(p. 756) Social Skills (Social Competence) Training for Children and Adolescents
MKA is a licensed psychologist who owns, directs, and practices at Alvord, Baker & Associates, LLC, located in Rockville and Silver Spring, Maryland, in the suburbs of Washington, DC. As an adjunct associate professor of psychiatry and behavioral sciences at the George Washington School of Medicine and Health Sciences, I also supervise second-year psychiatry fellows in cognitive-behavior therapy. After receiving my PhD in 1977, I worked for two years in a community mental health center prior to working for five years in a residential/day treatment center for youth. In 1983, I began a part-time solo practice (overlapped for a year with my other position and shared a small office space with my eventual business partner) while raising young children. Eight years later, my business partner and I moved to a larger building space, creating offices large enough to run groups for children and teens. Alvord, Baker & Associates incorporated in 1997 and grew to 20 psychologists and social workers by 2006, with two office locations to widen the geographic net and range of clientele. The original office is located in a building where we lease space, which has allowed for expansion over the years. Adding the second location 10 years ago was primarily driven by our long waitlist, especially for groups. I purchased a large space in a medical office building. All clinical offices are large enough to fit six children/teens to facilitate group therapy. This is key to running multiple groups simultaneously, especially on Saturday mornings. Alvord, Baker & Associates now comprises (1) a clinical practice that has a range of evidence-based services, (2) a research arm that collaborates with Catholic University to investigate the treatment effectiveness of our Resilience Builder Program (RBP) groups within both practice and school settings, and (3) a continuing education (CE) program that includes (p. 757) a cognitive-behavior therapy (CBT) training institute for children and adolescents, as well as general CE programs.
LHB is a licensed psychologist who practices at Alvord, Baker & Associates in the Rockville, Maryland, office. I received my PhD from Harvard University in 2012 and began working at the practice the same year. Dr. Alvord provides weekly supervision for all clinicians in the practice for the first two years, including individual supervision and peer consultation. I was particularly attracted to this practice due to its dedication to evidence-based treatments, the fact that the RBP group therapy was offered in addition to individual psychotherapy services, the practice’s commitment to research related to evaluating the effectiveness of the RBP, and the practice’s active participation in CE programming. I had previous experience running CBT- and dialectical behavior therapy (DBT)- based therapy groups during my practicum training and internship at McLean Hospital and valued the beneficial impact of group therapy for building social competence skills in youth. I also came from a strong research background, so it was important to me to continue in both clinical and research endeavors professionally. Alvord, Baker & Associates is a unique private practice in its synthesis of clinical work and research, and I have felt very lucky to be able to actively engage in both, including currently serving as our director of research.
The Niche Practice Activity
RBP (Alvord, Zucker, & Grados, 2011) is the group curriculum that we follow in the practice to build social competence and emotion regulation skills in children and adolescents (http://www.alvordbaker.com/groups/). We use the term “social competence” to encompass both the learning and the application of social skills. Thus, generalization of skills is emphasized. This is accomplished through free play/behavioral rehearsal during part of each group, weekly resilience builder assignments that are completed between sessions, a weekly success journal, and a field trip to practice skills in a public setting. Moreover, to encourage parents to be active partners in the generalization of skills, we provide weekly letters to parents, conduct mid-semester parent meetings, and ask parents to join the end of sessions approximately once per month. In addition, the groups also focus on building emotion regulation skills, which share a reciprocal relationship with social competence skills and are integral to successful interpersonal functioning. To this end, the RBP includes relevant group topics such as anxiety management and anger management (among others), and there is dedicated time at the end of each group to practice relaxation and self-regulation techniques (e.g., calm breathing, progressive muscle relaxation, visualization).
The RBP curriculum was developed by and for practicing clinicians rather than in a university clinic. Treatment goals are resilience-based and reflect the protective factors that have been found in the research literature to enhance resilience (Alvord & Grados, 2005). A CBT orientation guides the strategies employed. While evidence-based CBT skills provide the framework for the RBP, we are also in the process of empirically evaluating the effectiveness of the RBP. We have been collecting treatment outcome data in the practice since 2009, and in schools since 2015. Our research team is composed of four psychologists within our practice (all of whom also provide individual and group therapy), one master’s-level research coordinator, one psychology professor (p. 758) at the Catholic University of America (CUA; we collaborate with his Child Cognition, Affect, and Behavior Laboratory and our research is overseen by the CUA Institutional Review Board), and several CUA undergraduate and graduate research assistants.
Our clinical practice runs approximately 30 weekly RBP groups per school “semester” for grades kindergarten through high school. During the summer, a shorter session is offered and we enroll approximately half the number of groups. Groups are provided in both office locations and run by the majority of the clinicians in the practice. Dr. Alvord personally runs five groups in the practice and one in a school during the academic year, and four groups in the summer. The other clinicians typically run two to five groups, predominantly in the practice, with four other clinicians also running groups in the schools. The demand for these groups is high, and we always have a lengthy waitlist. The fact that we offer evidence-based, structured groups with notable qualitative and quantitative positive outcomes has been one of the major driving forces of the practice expansion.
Developing an Interest and Training in this Niche Activity
While in graduate school, I (MKA) took a formal course in group psychotherapy, primarily focusing on Yalom process groups and skills-based behavioral groups. My doctoral dissertation focused on pro-social behaviors through modeling and imitation learning in preschool and kindergarten children. The dissertation study was conducted in small groups: experimental and control groups within several schools. The statistically significant changes that I witnessed as a result of the experimental intervention led to my further interest in group therapy as a means to teach and develop social competence. Social learning theory as an explanation of how we develop and enhance relationships intrigued me, and I was interested in helping children who had difficulty navigating peer interactions. We know from longitudinal studies that children with poor peer relationships and weak self-control do not fare well along multiple domains. During my internship and postdoctoral year, I had the opportunity to run groups in community mental health and school settings. After receiving my PhD, I sought CE training and was introduced to Sheldon Rose’s group behavioral therapy books. However, I did not run groups for the first eight years of private practice, primarily due to a lack of sufficiently large physical space. Once we moved office locations, I was able to initiate a group program. In preparation for running groups, I developed a social competence group therapy program, which evolved—with input from many clinicians—into the RBP. The formal manual of the RBP was published by Research Press in 2011.
Joys and Challenges Related to this Niche Activity
I (MKA) am passionate about running social competence groups as I have seen the tremendous benefits and positive changes over time. The groups help children and teens feel validated and (p. 759) supported, which is key to gaining “buy-in” and embracing proactive change. Including parents in the process contributes to this change on a systemic level, which is rewarding. Given the well-known imbalance between need and services, providing therapy in a group setting enables the clinician to reach more children within the same timeframe. Moreover, every single group is unique, even if the agenda and skills topics are the same; diverse combinations of children bring different dynamics and interactions. I find that I am most excited about running groups because this variation keeps me interested, creative, and energized.
The logistics of forming and maintaining groups present the greatest challenge. It can be difficult to cluster together (for each of at times 30 weekly groups) five or six families of children who are a developmental and diagnostic fit and can attend group on the same day and time for at least 12 weeks. Thereafter, group absences and commitment are inherent hurdles. Over the years we have learned that children’s sickness and activities can get in the way of full participation. We allow two absences per semester without charge to address this issue. Though we have a low dropout rate once groups commence, we have found that some families change their mind immediately before the group starts (e.g., an extracurricular activity unexpectedly conflicts with the timing of the group). It can be problematic if, for example, a group suddenly drops from four members to two members; it can squash that group altogether and the remaining members need to try to be integrated into other groups. To mitigate this problem, we ask for a deposit of a small activity fee and one session to be paid in advance.
Behavior management presents a second challenge to running our groups. Given that deficits in social and emotional functioning are common denominators in the children and adolescents who join groups, it is not surprising that some participants have particular difficulty navigating how to act in the group setting. During groups, we try to draw attention to the positive behaviors we want the kids to demonstrate, rather than attending to the negative behaviors. To this end, the children earn points for exhibiting positive, cooperative behaviors (which they can later exchange for small prizes) and this positive reinforcement usually helps shape the behaviors of all the kids in the group. However, sometimes there are one or two children in a group who have significant difficulty with talking or acting in inappropriate ways and require regular redirection, which can be disruptive to the entire group flow. It may be necessary for a child to step outside the group to talk one on one with the leader before reentering the group room, and individual meetings outside of group time are also sometimes warranted to address continued behavioral disruptions.
Business Aspects of this Niche Activity
Our practice brand is built on evidence- and strength-based treatment. This positive frame parallels the resilient protective factors and has led to excellent success. Parents, school personnel, and local providers are drawn to the strength-based frame of the RBP and appreciate that we are collecting empirical data to measure effectiveness.
Group referrals come primarily from school counselors, pediatricians, psychiatrists, clinicians, and parents. We are careful to respect and support the therapeutic relationships that other (p. 760) providers have with mutual clients; we collaborate with all providers. All incoming calls from parents interested in groups are screened by an intake coordinator who conducts a brief phone interview to determine appropriateness of fit for group services. If the youth is not a good match, recommendations are made for other services (e.g., individual psychotherapy, testing, or services outside of our practice). If the youth would likely benefit from participation in our groups, then the RBP is explained, the family’s preference for day/time/office location of groups is collected, and the youth is placed into a master group spreadsheet. Once enough potential members are clustered together by age/gender/day/time of group, their information is passed to a clinician, who then completes an intake session to confirm they are an appropriate match for group.
We are a fee-for-service practice and do not participate on any insurance panels. However, families can submit for reimbursement from their insurance companies. Unfortunately, although one hour of group costs half of what we charge for a 45-minute individual therapy session, insurance companies seem to reimburse at a lower rate for group therapy. We decided long ago not to charge for the entire 12 weeks of group up front in order to make it more affordable for families; instead, we ask for monthly payments via credit card, or weekly payments by check. From the client’s perspective, group therapy is cost-effective.
Developing this Niche Activity into a Practice Strategy
For other mental health providers interested in running social competence groups for children and adolescents, we have various suggestions with regard to ethical and logistical parameters. The International Association for Group Psychotherapy and Group Processes offers ethical guidelines specific to group practice (http://www.iagp.com/about/ethicalguidelines.htm). The American Psychological Association (APA)’s Division 49, Society of Group Psychology and Group Psychotherapy, promotes ethics of both clinical practice and academic/research activities in the field (http://www.apa.org/about/division/div49.aspx); national APA guidelines for training are currently being developed. While there are no standard treatment guidelines for providing group psychotherapy, the American Group Psychotherapy Association (AGPA; www.agpa.org) has clinical practice guidelines that aim to integrate research with ongoing clinical practice and encourage the use of assessment and outcome measures.
There are multiple factors to take into consideration from a logistical standpoint. To begin with, you need to determine the setting in which groups will take place (e.g., office, school, hospital) and be sure you have adequate private space. The latter will in part depend on the number of members in each group. We have found that keeping groups small is ideal both in terms of space needed and, more importantly, in terms of enabling each group member sufficient time to actively participate. The setting will also be a factor in the frequency and duration of each group (e.g., coordinating with academic schedule in school settings; feasibility of weekend groups in private practice setting). Regardless of group setting, for social competence groups kids must have the opportunity to practice skills in natural settings outside of group (e.g., field trip) to generalize behavior changes.
(p. 761) It is important to determine whether you want to have time-limited versus ongoing groups. From our experience, one advantage of time-limited groups is that parents may find it easier to commit to a specified number of group sessions at a time. Deciding which group curriculum (or combination of curricula) you are going to use will go hand in hand with meeting the needs of the target population (e.g., age, developmental level, gender, diagnoses). In our groups, members have mixed presentations of internalizing and externalizing challenges and diverse strengths. We have found this provides group leaders with opportunities to highlight different positive behaviors in each member; this promotes self-esteem and helps them learn from each other. Along these lines, behavior management focused on attending to and reinforcing positive behaviors, while drawing minimal attention to negative behaviors (i.e., differential reinforcement), has been integral to effectively running our groups. Prior to the start of groups, it is also important to identify recordkeeping methods (e.g., notes on each member to track attendance, completion of at-home assignments, behavior and participation in group) and outcome measures (e.g., Behavior Assessment System for Children [BASC-3]) to evaluate the progress of group members and overall program effectiveness. The extent of parent involvement will depend on the curriculum used, goals, setting, and their availability; we recommend trying to involve parents to the greatest extent possible via multiple modes of communication. Cost of groups and payment structure need to be established, taking into account factors addressed in the business section above. Group leaders should have appropriate training prior to running groups (e.g., didactic, observation, co-leading). We typically have one primary leader per group, with co-leaders (leaders in training and/or graduate students) in some groups. Privacy and confidentiality need to be addressed with group members and parents with regard to discussions and interactions within and outside the group setting.
Group providers can start small and stay small, or grow larger. I (MKA) started by running two groups 33 years ago, and it has taken many years to develop a large-scale program. We hope that the reader will be willing to face the challenges and share in the joys of running groups and changing kids’ lives in positive ways!
For More Information
Clinicians interested in providing group services would benefit from reviewing online and/or printed materials from APA Division 49, Society of Group Psychology and Group Psychotherapy, and AGPA (links provided above). APA and AGPA both offer journals, workshops, symposia, open sessions, and other learning opportunities at their annual conferences. Social workers can find helpful resources through the International Association for Social Work with Groups, Inc. (http://iaswg.org/), including standards, group work strategies, and peer-reviewed journal publications.
In the Washington, DC, metro area, Dr. Sylvia Stultz assembled a consortium of therapy groups approximately 20 years ago. Practices and organizations paid a fee to be listed in a booklet that was distributed to schools and practices throughout the Virginia/Maryland/DC region. Ten years ago, I (MKA) took over coordinating the community of group therapists, and today we advertise in local parent magazines and host a website (www.groups4kids.com) and listserv. The website is (p. 762) most helpful for the community to view available groups. The listserv is for providers and allows us to discuss openings in specific groups and to gain support on various clinical topics; we also have an informal annual gathering of group providers. This type of consortium can be replicated in other communities to facilitate awareness and utilization of group services.
There are numerous group curricula available on the market to help children build social skills. For example, in addition to RBP (2011), other programs include the Skillstreaming series (McGinnis, 2011) and some that focus on special populations (e.g., autism spectrum disorders) such as Unstuck and On Target! (Cannon, Kenworthy, Alexander, Werner, & Anthony, 2011).
References and Resources
Aduen, P. A., Rich, B. A., Sanchez, L., O’Brien, K., & Alvord, M. K. (2014). Resilience Builder Program therapy addresses core social deficits and emotion dysregulation in youth with high-functioning autism spectrum disorder. Journal of Psychological Abnormalities in Children, 3(2), 1–10.Find this resource:
Alvord, M.K. & Grados, J.J. (2005). Enhancing resilience in children: A proactive approach, Professional Psychology: Research and Practice, 36, 238–245.Find this resource:
Alvord, M. K., & Rich, B. A. (2012). Resilience Builder Program: Practice and research in a private clinical setting. Independent Practitioner, 32, 18–20.Find this resource:
Alvord, M. A, Rich, B. A., & Berghorst, L. (2014). Developing social competence through a resilience model. In S. Prince-Embury & D. H. Saklofske (Eds.), Resilience interventions for youth in diverse populations (pp. 329–351). New York: Springer Books.Find this resource:
Alvord, M. A., Rich, B. A., & Berghorst, L. (2016). Resilience interventions. In J. C. Norcross, G. R. VandenBos, & D. K. Freedheim (Eds.), American Psychological Association handbook of clinical psychology (pp. 505–519). Washington, DC: APA Books.Find this resource:
Alvord, M. K., Zucker, B., & Alvord, B. (2011). Relaxation and self-regulation for children and teens: Mastering the mind-body connection (audio CD and digital). Champaign, IL: Research Press.Find this resource:
Alvord, M. K., Zucker, B., & Alvord, B. (2013). Relaxation and wellness techniques: Mastering the mind-body connection (audio CD and digital). Champaign, IL: Research Press.Find this resource:
Alvord, M. K., Zucker, B., & Grados, J. J. (2011). Resilience Builder Program for children and adolescents: Enhancing social competence and self-regulation—A cognitive-behavioral group approach. Champaign, IL: Research Press.Find this resource:
Cannon, L., Kenworthy, L., Alexander, K., Werner, M., & Anthony, L. (2011). Unstuck and on target! An executive function curriculum to improve flexibility for children with autism spectrum disorders (research ed.). Baltimore, MD: Pail H. Brookes Publishing Co.Find this resource:
McGinnis, E. (2011). Skillstreaming the elementary school child: A guide for teaching prosocial skills (3rd ed.) Champaign, IL: Research Press.Find this resource:
Reynolds, C. R., & Kamphaus, R. W. (2015). Behavior Assessment System for Children, Third Edition (BASC-3). Pearson.Find this resource:
Rich, B. A., Hensler, M., Rosen, H. R., Watson, C., Schmidt, J., Sanchez, L. … Alvord, M. K. (2014). Attrition from therapy effectiveness research among youth in a clinical service setting. Administration and Policy in Mental Health and Mental Health Services Research, 41(3), 343–352.Find this resource:
Watson, C. C., Rich, B. A., Sanchez, L., O’Brien, K., & Alvord, M. K. (2014). Preliminary study of resilience-based group therapy for improving the functioning of anxious children. Child and Youth Care Forum, 43, 269–286.Find this resource: