Social skills: What preemies and their families need to know - Sunnybrook Neonatal Follow-Up Clinic
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Social skills: What preemies and their families need to know

Plain language summary

All kids can run into problems when it comes to making friends and keeping them; preemies (those children born before their expected due date, sometimes by only a few weeks but for some, it may be that they are born up to 16 weeks before their due date) sometimes struggle more.  When people talk about “social skills” they are usually referring to what someone does (or what behaviours someone uses) when interacting with other people. These behaviours affect how a child makes and keeps friends, how well the child is liked by his/her peers, how successful a child is within the school community, and the degree to which a child knows what to do in difficult situations with friends and other peers.

Struggles with social skills are common and for some children these struggles can last for a long time. When a child has trouble fitting in it can be stressful for the child and his/her parents. The child’s difficulties may be related to one or a combination of the following kinds of social skill difficulties: (1) The child doesn’t know what to do, for example, she doesn’t know how to join in and get involved in play with her classmates at recess time; (2) The child may not want to engage in a particular skill or behaviour, for example, he does not maintain appropriate personal hygiene; (3) The child may know what to do and wants to but has a hard time interacting or carrying out the skill, for example, he tells a joke to make his friends laugh but the timing, delivery, or the joke itself was not quite right.

According to studies, compared to full-term peers, kids born preterm seem to have more difficulties with social skills; the difficulties may be greatest for those born very preterm. Problems with fitting in and making friends can be very complicated and solutions to make it better usually involve more than one strategy. There is a lot of information online about social skills and there are many programs out there that are designed to improve social skills in children. It is very difficult to know what kinds of programs or supports would be best for any one child so parents have to be smart consumers when it comes to looking into and signing up their child for social skills training programs. Based on our review of the scientific evidence, social skills training programs that seem to be the most useful usually involve the following:

  • The program is used as one part of a bigger plan and is delivered in the child’s school;
  • What is taught in the program is a good match for the child’s particular difficulties;
  • The program is at least 60 hours and occurs over a long time;
  • Skills are taught directly and involve practice in role plays and in real life;
  • The program is taught by trained people using a manual;
  • People close to the child (like parents, peers, and teachers) are involved and help the child practice the skills.

It can be helpful for parents to learn more about social skills to help teach their children what to do through modelling (showing) and encouraging lots of practice. Parents can advocate for their children to get support they needs through school to help create positive school communities in which all children feel like they belong. There are reputable resources available online to help parents and educators find appropriate social skills training programs for their schools. The Neonatal Follow Up Clinic at Sunnybrook can support parents and educators with knowledge and resources to help children develop important social skills.

Social skills: What preemies and their families need to know

Background on social skills

Beyond the safety of parent supervised play dates and structured play groups, as children get older, there is an unspoken expectation that every child will learn how to successfully navigate the social world. Some children seem to do this well without even trying; they make friends easily, they are well liked by their peers, and they appear to enjoy opportunities to interact and engage same-aged children. Of course there may be struggles along the way—even for the socially adept children—for others, the struggles seem to be persistent and a source of stress and worry for the child and his or her parents. Unfortunately, just like in parenting, there is no manual and the complexities of a child’s social world make it unlikely that any one strategy or intervention will eliminate a child’s struggles with social skills.  This does not mean that there is nothing we can do for a child who is experiencing social difficulties, rather this means that we should take a careful and informed approach when planning how to best support these children.

Social skills defined

Although there isn’t a single definition, the term “social skills” generally refers to the set of behaviours that one uses in interacting with others that produces socially important outcomes such as initiating and keeping positive relationships, peer acceptance, adjusting to school life, and coping with the demands of the social environment—including knowing how to manage problematic interactions and relationships. (1,2) In understanding a child’s social abilities, it is useful to distinguish the type of difficulty that the child is experiencing; there are 3 broad categories: acquisition, performance, and fluency. A social skill acquisition deficit means that the child does not know how to perform a particular social skill or does not know what to do in a particular social situation. It is thought of as a “can’t do” problem. A social skill performance deficit means that the child has a particular social skill in his/her skill set but does not carry out the skill at socially acceptable levels given the situation.(2) It is thought of as a “won’t do” problem.(2) A social skill fluency deficit means that the child knows how to and wants to perform a particular social skill but carries out the skill in an awkward way.(3) In addition to these skill deficits, a child may be exhibiting competing behaviours such as aggression or non-compliance or competing deficits such as being overly shy or withdrawn. These behaviours and deficits can also interfere with opportunities to learn and practice social skills.(2,4) One other term that you may come across in the social skills literature is the concept of social competence and this refers to the degree to which a child is successful in social interactions based on the judgments of relevant people, such as, parents, teachers, and peers.(2)

Having adequate social skills —the degree to which a child is functioning well socially in current social contexts—is important not just in the immediate sense but it’s also important in a future sense as research suggests that children with social skill difficulties are at risk for poorer adjustment later in life.(5)

What about preterm survivors and social skill development?

Research suggests that preterm survivors are more likely to struggle in some aspects of social functioning as compared to their term born peers.(6,7)

What can we do about social skill difficulties?

A Google search for ‘child social skills’ yields over 40 million hits—there are commercially available programs, curricula, books, apps, videos, and other resources. It’s hard to know where to start given the sheer amount of information that is out there.

Looking to the social skills research, social functioning difficulties are generally conceptualized as skill deficits and consequently the idea of teaching these skills directly seems to be a logical approach.(1,9) Over the last few decades, numerous social skills training (SST) programs have been developed. (10–12) These programs generally target the following domains: peer relationship skills, self-management skills, academic-related skills, compliance, and assertiveness skills.(13) Some programs are delivered to small groups of children by trained facilitators, others are delivered to an entire class by a classroom teacher, and there are even programs that incorporate parents or peers as the facilitators for one or two target children.(3,11)

What does the research tell us?

Most of the research about SST is with children and adolescence with autism spectrum disorders (ASD), attention deficit hyperactivity disorder (ADHD), or learning disabilities (LD).(2,4,10,11,14) There is huge variance across SST programs in terms of content (what is taught), duration (number of sessions), method of delivery (how the skills are taught and by whom), setting (where the sessions occur—in the natural environment or in a clinic), format (individual or group), evaluation (how skill development is monitored), treatment integrity (the degree to which the program was carried out as prescribed), and supporting evidence (the effectiveness of the program).(3,4,15)

To date, the research about the effectiveness of SST programs is mixed(3) and in general, SSTs have not had large and lasting effects for the children who participate in them.(2,10,15–17)

One persistent problem that seems to be limiting the impact of SST programs is related to generalization.(3,16) Generalization refers to the degree to which the skills learned in the SST program are demonstrated and used effectively in the natural environment. Generalization problems are inherently greater for any SST provided in the traditional clinic model—in a clinic or resource room—outside of the child’s natural setting.(3,15,16,18)

Experts have identified several other possible reasons why SST programs seem to have had limited positive effects including limitations in the research, e.g., difficulty with combining and comparing the effects of SST programs that have varying scope by design, variance in the kinds of measures used for assessment, limited reporting on long term outcomes, and inconsistent reporting on treatment integrity. As well as limitations in the delivery of SST programs, e.g., failure to ensure that the skills that are taught in the program are relevant for each child, variance in “dose”, that is, how much training is provided; the average SST program is about 30 hours (2-hour weekly sessions offered over several weeks), variance in what skills are taught, and the types of teaching strategies that are used.(1,4,15,19)

SST programs that appear to have better outcomes are ones that ensure:

  • The program is delivered as part of a multi-component plan to address social skills difficulties.(19)
  • The program is delivered in the natural environment, not in a contrived setting like a clinic or resource room.(3,11,15)
  • The program content is well matched to the needs of each child based on the nature of the social skill difficulties, i.e., acquisition, performance, or fluency deficits.(3,15,19)
  • The program is provided over a longer period of time.(3,10,15) 30 hours of instruction over 10-12 weeks is likely insufficient,(3) as Quinn et al. (1999) stated, “No educator would expect significant changes in overall reading achievement after just 30 hours of training for students with severe and persistent reading problems” (p.61).(15) One study suggests that SSTs with at least 60 hours of programming may produce better outcomes e.g., Gresham and colleagues (2006).(2)
  • The teaching strategies involve modelling, role-play or rehearsal, feedback, and generalization training.(3,18)
  • The program is delivered with fidelity—the skills are taught as outlined in the program manual.(3,10)
  • Parents, peers, and other people important to the child are involved to prompt and reinforce the use of social skills learned in the SST.(11)

Although the research to date about SST hasn’t been compelling, as Quinn and colleagues (1999) suggest, the cost of not teaching social skills is too high given the long term implications of poor social adjustment.(15) Experts and researchers agree that SST is an important component and should be included as part of a multi-component plan offered by schools and community agencies for children of all ages who are experiencing social skill difficulties. SST programs offered only as a standalone intervention are unlikely to result in meaningful and lasting change(1,16) particularly if the program is offered outside of the child’s natural environment, i.e., in a clinic as opposed to a school setting.(9,11)

What does this mean for you as the parent?

Knowing that successful social interactions are influenced by so many factors—the child, the responses of others, and the social context(12)—parents have a very important role in providing nurturing home environments that promote prosocial behaviours and in advocating for preschool and school environments that have a shared responsibility and interest in promoting social skill development.

If you are interested in capturing everyday opportunities to teach and practice basic social skills, this list from Boys Town is a good start for skills to consider but your child may be well beyond these basic skills and dealing with much more complex issues like bullying and exclusion in which case this list may not apply.

Regardless of how complex the social skill difficulties are, it may be useful to consider how your child is able to apply these skills—if difficulties are present is it an acquisition (“can’t do”), a performance (“won’t do”), or a fluency deficit?

If you are going to look into registering your child in a SST program offered in the community or if you are going to advocate for access to SST programming at your child’s preschool or school, the following questions—adapted from Sugai & Fuller, 1991(18)—may be useful in carrying out a cost-benefit analysis—which really means figuring out whether the possible benefits outweigh the time and money put toward that particular SST program.

  • Is the program manualized?
  • How strong is the research about the effectiveness of the SST program?
  • What are the assessment measures and who completes them—parents, teachers, and/or peers?
  • What are the teaching targets in the SST program and are they a good match for the struggles that my child is experiencing?
  • How many sessions are there and who will be involved?
  • Is there a parent behaviour management component included in the program? If not, what does parent involvement look like in this program?
  • What strategies are incorporated to promote generalization of the skills learned in the group to various settings within the school and other social venues?

What does this mean for schools?

Educators are in a unique and very important position to effect change in the lives of children. The school environment itself has a role in the degree to which the SST program will have positive effects.

School cultures that promote prosocial behaviours can better support the generalization of appropriate social skills into everyday student interactions.(16,20)

Social skill development should be built into the school curriculum as “young children, especially those who are at risk, need multiple opportunities to learn essential social skills and many more opportunities to practice and perform them skillfully”(p.74).(1) Enlist people in the child’s life—peers, various school staff members, and parents—to support them in practicing and mastering social skills.(1) The promotion of social skill development may be more effective if it is offered at multiple levels of intervention; universal, selected and targeted. Universal SST interventions are delivered to entire schools and the purpose is largely preventative. Selected or targeted SST interventions are offered to small groups of at-risk children or to individual children who are clearly having difficulty.(1,15) Demonstration of appropriate social skills should be acknowledged and reinforced across all settings at school and home to maximize the likelihood that the skills are maintained in the child’s repertoire.(15) Problem behaviours should be addressed appropriately with evidence-based behaviour management strategies, as persistent behavioural difficulties will limit opportunities for a child to learn and practice necessary social skills.(2,4,9)

Programs that are popular are not necessarily evidence-based. Look for programs with strong assessment tools that have been empirically validated.(21,22) For an overview of research-based social skills curricula, refer to the Collaborative for Academic, Social, and Emotional Learning (CASEL) Guide: Effective Social and Emotional Learning Programs: Preschool and Elementary School Edition (2013).

If your school is interested in evidence-based school-wide programming to promote prosocial behaviour, the Positive Behaviour Intervention and Supports (PBIS) (23) program is worth exploring:

What does this mean for Neonatal Follow Up (NNFU)?

We are invested in the children and families who belong to our follow up clinic. Given what the research is telling us about the multiple determinants of social skill development, we feel that NNFU can support parents by doing the following:

  • Knowledge translation. Share state of the art research about preterm survivors and social skill development. Inform parents of locally available SST programs that are empirically supported.
  • Support parent advocacy to promote school environments that nurture prosocial skill development. Help parents advocate for the provision of universal, selected, when necessary individualized interventions for social skill development within the school system.
  • Support parents in addressing behaviour problems early. Offer evidence-based parent behaviour management training.
  • Connect families to appropriate local community supports and services.


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