Assessing Behavior and Social Competence of Severely Emotionally Disturbed Youth Admitted to Psychiatric Residential Treatment

Journal of Child and Adolescent Psychiatric Nursing, Aug 2009 by Groot, Jodi Morstein

PROBLEM: Youth admitted to psychiatric residential treatment centers demonstrate behavioral problems and social competence deficits. Little systematic inquiry has quantified these issues or their impact on therapeutic care.

METHOD: Secondary data from Child Behavioral Checklists and Relationship Questionnaires were collected through retrospective chart reviews and were statistically analyzed.

FINDINGS: Seventy-one percent of the 113 subjects met clinical behavioral problem levels. Youth who were older than 15 years at admission lagged significantly behind 12th-grade norms in social competence, having scores congruent with 8th-grade students.

CONCLUSION: Youth in this study had significant behavioral problems, and deficits in social competence were identified among older youth.

Search terms: Residential treatment, social competence, SED youth

Background and Significance

One of 10, or as many as 7 million, youth in the United States are experiencing serious emotional disturbances (SEDs) that disrupt their functioning in homes, schools, and communities (Child Welfare League of America, 2009; Roberts, Attkinson, & Rosenblatt, 1998). Those with the most serious symptoms are often placed in psychiatric hospitals and residential treatment centers (RTCs) (Burns, Hoagwood, & Mzarek, 1998; Halfon, English, Allen, & DeWoody, 1994; Leventhal, & Zimmerman, 2004; Terpstra, 1998; Whittaker, 2004). Hospitalizations are often short term and focused on stabilization of acute symptoms. For approximately 8% of SED youth, longer term RTC placements are initiated when interventions in the community have not been sufficient to reduce harmful, destructive, or overtly aggressive behaviors that seriously threaten the safety of self or others (Burns, Hoagwood, & Maltsby, 1998).

While dramatic and disruptive behaviors, like a suicide attempt or assault on a peer, are often the catalyst for placement, little data have been gathered that explore these youth in terms of their general function in social relationships or social competence. Nurses and other providers have described these youth as immature and primitive in relationship skills and social understanding (Achenbach & Edelbrock, 1981; Curry, 1991; Rutter & Garmezy, 1983). Identifying and intervening related to these social competence deficits or delays could possibly impact the development of problem behaviors. Although clinical descriptions indicate that SED youth have significant deficits in social competence, little empirical evidence is available to validate these observations (Achenbach & Edelbrock; Rutter & Garmezy).

For clinicians advocating for resources to provide comprehensive treatment for this population, it is essential that empirical data and comprehensive assessment information be generated. Structured RTCs with reward and consequences have demonstrated the potential for decreasing aggressive child behaviors, although data are very limited (Blackman, Eustace, & Chowdhury, 1991; Curry, 1991). Behavioral measures can describe the actions of an SED youth, but do not reveal the psychological, developmental, or social factors that underlie those actions.

Measures of Behavioral Problems and Social Competence

Measuring Behavioral Problems

Behavioral checklists typically are employed in studies focused on youth with psychiatric symptoms. The Child Behavioral Checklist (CBCL) is the most widely used and well-validated tool of this sort (Furlong & Wood, 1999). The CBCL was designed to identify behavioral problems and discriminate between children referred for mental health services and those not referred. While overtly disruptive behaviors are often the symptoms that qualify SED youth for RTC placement, it is possible that social, emotional, and developmental factors may underlie behavioral difficulties.

Measuring Social Competence

A key indicator of psychological, social, and emotional health is an individual's effectiveness in social interactions or social competence. Although social competence historically has been measured by skills checklists, behavioral assessments, and peer reports (Merrell & Gimple, 1998; Rose-Krasnor, 1997), the perspective of developmental psychopathology points to the salience of assessing deficits in earlier competencies.

Accordingly, Schultz and Selman (1998) have developed the Group for the Study of Interpersonal Development (GSID) Relationship Questionnaire (ReI-Q), based on their relationship model. They propose that "social competence ultimately rests upon the capacity for forming close relationships with other people, and that capacity in turn is grounded in psychosocial competence or internal psychological development" (p. 2). Social competence is considered from an orthogenic perspective, implying movement from a relatively global state and lack of differentiation to a position of differentiation and hierarchic integration (Werner, 1948). This perspective allows for regression within the context of growth. It assumes that the development of social competence is based upon the growing ability of a person to differentiate and organize the social perspective of self and others on a cognitive as well as emotional level.