Prosocial skills may be necessary for better peer functioning in children with symptoms of disruptive behavior disorders

Introduction

Children with disruptive behavior disorders such as Oppositional Defiant Disorder (ODD) and Conduct Disorder (CD) experience substantial challenges in multiple life domains (Pardini & Fite, 2010; Rowe et al., 2010). Paramount amongst these challenges are marked problems with peers, which include peer rejection, peer neglect, and social-behavior and social-skills difficulties (Dodge et al., 2003; Dodge et al., 1986; Hoza et al., 2005b; Landau, Milich & Diener, 1998). To help reduce the negative social and behavioral impacts of psychopathology it is necessary to understand the factors that contribute most to peer problems in children with disruptive behaviors.

Peer relationship difficulties have emerged as a salient and important predictor of mental health and behavioral adjustment (Milich & Landau, 1984; Miller-Johnson et al., 2002; Ollendick et al., 1992; Silver et al., 2010). Children with impaired peer relationships are at elevated risk of compounding problems in multiple domains of their life (Dodge & Pettit, 2003; Ollendick et al., 1992). In contrast, adaptive peer relationships appear to buffer children, possibly through the development of positive social connections (Criss et al., 2002). Understanding the factors that most closely contribute to problematic peer functioning is critical to help prevent or mitigate the many short and long-term negative social and behavioral outcomes experienced by children with disruptive behavior.

Although associations between ODD, CD and problematic social functioning are somewhat established, many gaps in knowledge still exist. First, much previous research has investigated social functioning in children diagnosed with ODD or CD (Burke, Loeber & Birmaher, 2002; Pardini & Fite, 2010). Although informative and important, these studies omit a large number of children with symptoms of disruptive behavior disorders who are diagnostically subthreshold. Although not meeting DSM-IV criteria for ODD or CD, subthreshold children may also experience marked social difficulties (Drabick & Gadow, 2012; Hofvander et al., 2009). Categorization based on diagnostic cutoffs neglects relationships between the degree of symptoms and social impairment. Because of the severity and salience of symptoms comprising ODD and CD, it is possible that even a few symptoms may contribute to peer impairment (Drabick & Gadow, 2012). Investigation of the association between ODD and CD symptom dimensions with peer impairment is necessary to augment current understanding of symptom-impairment relationships (Lahey & Waldman, 2012).

Second, existing research has often neglected inclusion of other specific aspects of social behavior, which may influence or account for some of the association between symptoms of ODD and CD with peer problems. Studies that describe social behaviors that are positive, or prosocial, have received increased attention because of their important relationship with social functioning (Coie & Dodge, 1988; Eisenberg et al., 2001; Nelson & Crick, 1999; Seligman & Csikszentmihalyi, 2000). Specifically, prosocial skills in childhood are associated with higher peer status, less rejection and more adaptive social outcomes (Coie, Dodge & Kupersmidt, 1990; Crick, 1996). Children who exhibit strong prosocial skills may be capable of managing social challenges and most socially competent. Prosocial skills, when implemented effectively, may influence and somewhat counter the negative impacts of disruptive behaviors. This assertion is consistent with research that shows children who demonstrate aggressive behavior and prosocial skills have high social status (Blake, Kim & Lease, 2011; Rodkin et al., 2000). As such, prosocial skills may lessen, or moderate, the negative impact of symptoms of ODD and CD on peer impairment (Carson, 2013). Alternatively, prosocial skills may be intimately connected and of salient importance to peers (Eisenberg et al., 2001; Greener & Crick, 1999). It is possible that prosocial skills are necessary for appropriate peer functioning (Andrade & Tannock, 2013); however, children with symptoms of ODD or CD may not be exposed to situations or models that help develop their prosocial skills (Romano et al., 2005). Children with elevated ODD or CD symptoms may not have adequate knowledge of prosocial skills or how to implement these skills (Dodge & Pettit, 2003; Perren et al., 2007). Prosocial skills knowledge or implementation deficits may contribute to peer problems in children with disruptive behavior (Crick, 1996; Perren et al., 2007). As such, prosocial skills may partly account for, or mediate, the association between symptoms of ODD and CD with peer impairment. That is, prosocial skills may be an important link in the causal chain connecting symptoms of ODD and CD with peer impairment (Criss et al., 2002; Doyle et al., 2003; Mikami & Hinshaw, 2003). Although each plausible, these two related and important assertions are in need of investigation.

Finally, although empirically supported psychosocial treatments exist for children with disruptive behavior disorders, few effective treatments specifically target social impairment (Hoza et al., 2005a; La Greca, Silverman & Lochman, 2009; Mikami et al., 2013). Current well-established treatments primarily target development of children’s emotional, behavioral, and problem-solving skills (Kazdin, Siegel & Bass, 1992; Lochman & Wells, 2004; Webster-Stratton & Reid, 2003). Limited research shows positive effects of interventions primarily geared to augment social behavior (Mikami et al., 2011; Mikami et al., 2013). An increased understanding of the direct, indirect and contingent associations of ODD and CD symptoms and social impairment will inform the development of components to augment intervention effectiveness.

The overall objective of the present study was to test whether symptom dimensions of ODD and CD were related to social impairment and whether these associations were moderated or mediated by prosocial skills. The following hypotheses were proposed. First, elevated symptoms of ODD and CD would each be associated with greater peer impairment. Second, prosocial skills would lessen the negative impact of symptoms of ODD and CD on peer impairment, such that higher levels of prosocial skills would be associated with less severe peer impairment for children with many symptoms of ODD and CD. Third, prosocial skills would partially account for the association between symptoms of ODD and CD with peer impairment.

Method

Results

Missing data and descriptive statistics

Of the 149 participants there was some missing data that ranged from no missing (gender variable) to 12% (peer problems variable). The main reason for missingness was an inability to obtain complete assessment materials from some teachers. To assess the pattern of missingness, Little’s Missing Completely at Random test (MCAR) was conducted. This test was not significant, χ²(35) = 28.21, p = .785, indicating that the MCAR assumption was not violated. Thus, it is reasonable to assume that the missing values represent a random subset of values and that there is no systematic bias in patterns of missingness. Descriptive statistics are presented in Table 1.

Is the association between CD symptoms and peer impairment mediated and/or moderated by prosocial skills?

The model for CD symptoms is presented in Fig. 1. Fit indices suggest that the model fit the data well, χ²(1) = .701, p = .402, TLI > .99, RMSEA < .01, SRMR = .010. There was a significant main effect of CD symptoms on peer impairment, whereby children with higher CD symptoms had significantly more peer impairment. There was not a significant main effect of prosocial skills on peer impairment. However, there was a significant CD-by-prosocial interaction, suggesting that the association between symptoms of CD and peer impairment varied as a function of an individual’s level of prosocial skills (i.e., evidence of moderation). This interaction is plotted in Fig. 2.

Simple slopes analysis was conducted in order to better understand the interaction (Holmbeck, 2002). First, the effect of CD symptoms at high (i.e., more skills) and low levels of prosocial skills was examined (i.e., the slopes of the two lines in Fig. 2). At high levels of prosocial skills (+1 standard deviation), more CD symptoms are associated with significantly more peer impairment (B = .77, SE = .22, p = .001). However, at low levels of prosocial skills (−1 standard deviation), more CD symptoms are not associated with an increase in peer impairment (B = .13, SE = .16, p = .408). As such, children with few prosocial skills showed elevated peer impairment at low and high levels of CD. Next, the association between prosocial skills and peer impairment at high and low levels of CD symptoms was examined (i.e., the difference in the end-points of the two different lines in Fig. 2). At high levels of CD symptoms, prosocial skills were not significantly associated with peer impairment (B = .36, SE = .26, p = .175). However, at low levels of CD symptoms, individuals who had more prosocial skills had significantly lower ratings of peer impairment (B = −.61, SE = .31, p = .051). To summarize, the only children with relatively little peer impairment were those who had few CD symptoms plus high prosocial skills.

There was no evidence of prosocial skills mediating CD symptoms. That is, the direct effects of CD symptoms on prosocial skills, and of prosocial skills on peer impairment, were non-significant (i.e., no reason to test the indirect effect). Tests of the control variables revealed that children with higher levels of hyperactivity had significantly greater peer impairment (B = .18, SE = .04, p < .001). Also, after adjusting for all other factors, females had higher levels of peer impairment (B = .40, SE = .20, p = .039). Lastly, older children had lower levels of prosocial skills (B = −.05, SE = .02, p = .008), and children with higher levels of inattention had lower prosocial skills (B = −.04, SE = .02, p = .036).

Is the association between ODD symptoms and peer impairment mediated or moderated by prosocial skills?

The model for ODD symptoms is presented in Fig. 3. The TLI and the RMSEA suggested that this model did not fit the data particularly well, χ²(1) = 2.48, p = .116, TLI = .67, RMSEA = .10, SRMR = .02. Although there was a significant main effect of symptoms of ODD on both peer impairment and prosocial skills, there was no indication of moderation. Also, given that there was no significant direct relation between prosocial skills and peer impairment, any possibility of mediation is similarly ruled out. Thus, the effect of symptoms of ODD on peer impairment appeared to be independent of prosocial skills, both in terms of moderation and mediation. Neither the effects of age or gender were significant in this model.

Discussion

This study tested whether symptoms of ODD and CD were associated with peer impairment and whether these associations were moderated or mediated by prosocial skills in a sample of children referred to an urban children’s mental health clinic. We hypothesized that symptoms of disruptive behavior would be associated with greater peer impairment and prosocial skills would moderate and partially mediate the relationships. Results showed that symptoms of ODD and CD were each significantly associated with peer impairment. Contrary to expectation, prosocial skills did not partially account for the association between symptoms of ODD or CD with social impairment. However, the relationship between CD symptoms and peer impairment varied as a function of prosocial skills, such that children with less severe CD showed relatively less social impairment, but only if they had high prosocial skills.

Findings show that prosocial skills have an important influence on the association between symptoms of CD and peer functioning. This finding is salient given that children who show early symptoms of conduct problems are at much greater risk for antisocial behavior, substance abuse, school drop-out, relationship and mental health problems in adolescence and adulthood (Burke, Loeber & Birmaher, 2002; McMahon, Wells & Kotler, 2006; Rowe et al., 2010). However, contrary to our hypotheses, prosocial skills did not show a protective or buffering effect at relatively high levels of Conduct Disorder. Rather, the only children in the study who were doing relatively better in terms of peer functioning had low levels of conduct problems and high prosocial skills. Researchers have focused on the elucidation of factors that lessen the negative impacts of symptoms of CD, thereby informing intervention approaches to mitigate risk of these negative outcomes. The current study suggests that lower levels of conduct problems and higher prosocial skills may be necessary for better peer functioning. This finding has implications for intervention. For children with elevated levels of conduct problems, programs that mainly target reduction in conduct problem behavior without adequately developing prosocial skills may be insufficient to impact peer functioning. Development of prosocial skills, in multicomponent programs that also target reduction in conduct problems, may be important in order to impart change in social outcomes for children with conduct problems. A growing body of research highlights the importance of prosocial skills for the development of appropriate peer relationships (Crick, 1996; Eisenberg et al., 2001; Mayeux & Cillessen, 2003; Parkhurst & Asher, 1992; Perry, Perry & Rasmussen, 1986). Further research to illuminate the shared contribution of prosocial skills and conduct problems to peer functioning would be beneficial.

It is important to note that symptoms of ODD and CD when treated dimensionally were each associated with greater peer impairment. Although ODD showed a stronger relationship with peer impairment compared to CD, both were statistically significant. This finding points to the important relationship between symptom severity and social impairment, extending findings from diagnosed and undiagnosed groups of children (Drabick & Gadow, 2012; Pope, Bierman & Mumma, 1991). Although referred for clinical assessment, many children in the present study did not receive diagnoses of ODD or CD; however most showed symptomatology associated with social impairment. Results highlight the important influence of symptom dimensions on social functioning—a finding that is somewhat intuitive given the salience of individual symptoms of ODD and CD and logical links to social problems. For example, symptoms such as “often bullies, threatens or intimidates others” or “often initiates physical fights” may be sufficiently salient to cause peer problems regardless of other symptoms. Although beyond the scope of this study, future studies to determine the specific association between individual symptoms, or clusters of symptoms, with specific social problems would be informative.

Further, correlational findings from this study show that increased prosocial skills were associated with fewer symptoms of ODD and CD and less peer impairment. Although these findings should be considered preliminary, further research to determine the mechanisms by which prosocial skills influence the severity of disruptive behavior, and which prosocial skills are most closely linked to adaptive peer functioning, is important to more clearly specify potential avenues for intervention.

Contrary to hypotheses, no significant mediation effects were found. In this sample of children, prosocial skills were not part of the causal chain linking symptoms of disruptive behavior and peer impairment. This null finding is important and may indicate that symptoms of disruptive behavior and prosocial skills are not part of the same mechanism leading to peer problems. However, findings did show that prosocial skills lessened the negative influence of less severe CD symptoms on social impairment. As such, conduct problems and prosocial skills may act via different-but-complementary mechanisms to impact peer functioning. This finding highlights the value of considering positive social behaviors, in addition to symptoms of disruptive behavior, when determining factors that convey risk to the development of social problems.

Of note, although fewer prosocial skills were significantly associated with greater symptoms of ODD, prosocial skills did not significantly mediate or moderate the association between symptoms of ODD and peer impairment. Symptoms of ODD may be experienced differently by peers than CD (Burke, Loeber & Birmaher, 2002). Symptoms of ODD may be troubling to peers in a way that cannot be compensated by prosocial skills (Drabick & Gadow, 2012; Frankel & Feinberg, 2002; Pardini & Fite, 2010). For example, symptoms such as “often loses temper”, “often deliberately annoys people”, “often blames others for his or her mistakes or misbehavior” are somewhat incompatible with prosocial skills and may override any positive influence of prosocial skills. For children with symptoms of ODD, reduction of these problematic behaviors may be of primary importance to promote adaptive peer functioning. Although plausible, these assertions are in need of further systematic examination.