Evaluation of a group based social skills training for adolescents with
social skills deficits: A pilot-study
Masterscriptie Forensische Orthopedagogiek
Graduate School of Child Development and Education Universiteit van Amsterdam
Student: A.M. van der Poel Studentnummer: 12103446
Begeleiding UvA: Prof. dr. G. J. J. M. Stams Begeleiding Stichting De Ster: MSc U. Insam Tweede beoordelaar: dr. M. Assink
Abstract
The aim of this study was to examine changes in social skills, perceived social support, prosocial behavior, internalizing and externalizing behavior problems and self-esteem of N = 64 adolescents (35.9 % boys and 64.1 % girls) between 12 and 18 years old (M = 14.50; SD = 1.18) after attending a newly developed Social Skills Training, StayStrong. The changes in behavior were tested with a pre-/post-test design, whereby adolescents and their parents filled out questionnaires five weeks before and six weeks after the intervention. Positive changes were found after attending StayStrong. Results varied from small significant effects (externalizing problems, youth report) to large significant effects (social skills, youth self-report). These promising results warrant future (quasi-)experimental research.
Introduction
In the Netherlands there are various types of Social skills trainings (SSTs). The aim of these SSTs is to increase the social competences of a child or adolescent. The youth learn specific social skills and how they can use those skills to maintain positive friendships (Gresham, Van, & Cook, 2006). Stichting De Ster is an organization that organizes SST in the shape of camps. They have different camps for different age groups. Sterkamp (Star Camp) and Maankamp (Moon Camp) have shown a large and positive effect on social anxiety problems, social problems, internalizing problems and the self-perception of the children in the age of 8 to 13 (Van Vugt, Dekovic, Prinzie, Stams, & Asscher, 2013). StayStrong is another SST camp from Stichting De Ster, and it serves adolescents by the age of 12 to 17. This study will be the first to study the effectiveness of StayStrong.
Adolescence is a period in which several physical, psychological and social changes take place. The social environment of the adolescent and the social support they feel from friends become increasingly more important, where the immediate family has less and less influences (Bijstra, Van der Kooi, Bosma, Jackson, Van der Molen, 1993; Franco, Christoff, Crimmins, Kelly, 1983; Van Geuns, 2006). Social skills and prosocial behavior are important for building and maintaining adequate friendships (Bos, Muris, & Huijding, 2011; Segrin et al., 2007). In the present study, social skills are defined as the ability to interact appropriately and effectively with other people. Examples of social skills are to start a conversation, to greet each other, to stand up for yourself, to show empathy and to control yourself (Segrin, Hanzal, Donnerstein, Taylor, & Domschke, 2007; Van Vugt et al., 2010; Merrel & Gimpel, 2014). Prosocial behavior is the ability to support the other person so that it gives the other person a positive feeling in a certain situation (Bierhoff, 2005; Van der Ploeg, 2011). Prosocial behavior is, in contrast with social skills, more focused on the other person.
Social skills and prosocial behavior are important to build adequate friendships, which are important to derive social support from friends. Social support has been shown to have a
strong positive influence on self-image, it is a protective factor for depression, helps dealing with stressful life events and contributes to a positive general well-being (Rueger, Malecki, & Demaray, 2008; Smit, 1993). Social support includes talking about feelings and concerns and accepting each other (Demaray & Malecki, 2002; Bokhorst, Sumter, & Westenberg, 2009). Because social support from friends becomes more and more important during adolescence, being able to use social skills or show prosocial behavior becomes more and more important as well. To improve social skills and prosocial behavior, so that adolescents will experience social support, SST can be used (Hermanns, Verheij, & Nijnatten, 2008).
By visiting a SST adolescents learn concrete social skills to decrease their lack of social skills (Blonk, Prins, Sergaent, Ringrose, & Brinkman, 1996). The classical SST is a short and structured program that is delivered in a group. The method that is used to improve social skills and prosocial behavior includes instructions, modelling, practicing by role-playing and positive reinforcement (Maag, 2006; Spence, 2005). These methods that are used are all based on the following theories: social learning theory (Bandura, 1977), operant learning theory (Skinner, 1953), social information processing theory (Ladd & Mize, 1983), structured learning theory (Goldstein, Sprafkin, Gershaw, & Klein, 1983), and multiple cognitive approaches (Cook et al., 2008; Kazdin, 1992). SSTs are used for children and adolescents who experience various types of problems in their social environment, such as internalizing problems (e.g., anxiety and depression) and externalizing problems (e.g., aggression and delinquent behavior). With the training youth discuss and learn about themes as friendship, bullying and anger (Gresham, Van, & Cook, 2006).
Research on the effectiveness of SSTs show different results (Spence, 2005). Various studies found small but positive treatment effects on social skills (Cook et al., 2008; Durlak, Weiberg, & Pachan, 2010; Mychailyszyn, Brodman, Read & Kendall, 2012; Van der Stouwe et al., 2019). Cook and colleagues (2008) conducted a mega-analysis on five meta-analyses
examining SST with adolescents. Their conclusion on basis of these five meta-analyses is that SST has little but positive effect on social skills and prosocial behavior. Durlak and colleagues (2010) found these positive effects on the improvement of the ability to adapt to another person, the ability to solve social conflict and to stand up for oneself when being bullied. Conley, Durlak and Kirsch (2015) found that these effects were even greater when SST includes supervised practice.
When breaking down these findings in internalizing or externalizing problems, the outcomes show different results. Mychailyszyn, Brodman, Read and Kendall (2012) conducted a meta-analysis on the effect of SST on the symptoms of internalizing problems, such as anxiety and depression. They found a medium positive effect on the improvement of internalizing problems. However, they did not find this effect in the long term. Twelve months after the end of the study this effect was no longer visible. Studies on externalizing problems yield equivocal results. Some studies find small positive effects (e.g., Bartels, Schuursma, & Slot, 2001; Brezinka, 2002; Wilson, Lipsey, & Derzon, 2003), but others find no effect at all (Van der Stouwe et al., 2019). Bijstra and Nienhuis (2003) argue that externalizing problems are more difficult to change. They contend that SSTs therefore generally show more effect on reducing internalizing problems than externalizing problems. Others found that SSTs had more effect in adolescents with a higher level of externalizing problems (Beelman et al., 1994), which was not replicated in the meta-analysis by Van der Stouwe and colleagues (2019).
An explanation for the previously mentioned small to medium effects of social skill training could be that with most of the SSTs the immediate social system of the adolescent is not involved in the training. This means that the participant cannot generalize the learned skills to daily practice (Cook et al., 2008; Kwadijk, 2008). Besides, research showed smaller treatment effects in groups where deviancy training occurred, which contributed to negative peer influences on antisocial behavior (Ang & Hughes, 2002; Dishion, McCord, & Poulin,
1999). It is therefore important to match the group, so that it is not too big and somewhat homogeneous with age, gender and intelligence (Ringrose, 2000). Other studies found smaller effects when the youth was forced to follow the training or when motivation was small (Collot d’Escury-Koenigs, Van der Linden, & Snaterse, 1999; Van der Stouwe et al., 2019). Last, some studies did find larger effects when the SST targeted specific problem-solving or specific goals during treatment. Defining explicit goals for each individual participant is important for the effectiveness of a social skills training (O’Mara, Marsh, Craven & Debus, 2006; Durlak et al., 2010; Van der Stouwe et al., 2019). Overall, it can be expected that with some improvements, SSTs could have larger effects on social skills and prosocial behavior.
StayStrong is based on the classical SST, but Stichting De Ster made some adjustments on the earlier mentioned suggestions to improve its effectiveness. StayStrong is a multi-component group based social skill training, using problematic group situations, physical education and mentoring, representing natural situations of the everyday life of adolescents. During the six days of camp they can practice newly acquired social skills in a naturalistic setting. Besides, Stichting De Ster does an intake to obtain a clear image of the individual and his problems. Also, they set specific goals together with the adolescent, and they ask the adolescent if he is really motivated to work on them. Last, parents are involved in StayStrong by receiving information on the working principles of the intervention during the camp. By making these adjustments Stichting De Ster tries to overcome most of the shortcomings of regular SSTs.
Research has already been done on Sterkamp and Maankamp, which are two SSTs from Stichting De Ster with the similar adjustments as StayStrong. Research shows that these camps have large positive effects on the social skills and prosocial behavior of children in the age of 8 to 13 (Van Vugt et al., 2013). This study is the first to evaluate StayStrong. The research questions of this study are: 1) To what extent is there a positive change in the social skills
deficits, perceived social support and the prosocial behavior of adolescents between 12 and 17 years old after attending the social skills training StayStrong? 2) To what extent is there a positive change in decreasing internalizing and externalizing behavior problems and increasing a positive self-image of adolescents between 12 and 17 years old after attending the social skills training StayStrong? It is expected that adolescents will report more social skills, more perceived social support and more prosocial behavior after attending StayStrong. Besides, it is expected that internalizing problems will decrease more than externalizing problems after attending StayStrong, because externalizing problems are harder to change (Bijstra & Nienhuis, 2003), and the intervention is primarily focused on the reduction of internalizing problems instead of externalizing problems through social skills training.
Method
participants
The research group comprised N = 64 adolescents between the age of 12 and 18 (M = 14.50, SD = 1.18). The gender distribution was 35.9 % boys and 64.1 % girls. From the research group 35% attended vocational education and 65% attended high school. In 89.3% of the cases at least one parent had finished higher education. A total of 91,4% of the youth had a Dutch background and 8,6% did have a different ethnic background.
Procedure
This study was approved by the ethics committee of the University of Amsterdam. The youth and parents were informed in advance about the study and signed an informed consent form. The youth filled out five questionnaires: the Child Behavioral Scala – Adolescence (CBSA), the Youth Self Report (YSR), the Adolescent Social Self-Efficacy Scale (S-EFF), the Strengths and Difficulties Questionnaire, prosocial scale (SDQ-prosocial) and the Multidimensional Scale of Perceived Social Support (MSPSS). The parents filled out the Child Behavioral Checklist (CBCL) (see Instruments). They all could fill out the questionnaires on
paper or digital. This has been done to increase the demographic radius of the participants. The pre-measurements took place five weeks before the camp started, and the post-measurements took place six weeks after the camp had ended.
Program ‘StayStrong’
The youth who participated had been referred by a psychologist or a general practitioner (GP) or parents had contacted Stichting De Ster themselves. Before camp adolescents had an intake to set their own goals. This was done to make sure that the adolescents would be motivated by themselves to go on camp (see Collot d’Escury-Koenigs, Van der Linden, & Snaterse, 1999; Van der Stouwe et al., 2019). Subsequently, the youths were divided in groups of two or three based on their gender, age, cognitive functioning and interests. Youth with fear of speaking in front of a group were partnered with youth who find it less stressful to speak in front of a group.
Besides doing the intakes with the youth, the volunteers were recruited before camp based on an intake procedure as well. These volunteers included child and youth psychologists, actors, fitness experts and a group of educational experts and other motivated volunteers. The ratio volunteer versus adolescents is one volunteer for every two or three adolescents in order to make sure that there was intensive supervision for every adolescent on camp. The volunteers were all matched to one of the groups based on their own experience and ability to help the children with their goals. Besides, they received training about the content and the principles of the program and did receive intensive coaching by the GP. This GP was responsible for the whole treatment during camp and logged everything that happened with the adolescents.
During the 6-day camp the theme was making a movie. This means that the adolescents wrote a script for their movie and filmed pieces of their movie every day. The script is about a difficult situation or theme that most adolescents fear, like fitting in with a group or standing
up for yourself. During fixed program components the adolescents could discuss these topics, trying out different solutions while filming the script. In addition, the program consisted of several conventional camp activities (like live cluedo, and an entertaining evening to conclude) and several fixed program components daily. These fixed program components are 1.5 h of social skills training, 1 h of role play, 30 minutes to write the script, 30 minutes of dressing room (where they learn about hygiene, how to keep yourself clean, what to do with a pimple, because that is a big topic in this age-group as well) and 1 h to film that script. Each day the adolescents had a 1 h meeting with their mentor in a subgroup of two or three children. Research conducted on mentoring programs suggested that a mentor had a positive outcome on the development of the adolescent (Raposa et al., 2019).
All these program components are based on various evidence-based methods and techniques based on cognitive behavioral and social learning theory. During the social skill training, different elements of cognitive behavioral therapy were used (Beck, 1976; Ellis, 1962). The adolescents learn what the influence of negative automatic and unhelpful thoughts can be on their feelings and behavior, and they learn how they can change it into helping or neutral thoughts (Bennett-Levy et al., 2004). The youths are challenged to experiment with their new helpful thoughts and new behavior. The adolescents have the whole week to practice and experiment those new learned behavior and gain success experiences (Scholing, 2002). The adolescents can observe behavior from the other adolescents or the volunteers during camp in accordance with social learning theory (Bandura, 1977). There is a heterogeneous group of adolescents and volunteers during a camp week, so that they can observe different strategies, engage in conversation with each other and share different solutions with each other (Bijstra & Nienhuis, 2003).
Because the adolescents are going to experiment with behavior that is new for them, it is important that camp is a safe environment so that they dare to experiment. During the camp
a lot of positive feedback is given and experimenting with new behavior is rewarded with a lot of compliments. “Reinforced practice” techniques are used in which desired behavior is rewarded and undesirable behavior is ignored (Prins, Bosch, & Braet, 2011). The volunteers were intensively trained in this as well.
Parents are also involved in the learning process of the adolescents in order to help the adolescents to develop and maintain social skills. One of the ways of achieving this was by giving them a presentation about the program of StayStrong and all the theories that their children learn in camp, and mailing these theories during the camp. Besides, there is always a follow-up, 6 weeks after StayStrong, during which the adolescent and his/her parents were present. This follow-up provided parents insight in the development of their child during camp regarding their goals, and parents were given individual advice how to deal with the goals at home or about further help. During this follow-up the adolescent had a last mentoring moment to discuss a difficult situation they faced when they were at home. Besides this follow-up, Stichting De Ster provides an outpatient facility (De Sterpoli), which enabled parents and adolescents to consult the pedagogical team with questions they may have. This provided parents with ways to encourage the adolescent to practice and retain the newly learned skills at home (Cook et al., 2008; Kwadijk, 2008).
Instruments
Child Behavioral Scala – Adolescence (CBSA)
This questionnaire is the Dutch version of the Self-Perception Profile for Adolescents (Harter, 1988), and was standardized for the Dutch adolescents between the age of 12 to 18 (Treffers et al., 2002). The aim of this questionnaire is to get an impression of the competences of adolescents of their global self-esteem and in six areas. The present paper only looked at
their global self-esteem. Each item of the questionnaire proposes two alternatives to the adolescent. The adolescent chooses one of the two alternatives and indicates whether he or she is totally agreeing with it or agreeing a little with it. The reliability of the total score for self-esteem was high at pre- test (α = .86) and post-test (α = .92)
Youth Self Report (YSR)
The original Youth Self Report (YSR) has been developed by Achenbach and Edelbrock (1987) in America. It has been translated into Dutch and standardized for the Dutch adolescents between the age of 11 and 18 (Verhulst, Van der Ende, & Koot, 1997). The aim of the questionnaire is to give an insight of the adolescents’ own experience of their behavior and own skills. The questionnaire consists of two parts, namely a part about skills with questions about sports, hobbies and school, and a part about emotional and behavioral problems. In the present study, only the last part was used. The adolescent answered questions on a three-point scale about how well a question applies. The reliabilities of the internalizing problems were high at pre-test (α = .90) as well as post-test (α = .93). Also, the reliabilities of the externalizing problems were high at both pre-test (α = .85) and post-test (α = .87).
Adolescent Social Self-Efficacy Scale (S-EFF)
The aim of the Social Self-Efficacy Scale (S-EFF) is to measure the self-efficacy of adolescents regarding situations with peers, and to measure their social skills. The S-EFF was developed by Connolly (1989), and the instrument turned out to be valid and reliable. For the current study, the S-EFF had been translated into Dutch. The questionnaire is completed based on self-reporting and comprises 25 items categorized in five scales; dealing with social assertiveness, performance in public spaces, participation in social groups, aspects of friendship and intimacy and giving or receiving help. Adolescents score the questions on a seven-point scale. Current research showed the S-EFF to be reliable at both pre-test (α = .91) and post-test (α = .94).
Strengths and Difficulties Questionnaire, prosocial scale (SDQ-prosocial)
The Strengths and Difficulties Questionnaire (SDQ) is a self-reporting questionnaire that aims to measure social-emotional health in children aged 11 to 16 years (Goodman, 1997). This questionnaire consists of five scales, but current research only includes the scale that measures "prosocial skills". These are questions about providing help to others and being kind to others. The SDQ-prosocial is filled out based on a three-point scale in which the answer options vary from "Not true" to "Certainly true". The SDQ-prosocial scale showed to be unreliable in this study both at pre-test (α = .51) and post-test (α = .54).
Multidimensional Scale of Perceived Social Support (MSPSS).
The Multidimensional Scale of Perceived Social Support (MSPSS) is a self-reporting questionnaire for adolescents that allows one to quickly get an impression of a person's subjective sense of social support (Zimet, Dahlem, Zimet & Farley, 1988). For current research, the questionnaire had been translated from English into Dutch. Only the subscale “friends” was included in this study, which aimed to examine the experienced social support of friends. Respondents answered the questions on a seven-point scale, where the answer options range from "strongly disagree" to "strongly agree". The subscale ‘friends' of the MSPSS was highly reliable both at pre-test (α = .89) and post-test (α = .90).
Child Behavioral Checklist (CBCL) 6–18
The original Child Behavioral Checklist (CBCL) has been developed by Achenbach and Edelbrock (1983) in America. It has been translated into Dutch and standardized for Dutch youth between the age of 6 and 18 (Verhulst, Van der Ende, & Koot, 1996). The aim of the CBCL is to identify competences and problems in children, as observed by their parents/caregivers. Like the YSR, the questionnaire consists of two parts, namely a part about skills and a part about emotional and behavioral problems. In this study, only the second part was used. This part consisted of 118 items with specific behaviors for which parents can
indicate on a 3-point scale whether – and if so, how often – the specified behavior occurs. Completion of the questionnaire results in various scale scores, two of which were used for this study: the broad-band scales for internalizing and externalizing problems. The reliabilities of the internalizing problems were high at pre-test (α = .82) and post-test (α = .85). Also, the reliabilities of the externalizing problems were high at pre-test (α = .89) and post-test (α = .93).
Statistical Analysis
To answer the research questions a series paired t-tests were conducted. This way changes in scores could be compared across two measurement occasions (between pre-test and post-test) and tested for significance. Besides, Cohen’s d was computed as an effect size. A Cohen’s d of .20 indicates there is a small effect, a Cohen’s d of .50 indicates a medium effect, and a Cohen’s d of .80 indicates a large effect (Cohen, 1988).
Results
Table 1 shows the means and sum scores before and after StayStrong for all outcome variables (N = 64). A series of paired T-tests were used to examine the significance of effects. Adolescents reported a medium, significant effect on improving their self-esteem after participation in StayStrong (d = -.52). According to both the adolescents (d = .41) and their parents (d = .44), internalizing problems decreased significantly, with a small to medium effect size, after participating in StayStrong. Adolescents also reported a small but significant decrease in externalizing problems (d = .24), which effect was not found when using parent report. Fourth, adolescents showed a large significant effect on social skills (d = .93). And last, a small significant effect was found for experienced social support from friends (d = .31).
Table 1. Means/sum scores and effect sizes on the before and after measurement of Stay Strong Pre-test Post-test t d N M SD M SD Total self-esteem¹ 45 2.62 .35 2.83 .45 -4.30*** .52 Internalizing problems² 43 18.91 9.61 14.88 10.54 3.63*** .41 Externalizing problems² 44 8.96 6.4 7.36 6.08 3.17** .24 Internalizing problems (parent)³ 52 17.92 7.36 14.72 7.36 3.87*** .44 Externalizing problems (parent)³ 54 9.8 8.4 8.75 7.35 1.15 .11 Social skills4 42 3.99 .87 4.81 .91 -6.59*** .93 Social support5 46 4.86 1.25 5.26 1.29 -2.33* .31
Note. If Cohen’s d is positive it represents an effect in the expected direction. *p<.05. **p<.01. ***p<.001
Discussion
This study examined the extent to which there is a positive change in social skills deficits, perceived social support, prosocial behavior, internalizing and externalizing behavior problems and self-image of adolescents between 12 and 17 years after attending the social skills training StayStrong. At post-test the adolescents showed a great improvement in social skills and a medium improvement in self-esteem. Both adolescents and parents reported a small to medium improvement in internalizing problems. Adolescents reported a small improvement in externalizing problems. Although parents also reported an improvement in externalizing problems, this change was not significant.
The result found in this study are mostly in line with the expectations based on previous studies in which positive effects of SSTs emerged (Cook et al., 2008; Durlaket al., 2010; Van der Stouwe et al., 2019). A possible explanation for the large positive change on social skills after attending StayStrong is that improving the social skills of the adolescents is the main goal of StayStrong. Besides, adolescents can practice their newly acquired social skills in their contact with peers during camp, receiving substantial positive reinforcement. This way, the adolescents can have success experiences, which gives them confidence in their own social skills (Prinsen, 2009). Success experiences and increased confidence may also explain the positive change in self-esteem (McKay & Fanning, 2016).
It is plausible to suggest that the positive effects on internalizing problems derive from the positive changes in both social skills and self-esteem. With increasing social skills friendships are thought to increase as well (Bos, Muris, & Huijding, 2011; Segrin et al., 2007). More and better friendships may positively affect experienced social support, enabling conversation about (problematic) feelings and anxieties with friends (Demaray & Malecki, 2002; Van Geuns, 2006; Bokhorst et al., 2009). As expected, the effects on externalizing problems proved to be smaller than the effects on internalizing problems. A possible explanation could be that externalizing problems are more difficult to change than internalizing
problems (Bijstra & Nienhuis, 2003). Another explanation could be that externalizing problems were less present in the experimental group. A post-hoc analysis showed that 32 parents (56.4%) reported internalizing problems in the clinical range, whereas only 13 parents (23%) reported externalizing problems in the clinical range. At total of 26 adolescents (59.1%) reported internalizing problems in the clinical range, only 3 adolescents (6.9%) reported externalizing problems in the clinical range. This indeed shows that externalizing problems were less present compared to internalizing problems. Last, the intervention was more tailored to target internalizing problems than externalizing problems through social skills training.
Research suggests that externalizing problems reduce more when focusing on the effect the behavior of the adolescent has on his environment and the understanding of social events (Bellack, Mueser, Gingerich, & Agresta, 1997; Langeveld, Gundersen, & Svartdal, 2012; Wilson et al., 2003) or cognitive distortions related to aggressive behavior (Helmond, Overbeek, Brugman, & Gibbs, 2014; Hoogsteder et al., 2014). This would indicate that for reducing externalizing behavior StayStrong should focus more on social information processing, including cognitive distortions or irrational thoughts that are associated with aggression, such as hostile attribution bias (Helmond et al.. 2014; Van Stam et al., 2014). This might be a minimal adjustment, because it should not jeopardize the character and effectiveness of the current intervention.
These results are largely in line with the previous evaluation study on Star camp and Moon camp, which found positive changes in internalizing problems and self-esteem in school-aged children between 6 and 12 years old (Van Vugt et al., 2013). However, internalizing problems and self-esteem showed a small change after Star camp, whereas these changes were medium after StayStrong. Many adolescents struggle with their self-esteem (Orth, Robins, & Widaman, 2012) and are more self-aware than younger school-aged children, which may explain the larger effect for StayStrong compared to Star camp (i.e., ceiling effect). Another
explanation could be that adolescents have a higher motivation to attend the social skills training compared to younger children, because they are much more aware of their behavior problems and social skills deficits. Moreover, adolescents tend to have more self-insight, which may increase their treatment motivation (Schneider, 2008). Notably, research shows that children who are less motivated to join camp show smaller effects after the treatment (Collot d’Escury-Koenigs, Van der Linden, & Snaterse, 1999). Finally, this study finds large effects on social skills, but social skills were not assessed in the evaluation study of Star Camp and Moon camp by Van Vugt et al. (2013).
After attending the booster session, Moon camp, results were substantially larger (Van Vugt et al., 2013), and much more in line with the results of the present study if considering the magnitude of effects. However, we suggest that the effects of StayStrong may further increase, or at least stabilize, after a booster session. Research suggests that practicing newly acquired skills in booster sessions can help developing those skills more (Michalski, Mishna, Worthington & Cummings, 2003). This should be examined in future effectiveness studies. Nevertheless, it is also conceivable that younger children do more profit from a booster session than adolescents, due to differences in social-cognitive abilities between school-aged children and adolescents (Bjorklund & Causey, 2018). This would mean that a booster session after StayStrong would not make a difference.
This study has a number of limitations. First, the generalizability of the results is low, because the adolescents primarily attended secondary schools of higher educational levels, and were from higher socioeconomic backgrounds, while most of them were Dutch. Second, the instrument that measured prosocial behavior was not reliable, and could therefore not be used. This means that no changes in prosocial behavior could be tested. Last, program integrity has not been taken into account in the present study. Especially with externalizing behavior,
probably even more than internalizing problems, program integrity should be high in order to obtain positive results (Goense, Assink, Stams, Boendermaker, & Hoeve, 2016).
Despite these limitations, the present study revealed some promising results given the positive changes in most outcomes after StayStrong. Some recommendations for future research would be to include a reliable questionnaire to assess prosocial behavior and to assess social information processing, including cognitive distortions associated with both internalizing and externalizing problem behavior (see Hoogsteder, Wissink, Stams, Van Horn, & Hendriks, 2014; Van der Helm et al., 2013). Secondly, program integrity should be taken into account. Third, the StayStrong social skills training may be somewhat changed to be able to better address and target externalizing problems. Besides previous recommendations, it would be valuable to conduct (quasi-)experimental research because of the promising results of this study. Last, it would be interesting to include long-term follow-up measurements to examine whether changes remain or increase over longer periods of time. To conclude, adolescents and their parents experienced a positive change after attending StayStrong, which warrants further investigation of this promising social skills intervention.
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