Social Competence of
Children with Central
Nervous System Tumors
Kristina K. Hardy, PhD
Children’s National Medical Center
Washington, DC
With special thanks to Victoria Willard, PhD
St. Jude Children’s Research Hospital
Session Objectives
 Identify
the risk factors that impact the
social competence of a child with a central
nervous system (CNS) tumor
 Examine the consequences of these risk
factors and the long-term implications
 Identify early interventions that facilitate a
social connection during and after
Social Competence:
What is it?
What do you call it?
Social Functioning
Social Skills
Social Performance
Social Networks
Social Behavior
Peer Relationships
Social Adjustment
Social Competence
Social or Sociometric Status
Social Interaction
Social Competence:
A Working Definition
 The
socially competent individual is
someone “who is able to make use of
environmental and personal resources to
achieve a good developmental outcome”
Involves coordination of affect, cognition, and
Notice that this is not predicated on the quality
of the environment, but a child’s ability to
make the most of what s/he has to work with
Waters & Sroufe, 1983
Age of the child
Qualitative shift around ages of 4-7 and 11-14 in
social reasoning skills
Elementary, middle and high school
Differences in context of interactions
• Play, extracurricular activities, dyads, etc.
First exposed to large numbers of kids
Possibly a sensitive period for development of
behaviors, attitudes and preferences that influence
peer interactions/relationships
Tri-Component Model
Social Adjustment
Social Performance
The degree to which people are currently
achieving socially and developmentally
appropriate goals
The extent to which a person is able to respond
appropriately within a social situation
Social Skills
Cavell, 1990
The abilities that allow a person to perform a
given social task competently
Risk factors
Social Outcomes in
Childhood Brain Disorder
Yeates et al., 2007
Risk Factors
Medical Risk factors
Age at diagnosis
Tumor type (e.g., craniopharyngioma, pontine glioma)
Younger age
Critical developmental period (preschool,
Association with late effects
Environmental Risk Factors
Parent involvement
Providing opportunities for social interaction
Monitoring social situations
Providing a good model
School involvement
How connected is the child with school and what is
the quality of that connection?
What provisions have been made to maintain contact
with the school during treatment (especially in terms
of maintaining/resuming school attendance when
Individual Risk Factors
Cognitive status
Shy or aggressive children may have problems
Children who are anxious or depressed are likely to have
difficulty with social interactions
Pre-existing mental health diagnoses like ADHD and autistic
spectrum disorders are associated with problems with social
Attention and executive functioning
Behavioral and emotional regulation
Verbal skills
Pre-morbid sociometric status
How well-liked is this child by his or her peer group?
How many friends does this child have?
Social outcomes in children
with CNS tumors
Tri-Component Model Revisited
20 articles measuring social functioning in BT
Majority of research
None – tough to conduct with this population
One study (facial expression recognition)
Schulte & Barrera, 2010
Daily functioning in long-term
survivors of medulloblastoma
Maddrey et al., 2005
Long-term Social Functioning
Few friends
No dating
“Out of sync”
Deficits impact their ability to interact in an
age-appropriate manner with peers and
Survivors & the Peer Group
Exclusion from normal peer interactions
Difficulty communicating
Act younger than their age
More comfortable with adults than children
A marked change from premorbid
Vance, Eiser & Horne, 2004
Perceptions of Social Competence
Hardy, Willard, Watral & Bonner, 2010
Survivors & the Peer Group
Fewer friends than comparison classmates
Reciprocal friends also have social deficits
Lower popularity, more isolated, less accepted, teased
Fewer reciprocal friends
Picked less often as “best friend”
Misperception of friends
Identified friends are more socially desirable
Gender differences
Males more prosocial; females more isolated
Vannatta et al, 1998; Vannatta, Gerhardt et al, 2006-2008
Survivors & Friends
Survivors are not as engaged with friends
as typically-developing children
Survivors do not participate in interactions
that require comfort, trust, negotiation
Imaginative play
Katz, Leary, Brieger & Friedman, 2011
Attention and Executive Functioning
There is a strong correlation between parentreported social problems and attention
In one study, parent report of social deficits was
actually a stronger predictor of objectivelymeasured attention impairment than parent report
of attention difficulties.
Attention problems were significantly related
to difficulties with adaptive functioning
such that deficits in attention caused by treatment
with radiation led to impairment in daily living
Patel, et al, 2007; Papazoglou, et al, 2008, 2009
Facial Expression Recognition
 In
healthy children, the ability to decode facial
expressions is associated with ratings of
social competence
 Deficits
Low peer sociometric status
Social anxiety
Diagnostic Analysis of Nonverbal
Accuracy – Revised (DANVA2)
Baum &Nowicki, 1998
Diagnostic Analysis of Nonverbal
Accuracy – Revised (DANVA2)
Baum &Nowicki, 1998
Survivors’ Social Skills:
Facial expression recognition
Bonner, Hardy, Willard, et al, 2008
Social Functioning &
Facial Expression Recognition
 Medical predictors of deficits in facial expression
Treatment with radiation
Younger age at diagnosis
 Associations with measures of social functioning:
More errors associated with poor reported social
Bonner, Hardy, Willard, et al., 2008
Gender Differences in Facial
Expression Recognition
Willard, Hardy & Bonner, 2009
Gender Differences in Facial
Expression Recognition
 Female
survivors experienced significantly
more parent-reported social problems than
male survivors
 These
social problems were significantly
associated with number of errors in facial
expression recognition
But only in females – no associations in males
Willard, Hardy & Bonner, 2009
Assessment and
A Conceptual Model of Assessment
Social-Cognitive Factors
Social Experience
Medical Factors
Step 1: Asking the right questions
 Asking
about peer relations is important
starting at diagnosis
Ask the child, the parent, and (if possible) the
Ask about how well-liked the child is by his or
her peer group at large
Ask about how many good friends the child
Ask about a plan to maintain safe and
appropriate contact with peers
Tools for getting information
Questionnaire measures can be helpful to start
the conversation and screen for early problems
 If the child has had a neuropsychological
assessment, consider any weaknesses in
attention or general cognitive functioning
 Asking simple questions (e.g., “Has s/he been
able to see any friends in the last month?”)
frequently can capture issues early on
 School attendance is a big indicator – if the child
is not regularly in school, s/he is not likely to
have regular contact with same-aged peers.
Measurement Tool:
Social Functioning subscale:
Problems with…
1.Getting along with other children
2.Other kids not wanting to be his/her friend
3.Getting teased by other children
4.Not able to do things that other children
his/her age can do
5.Keeping up when playing with other children
Varni and colleagues, 1999, 2001, 2002
Measurement Tool:
Child Behavior Checklist
Social Problems subscale:
Clings to adults/dependent
Complains of loneliness
Doesn’t get along with others
Easily jealous
Feels others are out to get him
Gets teased
Not liked by others
Prefers being with younger children
Speech problems
Achenbach, 1991; Achenbach & Rescorla, 2001
Measurement Tool:
Conners’ Rating Scale
Peer Relations subscale:
Has trouble keeping friends
Has no friends
Appears to be unaccepted by
Interacts well with other children
Has poor social skills
Does not know how to make friends
Is one of the last to be picked for teams or
Conners, 1997, 2008
Measurement Tool:
Social Skills Rating/Improvement System
Social Skills
Says “thank you”
Follows household rules
Takes turn in
Interacts well with other
Makes friends easily
Tolerates annoying peers
Joins activities that have
Gresham & Elliott, 1990, 2008
Problem Behaviors
Keeps others out of social
Stereotyped motor
Sleeping problems
Measurement Tool:
Emory Dyssemia Index
Gaze and Eye Contact
Space and Touch
Facial Expression
Social rules/norms
Nonverbal Receptivity
Duke & Nowicki, 2005
Fails to look at others
Stands too close
Speaks too softly
Fails to look interested
Interests “out of sync”
Lacks “common sense”
Behavior is “out of
Measurement Tool:
Social Competence Inventory
Social Initiative
Often suggests
Withdrawn from peers
Hesitant with peers
Spectator instead of
Tends to be dominated
by peers
Is often a leader
Easily makes contact
with unfamiliar kids
Rydell, Hagekull & Bohlin, 1997
Prosocial Orientation
Tries to comfort peers
Is able to interpret
Able to sympathize
Shares belongings
Criticizes peers
Plays and cooperates
Measurement Tool:
Social Problem Solving
and some other
kids are playing on the
jungle gym at school.
You would like to play
with them, but they
haven’t asked you.
What could you do or
say so that you can
play with Alex and the
other kids?
Rose & Asher, 1999, 2004
Strategy & Goal
You and your friend
are planning to study
for a test together. You
want to study with only
your friend, but your
friend asks another
person to study with
What would you say
or do?
What would your goal
Assessment Limitations
Questionnaire ratings (especially by parents) don’t always
correlate well with the child’s real-life social competence
 Peer relations researchers don’t rely on questionnaire data;
they collect information from entire peer groups (called
 Sociometric procedures are impractical and not costeffective for pediatric cancer survivors
 Moreover, although sociometrics are good at describing what
is happening, they provide little information as to why….
 We have not been able to identify skills deficits that could be
targeted in an intervention
Step 2: What can be done when
there is a problem?
In order for a good referral to be made, having an idea of
why the problem is occurring is important
• Cognitive late effects
• Disfigurement or physical limitations
• Child is not in school or no longer participates in extracurricular
• Parent is overprotective OR child is afraid to do things on his or her
• New symptoms of anxiety or depression
• Lack of appropriate social skills
Intervention – what is in the
completed studies
 Very small sample sizes (n = 13 to 32) and
no randomized design
Involved skills training at the group level
Limited by the measures used to assess
change (largely parent report)
Discrepancy between measure scores and
parent anecdotal report
Barakat et al, 2003; Barrera & Schulte, 2009; Die-Trill et al, 1996; Mulhern et al, 2004; Conklin et al, 2010
DieTrill et al., 1996
 Small
study of a group intervention for
male survivors focused on
assertiveness training and how to
handle teasing
 Boys and parents liked the intervention
and reported better social functioning,
but the measure was not standardized
Barakat et al., 2003
 13
children completed social skills training
 Social functioning was measured by
standardized rating scales 1 month before
the intervention and 10 months afterwards
 Again, ratings of social skills improved, but
the single arm design and small sample
size limits the ability to interpret the
Barrera & Schulte, 2009
Pilot study of an 8-week social skills group for
32 brain tumor survivors
Assertiveness training
Friendship making skills
Study was feasible and associated with improved
parent ratings of survivors’ self-control, social
skills, and quality of life
Again, a single arm design and reliance on parent
report limits generalizability of findings
What can clinic providers do?
Frequent assessment and prompt referral is likely to be
the best approach
Try to match an intervention with the reason you think a
problem is occurring
E.g., If the child is not being given an opportunity to socialize due
to a parent’s fears about contagious illness, parent education
may be needed
When social skills instruction is needed, it is important to
keep in mind that this type of intervention tends to make
it more likely that children can make a friend, not
necessarily that they will be better liked by their peer
group at large
What is on the horizon?
 Addressing
problems with cognitive
Data from the Ritalin trial showed
improvements in social functioning after
treatment with stimulant medications
Computerized cognitive training?
Cognitive rehabilitation?
 Understanding
what social skills need to be
Do we focus on teaching skills?
What skills should we teach?
Children with CNS tumors are at risk for social
problems, especially after treatment ends
 Problems are likely to be related to changes in
cognitive functioning, as well as pre-existing
social difficulties, but environmental factors like
prolonged school absences also are likely to
play a role
 Intervention strategies are few, but monitoring of
social functioning should be done early and

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