinical skills that are effective for remediating peer problems.
Establishing positive peer relationships may be one of the most critical developmental milestones for children and adolescents (Parker et al., 2006). Importantly, problems in peer relationships are not circumscribed to a handful of child DSM diagnostic categories, but rather span categories, and may even constitute a referral for treatment as a stand-alone problem. Therefore, clinical skills related to the assessment and treatment of peer problems are needed for all clinicians working with children and families. As outlined in this chapter, the stakes are high for children experiencing problems in peer relationships, and these children cannot afford to participate in interventions that do not work. An approach that integrates evidence-based interventions, consistently over time, in all settings where impairment is present, is what is needed to make a real difference for affected youth and those around them.