Social competence refers to a person's ability to interact positively and effectively with others across different contexts.1,2 Social participation is the act of being involved or engaged with others.3 The ability to develop and maintain meaningful relationships with others has a long-term protective impact on an individual's psychological well-being, achievement in school and work, community participation levels, law-abiding behavior, and avoidance of substance abuse.4,5 Adolescence is a developmental stage of increasing social expectations and personal initiation of strategies to gain acceptance and maintain friendships.6,7
Adolescents with congenital or acquired diagnoses, such as brain injury and fetal alcohol spectrum disorders (FASD), can struggle to make and keep friends.8-10 Social dysfunction is frequently reported clinically in these populations as having a lasting negative impact, with early research detailing varying prevalence estimates of social competence difficulties.10-13 Prevalence rates for youth with traumatic brain injury (TBI) differ according to specific study samples and choice of measurement tools. A systematic review of 28 studies confirmed an elevated risk of social dysfunction for youth with TBI, despite methodological weaknesses in the literature.11 In a sample of 113 children (74 TBI; 39 typically developing), 23% of youth in the TBI group demonstrated social impairments two years post injury in the absence of pre-injury difficulties.14 In a sample of 87 children aged eight to 13 years old, 47% percent of children with severe TBI had a mutual friend in their classroom compared to almost 88% of children with orthopedic injury or a mild to moderate TBI.15 Studies of prevalence in youth with cerebral palsy (CP) are also emerging, indicating difficulties with social functioning in 33% to 45% of children.10,13 In contrast, another study demonstrated similar developmental curves of social interaction between typically developing peers and children with CP with no intellectual impairment.16 In this study, lower levels of ability to socially interact and wide variation in results were revealed for individuals with CP and an intellectual impairment.16 Most youth with FASD are reported to experience difficulties with social competence, although exact prevalence data in the literature is limited.9,17-19
Group social skills interventions (GSSIs) aim to increase social knowledge and skills in adjusting behavior in social interactions, and usually encompass a combination of didactic teaching, modeling, role play, and homework tasks to encourage generalization of skills to everyday situations.20 They vary in intensity, duration, whether an intervention manual is used, and if a parent group is included. Investigation of the efficacy of GSSIs has primarily reported on evidence in the autism spectrum disorder (ASD) population and, to a lesser extent, the attention-deficit hyperactivity disorder (ADHD) population as difficulty with social skills is a core feature of the diagnosis in these populations.21,22 Systematic reviews investigating the efficacy of GSSIs for youth with ASD indicates a medium effect on improving social competence with effect sizes ranging from 0.47 to 0.56.21,23,24 The efficacy of GSSIs in improving social competence in children and youth with ADHD has been investigated through two systematic reviews revealing the methodological limitations in the literature, and making it difficult to conclude whether GSSIs are effective in increasing social competence.22,25
With limited research into the efficacy of GSSIs in populations with acquired and congenital diagnoses other than ASD and ADHD, there is insufficient information available to guide clinicians in their clinical practice. This review will examine the evidence for GSSIs with an available intervention manual that may be suitable for use in clinical trials and ultimately clinical practice for youth with difficulties with social functioning related to a diagnosis such as acquired brain injury (ABI), CP, or FASD.
A preliminary search of PROSPERO, PubMed, the Cochrane Database of Systematic Reviews, and the JBI Database of Systematic Reviews and Implementation Reports was conducted on GSSIs for adolescents with acquired, congenital, and developmental disabilities. Current and in-progress systematic reviews of GSSIs focus specifically on ASD21,24 and ADHD,22,25 and do not include other acquired and congenital disabilities. Given the social difficulties experienced by youth with ABI, CP, and FASD, and inadequate empirical evidence for treatment, this review will evaluate GSSIs across acquired and congenital diagnosis groups and offer evidence to support treatment choice in different populations of youth.
- i) Do GSSIs, with a supporting intervention manual, increase social knowledge, social competence, or social participation in adolescents with acquired, congenital, or developmental disabilities?
- ii) What are the features of individual GSSIs?
This review will consider studies that include adolescents (aged 11 to 17 years) with an acquired, developmental, or congenital disability. As this review will focus on adolescents of high school age who have different needs to children attending primary school, where the included age in studies extends beyond the 11-to-17 age range, a mean age of no less than 11 and no higher than 17 will be used to ensure findings are relevant for high school students. Studies of adolescents with a primary mental health disorder will be excluded.
This review will consider studies that evaluate GSSIs with the primary aim of the intervention to improve social knowledge, social competence, or social participation. Group interventions that have an available manual will be included. Interventions will have a component of face-to-face delivery, while other intervention components may include education (via additional appointments, written information sheets, internet-based platforms, or additional parent groups) and individualization of the group program (via additional appointments, phone- or internet-based contact). Interventions may be run by any health professional or youth worker and delivered in community, research, or hospital settings. Given that the focus of this systematic review is to inform health practitioners of interventions they could deliver in clinical settings, GSSIs that are only delivered in schools will be excluded. No limits will be placed on the duration, frequency, or intensity of interventions.
This review will consider studies that compare the intervention to either another intervention or no intervention.
This review will consider studies that evaluate social competence as a primary outcome. Social competence will be measured by a tool suitable to detect change after a clinical intervention, including but not limited to the Social Skills Improvement System-Rating Scale (SSIS-RS) and the previous version, the Social Skills Rating Scale (SSRS); the social subscale of the Adaptive Behavior Assessment System (ABAS), the Vinelands Adaptive Behavior Scale, or the Child Behavior Checklist and the Social Responsiveness Scale (SRS). Secondary outcomes may include social participation, with measures including but not limited to behavior rating scales such as the Child and Adolescent Scale of Participation (CASP), or social knowledge, often measured by a tool developed by authors of an intervention to test retention of knowledge. Naturalistic observation scales, interviews, goal setting, or sociometric techniques of measuring social competence, social participation, or social functioning will be included if they have used a validated tool or a reproducible rating scale.
Types of studies
Preliminary searching revealed a considerable number of existing randomized controlled trials testing the efficacy of GSSIs to improve social competence and social participation in youth with acquired and congenital disability. Given the reduced risk of bias in evaluating the efficacy of interventions tested using a randomized control trial study design, this review will only include randomized controlled trials.26 Studies published in English and from database inception to the present will be included.
The proposed systematic review will be conducted in accordance with JBI methodology for systematic reviews of effectiveness.27 This protocol has been registered in PROSPERO: CRD42020158189.
The search strategy aims to locate both published and unpublished studies. An initial limited search of PubMed and PsycINFO was undertaken to identify articles on the topic. The text words contained in the titles and abstracts of relevant articles, and the index terms used to describe the articles were used to develop a full search strategy (see Appendix I) with assistance from a medical librarian. The search strategy, including all identified keywords and index terms, will be adapted for each included information source.
The databases to be searched include: PubMed, CINAHL (via EBSCOhost), Embase, CENTRAL (via the Cochrane Library), PsycINFO (via EBSCOhost), and Web of Science. Sources of unpublished studies and gray literature to be searched include Clinical Trials Registry (ClinicalTrials.gov and WHO-International Clinical Trials Registry Platform), Google Scholar, and ProQuest Dissertations and Theses. The reference lists of all studies selected for critical appraisal will be searched for additional studies.
Following the search, all identified citations will be collated and uploaded into EndNote X9 (Clarivate Analytics, PA, USA) and duplicates removed. Titles and abstracts will then be screened by two independent reviewers for assessment against the inclusion criteria for the review. Potentially relevant studies will be retrieved in full and assessed in detail against the inclusion criteria by two independent reviewers for the full text screening stage. Reasons for exclusion of full text studies that do not meet the inclusion criteria will be recorded and reported in the systematic review. Disagreements that arise between the reviewers at each stage of the study selection process will be resolved through discussion or with a third reviewer. The results of the search will be reported in full in the final systematic review and presented in a Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow diagram.28
Assessment of methodological quality
Eligible studies will be critically appraised by two independent reviewers at the study level for methodological quality in the review using the Cochrane risk-of-bias tool (RoB 2) for randomized trials.29 Random allocation, deviation from intended interventions, management of missing data, outcome measurement, and data analysis will be evaluated. Authors of papers will be contacted to request missing or additional data for clarification, where required. Any disagreements that arise between the reviewers will be resolved through discussion or via consultation with a third reviewer. The results of the critical appraisal will be reported in narrative form and in a table. In this review, a randomized control trial design is considered essential for methodological rigor, with studies not meeting this quality threshold excluded.
Data will be extracted from studies included in the review by two independent reviewers using the standardized JBI data extraction tool available in the JBI System for the Unified Management, Assessment and Review of Information (JBI SUMARI; JBI, Adelaide, Australia). The data extracted will include specific details about the populations, study methods, interventions, adverse events, and outcomes of significance to the review objective. Any disagreements that arise between the reviewers will be resolved through discussion or with a third reviewer. Authors of papers will be contacted to request missing or additional data, where required.
Studies will, where possible, be pooled with statistical meta-analysis using RevMan Version 5.3.5 (Copenhagen: The Nordic Cochrane Centre, Cochrane), with separate meta-analyses performed according to timing of the outcome measures (eg, immediately post, three- to six-months follow-up, six- to 12-months follow-up, and 12+ months follow-up). Effect sizes will be expressed as weighted (or standardized) final post-intervention mean differences (for continuous data) and their 95% confidence intervals. Heterogeneity will be assessed statistically using the standard chi-squared and I2 tests. Statistical analyses will be performed using a random effects model.30 Subgroup analyses will be conducted where there is sufficient data to investigate the efficacy of GSSIs in different populations (eg, acquired versus congenital conditions), types of programs, and methods of implementation (eg, presence of a concurrent parent group). Sensitivity analyses will be conducted to test decisions made regarding risk of bias. Where statistical pooling is not possible, the findings will be presented in narrative form, including tables and figures to aid in data interpretation, where appropriate. A funnel plot will be generated to assess publication bias if there are 10 or more studies included in a meta-analysis. Statistical tests for funnel plot asymmetry will be performed where appropriate.
Assessing certainty in the findings
The Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach for grading the certainty of evidence will be followed31 and a Summary of Findings (SoF) will be created using GRADEpro (McMaster University, ON, Canada). The SoF will present the following information where appropriate: absolute risks for the treatment and control, estimates of relative risk, and a ranking of the quality of the evidence based on the risk of bias, directness, heterogeneity, precision, and risk of publication bias of the review results. The outcomes reported in the SoF will be social knowledge, social competence, and social participation.
David Honeyman, The University of Queensland librarian, for his assistance with search strategy development.
This review contributes to the partial fulfilment of the requirements for the Doctor of Philosophy at the University of Queensland, Brisbane, Australia, for RG.
RG is supported by a NHMRC Postgraduate Scholarship (APP1168214), Children's Hospital Foundation scholarship top-up (50278) and the AusCPCTN. LS is supported through a NHMRC Career Development Fellowship (1160694).
Appendix I: Search strategy
Search conducted in March 2020.
Web of Science
Search conducted in March 2020.
Search conducted in March 2020.
Search conducted in March 2020.
Search conducted in March 2020.
Unpublished studies and gray literature search terms
Clinical Trials Registry (clinicaltrials.gov)
(EXPAND[None] “cerebral palsy” OR EXPAND[None] “brain paralysis” OR EXPAND[None] “central palsy” OR EXPAND[none] “central paralysis” OR EXPAND[none] “cerebral paralysis” OR (encephalopathy OR encephalopathies) AND infantile OR EXPAND[none] “spastic diplegia” OR EXPAND[none] “little disease” OR EXPAND[none] “little's disease” OR quadriplegic OR quadriplegia OR quadriparesis OR hemiplegic OR hemiplegia OR hemiparesis OR ADHD OR EXPAND[none] “Attention-deficit/hyperactivity disorder” OR EXPAND[none] “attention deficit disorder with hyperactivity” OR EXPAND[none] “Attention deficit” OR EXPAND[none] “hyperkinetic disorder” OR EXPAND[none] “hyperkinetic syndrome” OR EXPAND[none] “fetal alcohol spectrum” OR EXPAND[none] “foetal alcohol spectrum” OR EXPAND[none] “Fetal alcohol syndrome disorder” OR EXPAND[none] “foetal alcohol syndrome” OR EXPAND[none] “Fetal Alcohol Effect” OR EXPAND[none] “Fetal Alcohol Effects” OR EXPAND[none] “Alcohol Related Birth Defect” OR EXPAND[none] “Alcohol Related Birth Defects” OR EXPAND[none] “Alcohol Related Neurodevelopmental Disorder” OR EXPAND[none] “Alcohol Related Neurodevelopmental Disorders” OR FASD OR autistic OR EXPAND[none] “autism spectrum disorder” OR autism OR asperger OR asperger's OR aspergers OR EXPAND[none] “pervasive development” OR EXPAND[none] “pervasive developmental” OR EXPAND[none] “head injuries” OR EXPAND[none] “acquired brain injuries” OR EXPAND[none] “acquired head injuries” OR EXPAND[none] “traumatic head injuries” OR EXPAND[none] “brain tumor” OR EXPAND[none] “brain tumour” OR EXPAND[none] “brain tumours” OR encephalitis OR stroke OR “cerebrovascular accident” OR “cerebrovascular trauma” OR “traumatic brain injuries AND EXPAND[none] “OR “brain injuries”) AND (EXPAND[none] “Interpersonal skills” OR EXPAND[none] “social skills” OR EXPAND[none] “friendship skills” OR EXPAND[none] “relational Skills” OR EXPAND[none] “social competence” OR EXPAND[none] “peer interaction” OR EXPAND[none] “psychosocial functioning” OR EXPAND[none] “social function” OR EXPAND[none] “social interaction” OR friendship) AND (intervention Or interventions OR program OR programs OR training OR treatment OR treatments OR therapy OR therapies) AND (adolescent OR adolescents OR adolescence OR “teenager” OR “teenagers” OR “teen” OR “teens” OR youth OR youths OR child OR children OR childhood)
WHO-International Clinical Trials Registry Platform
Autism Spectrum Disorder AND social OR Attention Deficity Hyperactivity Disorder AND social OR Brain injury AND social OR cerebral palsy AND social OR fetal alcohol spectrum disorder AND social OR foetal alcohol spectrum disorder AND social
These combinations of search terms will be used, and the first 100 results for each will be examined:
ProQuest Dissertations and Theses
(“Cerebral Palsy” OR “brain paralysis” OR “central palsy” OR “central paralysis” OR “cerebral paralysis” OR ((encephalopathy OR encephalopathies) AND infantile) OR “spastic diplegia” OR “little disease” OR “little's disease” OR quadripleg∗ OR quadriparesis OR hemiplegi∗ OR hemiparesis OR “Attention Deficit Disorder with Hyperactivity” OR ADHD OR Attention-deficit OR “Attention deficit” OR “hyperkinetic disorder” OR “hyperkinetic syndrome” OR “Fetal Alcohol Spectrum Disorders” OR “fetal alcohol spectrum” OR “foetal alcohol spectrum” OR “Fetal alcohol syndrome disorder” OR “foetal alcohol syndrome” OR “Fetal Alcohol Effect” OR “Fetal Alcohol Effects” OR “Alcohol Related Birth Defect” OR “Alcohol Related Birth Defects” OR “Alcohol Related Neurodevelopmental Disorder” OR “Alcohol Related Neurodevelopmental Disorders” OR FASD OR “Autism spectrum disorder” OR autism OR “autistic disorder” OR “asperger syndrome” OR “child development disorders, pervasive” OR asperger OR asperger's OR aspergers OR “pervasive development” OR “pervasive developmental” OR “Brain Injuries” OR “chronic brain injury” OR “traumatic brain injuries” OR “brain neoplasms” OR “cerebrovascular trauma” OR stroke OR “head injur∗” OR “acquired brain injur∗” OR “acquired head injur∗” OR “traumatic head injur∗” OR “brain tumor” OR “brain tumour” OR “brain tumours” OR encephalitis OR “cerebrovascular accident” OR “traumatic brain injur∗” OR “brain injur∗”)
((“Social Skills” OR “social participation” OR “social behavior” OR “interpersonal relations” OR socialization OR “social adjustment” OR “Interpersonal skills” OR “social skills” OR “friendship skills” OR “relational Skills” OR “social competence” OR “peer interaction” OR “psychosocial functioning” OR “social function” OR “social interaction” OR friendship)
(intervention∗ OR program∗ OR training OR treatment∗ OR therap∗))
(adolescen∗ OR teenager∗ OR teen∗ OR youth∗ OR child∗)
1. Rubin KH, Rose-Krasnor L. Van Hasselt VB, Hersen M. Interpersonal problem solving and social competence in children. Handbook of social development: a lifespan perspective
. Boston, MA: Springer US; 1992. 283–323.
2. Yeates KO, Bigler ED, Gerhardt CA, Rubin KH, Stancin T, Taylor HG. Anderson V, Beauchamp MH, et al. Theoretical approaches to understanding social function in childhood brain insult: theory and practice. Developmental social neuroscience and childhood brain insult
. New York: The Guilford Press; 2012. 207–230.
3. Bedell G. Anderson V, Beauchamp MH. Measurement of social participation. Developmental social neuroscience and childhood brain insult: implication for theory and practice
. New York: Guilford Press Publications; 2012. 185–204.
4. Rabiner DL, Godwin J, Dodge KA. Predicting academic achievement and attainment: the contribution of early academic skills, attention difficulties, and social competence. School Psych Rev
2016; 45 (2):250.
5. Jones DE, Greenberg M, Crowley M. Early social-emotional functioning and public health: the relationship between kindergarten social competence and future wellness. Am J Public Health
2015; 105 (11):2283–2290.
6. Lerner RM. Adolescent maturational changes and psychosocial development: a dynamic interactional perspective. J Youth Adolesc
1985; 14 (4):355–372.
7. Vernon T, Miller A, Ko J, Barrett A, McGarry E. A randomized controlled trial of the social tools and rules for teens (start) program: an immersive socialization intervention for adolescents with autism spectrum disorder. J Autism Dev Disord
2018; 48 (3):892–904.
8. Yeates KO, Bigler ED, Dennis M, Gerhardt CA, Rubin KH, Stancin T, et al. Social outcomes in childhood brain disorder: a heuristic integration of social neuroscience and developmental psychology. Psychol Bull
2007; 133 (3):535–556.
9. Kully-Martens K, Denys K, Treit S, Tamana S, Rasmussen C. A review of social skills
deficits in individuals with fetal alcohol spectrum disorders and prenatal alcohol exposure: profiles, mechanisms, and interventions. Alcohol Clin Exp Res
2012; 36 (4):568–576.
10. Voorman JM, Dallmeijer AJ, Van Eck M, Schuengel C, Becher JG. Social functioning and communication in children with cerebral palsy: association with disease characteristics and personal and environmental factors. Dev Med Child Neurol
2010; 52 (5):441–447.
11. Rosema S, Crowe L, Anderson V. Social function in children and adolescents after traumatic brain injury: a systematic review 1989–2011. J Neurotrauma
2012; 29 (7):1277–1291.
12. Vivien K, Blair P, Fred F, O’Connor MJ. Impact of a social skills
intervention on the hostile attributions of children with prenatal alcohol exposure. Alcohol Clin Exp Res
2010; 34 (2):231–241.
13. Weber P, Bolli P, Heimgartner N, Merlo P, Zehnder T, Katterer C. Behavioral and emotional problems in children and adults with cerebral palsy. Eur J Paediatr Neurol
2016; 20 (2):270–274.
14. Anderson V, Beauchamp MH, Yeates KO, Crossley L, Ryan N, Hearps SJC, et al. Social competence at two years after childhood traumatic brain injury. J Neurotrauma
2017; 34 (14):2261–2271.
15. Yeates KO, Gerhardt CA, Bigler ED, Abildskov T, Dennis M, Rubin KH, et al. Peer relationships of children with traumatic brain injury. J Int Neuropsychol Soc
2013; 19 (5):518–527.
16. Tan SS, van Gorp M, Voorman JM, Geytenbeek JJ, Reinders-Messelink HA, Ketelaar M, et al. Development curves of communication and social interaction in individuals with cerebral palsy. Dev Med Child Neurol
2020; 62 (1):132–139.
17. Greenbaum RL, Stevens SA, Nash K, Koren G, Rovet J. Social cognitive and emotion processing abilities of children with fetal alcohol spectrum disorders: a comparison with attention deficit hyperactivity disorder. Alcohol Clin Exp Res
2009; 33 (10):1656–1670.
18. Stevens SA, Dudek J, Nash K, Koren G, Rovet J. Social perspective taking and empathy in children with fetal alcohol spectrum disorders. J Int Neuropsychol Soc
2015; 21 (1):74–84.
19. Schonfeld AM, Paley B, Frankel F, O’Connor MJ. Executive functioning predicts social skills
following prenatal alcohol exposure. Child Neuropsychol
2006; 12 (6):439–452.
20. Ellingsen R, Bolton C, Laugeson E. Leaf JB. Evidence-based social skills
groups for individuals with autism spectrum disorder across the lifespan. Handbook of social skills and autism spectrum disorder: assessment, curricula, and intervention
. Cham: Springer International Publishing; 2017. 343–358.
21. Gates JA, Kang E, Lerner MD. Efficacy of group social skills
interventions for youth with autism spectrum disorder: a systematic review and meta-analysis. Clin Psychol Rev
22. Storebø OJ, Skoog M, Damm D, Thomsen PH, Simonsen E, Gluud C. Social skills
training for attention deficit hyperactivity disorder (ADHD) in children aged 5 to 18 years. Cochrane Database Syst Rev
23. Reichow B, Volkmar FR. Social skills
interventions for individuals with autism: evaluation for evidence-based practices within a best evidence synthesis framework. J Autism Dev Disord
2010; 40 (2):149–166.
24. Wolstencroft J, Robinson L, Srinivasan R, Kerry E, Mandy W, Skuse D. A systematic review of group social skills
interventions, and meta-analysis of outcomes, for children with high functioning asd. J Autism Dev Disord
2018; 48 (7):2293–2307.
25. Willis D, Siceloff ER, Morse M, Neger E, Flory K. Stand-alone social skills
training for youth with adhd: A systematic review. Clin Child Fam Psychol Rev
2019; 22 (3):348–366.
26. McKenzie JE, Brennan SE, Ryan RE, Thomson HJ, Johnston RV, Thomas J. Higgins JPT, Thomas J, Chandler J, Cumpston M, Li T, Page MJ. Defining the criteria for including studies and how they will be grouped for the synthesis. Cochrane Handbook for Systematic Reviews of Interventions
2nd EditionChichester: John Wiley and Sons; 2019. 33–66.
27. Tufanaru C, Munn Z, Aromataris E, Campbell J, Hopp L. Chapter 3: Systematic reviews of effectiveness. In: Aromataris E, Munn Z, editors. JBI Reviewer's Manual [internet]. Adelaide: JBI, 2017 [cited 2019 Nov 1]. Available from: https://reviewersmanual.joannabriggs.org/
28. Moher D, Liberati A, Tetzlaff J, Altman DG. the PRISMA Group. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. Ann Intern Med
2009; 151 (4):264–269.
29. Sterne JAC, Savović J, Page MJ, Elbers RG, Blencowe NS, Boutron I, et al. Rob 2: A revised tool for assessing risk of bias in randomised trials. BMJ
30. Tufanaru C, Munn Z, Stephenson M, Aromataris E. Fixed or random effects meta-analysis? Common methodological issues in systematic reviews of effectiveness. Int J Evid Based Healthc
2015; 13 (3):196–207.
31. Schünemann H, Brożek J, Guyatt G, Oxman A. Handbook for grading the quality of evidence and the strength of recommendations using the GRADE approach [internet]. Updated Oct 2013. The GRADE Working Group; 2013 [cited 2019 October 27]. Available from: https://gdt.gradepro.org/app/handbook/handbook.html