Social Competence: Evaluation of an outpatient therapeutic recreation treatment program for children...

THERAPEUTIC RECREATION JOURNAL Vol. 40, No. 4, 241-254, 2006

Social Competence: Evaluation of anOutpatient Recreation TherapyTreatment Program for Children withBehavioral DisordersErin Rothwell, Jennifer Piatt, and Kelly Mattingly

The purpose of this article is to present the results from an evaluation of a recreation therapycomponent of an outpatient treatment program for children with behavioral disorders. Thedevelopment of social competencies during childhood is vital for the developmental outcomesthat affect success later in life. Social skills, an indicator of social competence are thosebehaviors within a given situation that predict social outcomes for children (Gresham, 1986). Thelack of social skills contribute to participants being referred to this program after severaldisciplinary problems at school and home such as extreme aggressiveness or withdrawal,hyperactivity, or poor reality testing. The program allows an interdisciplinary approach thatinvolves psychiatry, social work, recreation therapy, and other supportive disciplines. Therecreation therapy component of this program teaches 'formal' social skills classes, but socialskills are reinforced throughout the entire program. The evaluation was the project for arecreation therapy practicum at this facility.

Erin Rothwell, Ph.D., TRS, CTRS, CRSS is a Assistant Research Professor at the Universityof Utah College of Nursing and her research interests are in group development, socialcompetency and community-based research. She completed her recreation therapy practicumduring the Fall of 2002 at the University of Utah Neuropsychiatric Institute and continues topractice as a Recreation Therapist. Jennifer Piatt, Ph.D., CTRS is a Assistant Professor atCalifornia State University-Sacramento. She has worked in the mental health field for 8 yearsand has been a practicing Certified Therapeutic Recreation Specialist for 9 years. KellyMattingly, TRS, CTRS graduated from the University of Utah with a bachelor's degree inLeisure Studies, emphasis in Therapeutic Recreation. She has worked in child psychiatry for16 years and currently working as in Education Counseling. She lives in Salt Lake City, Utahwith her husband and two children.

Fourth Quarter 2006 241

KEY WORDS: social competence, recreation therapy, children, outpatient, behavioral disor-ders, social skills

According to the U.S. Surgeon GeneralReport, one in 10 children under the age of 18will experience a significant mental healthproblem during their school years, but onlyone in five of those who need treatment willreceive appropriate mental health services(United States Public Health Services [PHS],2000). Untreated mental illnesses and mentalhealth problems in youth are especially prob-lematic because they affect the developmentalprocess. Adding an unstable environment (i.e.neglect, abuse, poverty) to this situation onlyexacerbates problems with mental health andappropriate behavior, including thoughts andemotions (PHS, 2000).

Children who experience mental illness,poverty, parental substance abuse, and vio-lence often lack necessary social skills forlearning effectively in the classroom (Rose,1996). Mash and Barkely (1996) have alsonoted that children with conduct disorders,delinquency, depression, and anxiety fre-quently exhibit social skill deficits. Thus, so-cial competence, and more specifically, socialskills are one potential area of interventionwhen addressing mental health concerns orenvironmental instability among children(Cartwright-Hatton, Tschemitz, & Gomersall,2005; Hops, 1983). A potential means of ad-dressing social skills within the mental healthenvironment is through recreation therapy.

Recreation therapy aims to develop, main-tain, and facilitate expressions of appropriateleisure lifestyles for individuals with social,mental, emotional, or physical limitations (Na-tional Therapeutic Recreation Society, 1994;Peterson & Gunn, 1984; Peterson & Stumbo,2000; Stumbo & Peterson, 2004). The LeisureAbility Model provides definition and direc-tion for the delivery of recreation therapy ser-vices (Peterson & Gunn, 1984; Peterson &Stumbo, 2000; Stumbo & Peterson, 2004).The model takes into account the biologicaland/or psychological factors as well as the

social context that many other treatments inthe mental health field have neglected (Long,2004). Through the functional intervention,leisure education, and recreation participationcomponents of the Leisure Ability Model, rec-reation therapy professionals may be able toimprove social skills in youth. Therefore, thepurpose of this study was to evaluate theeffectiveness of an out-patient recreation ther-apy program designed to enhance social skillsof children with behavior disorders. The pro-gram is conceptually grounded in the LeisureAbility Model, and evidence of such effective-ness would also indirectly support the asser-tion that this model can be used to effectivelydesign practical interventions.

Literature Review

Mental Illness and Social SkillAcquisition

Mental illness usually first shows signsduring childhood rather than when an individ-ual enters adulthood (Giaconia, et al., 1994;Lauria-Horner, Kitcher, & Brooks, 2004). Thistendency for early onset is disturbing due tothe potential impact of mental illness on hu-man development. When considering that ap-proximately 10 million, or 20%, of children inthe United States have some form of mentalillness (PHS, 2002), the need to identify mech-anisms for minimizing this developmental im-pact seems obvious. More concerning are re-search findings that indicate, one in 10children experience mental illness severeenough to cause some level of impairmentaffecting normal development and functioning(Burns, et al., 1995; Shaffer, et al., 1996). Thisimpairment is often in the area of social com-petency, which is illustrated by the fact that theprimary referral for children to school-basedmental health services is often based on ateacher's judgment of the child's social com-petency (Gresham & Noell, 1996).

242 Therapeutic Recreation Journal

The development of social competenciesduring childhood is vital for developmentaloutcomes that affect success later in life (Fos-ter & Ritchey, 1979; Lockwood, Kitzmann, &Cohen, 2001). Children with behavioral disor-ders frequently display problematic behaviorsthat affect social competencies in peer rela-tionships (Farmer & Hollowell, 1994; Stein-berg & Knitzer, 1992) and academic success(Lockwood, et al, 2001; Walker & Hops,1976). Inadequate social competence duringchildhood is related to juvenile delinquency(Foster & Ritchey; Loeber, 1985; Roff, Sells,& Golden, 1972; PHS, 2000) and the devel-opment of antisocial behavior patterns(Dodge, Cole, & Brakke, 1982). Social com-petence has also been considered important inpsychiatric diagnosis, treatment, and adjust-ment of psychiatric patients to community life(Gresham, 1986), and mental health problems(Cowen, Pederson, Babigan, Izzo, & Trost,1973).

A sub-domain of social competence is so-cial skills (Gresham, 1986; Gresham & Re-schly, 1987). Social competence can be viewedas an evaluative term based on a judgment thata person has performed a task adequately; andsocial skills are specific identifiable behaviorsthat an individual exhibits to perform compe-tently on a task (Greshem; Hops, 1983). Socialskills are considered "those behaviors which,within a give situation, predict important so-cial outcomes for children" (Greshem, p. 150).Outcomes include peer acceptance, significantother's judgment, and behaviors that consis-tently correlate with peer acceptance and sig-nificant others' judgment; therefore, socialskills can be considered an essential compo-nent of social competence (Hops).

The level of social skills of a child with amental illness plays a major role in the forma-tion of adaptive behavior (de Bildt, et al.,2005). Children with mental health issues, spe-cifically emotional and behavioral disorders,often display negative behaviors such as ag-gression and disruptions that have a directimpact on the relationships they form withpeers early on (Coleman, 1992; Erdley &

Asher, 1999; Farmer & Hollowell, 1994;Kauffman, 1993; Rosenberg, Wilson, Ma-heady, & Sindelar, 1992). This also makesthem at greater risk of being rejected by peersin various social situations and developingchronic behavior problems (Erderly & Asher).These are serious concerns to the developmen-tal process, as children who experience peerrejection are more apt to have problems withschool transitions (i.e. elementary to juniorhigh, etc.), experience long-term adjustmentdifficulties, and are more likely to drop out ofschool (Erdley & Asher; Lockwood, et al.,2001).

Recreation TherapyRecreation therapy is an intervention that

can address social competency, and especiallysocial skills in children with the diagnosis of amental illness. The primary purpose of recre-ation therapy is to "restore, remediate or reha-bilitate in order to improve functioning andindependence as well as reduce or eliminatethe effects of illness or disability" (AmericanTherapeutic Recreation Association, 1987).By increasing social skills through recreationtherapy, the negative effects of a mental illness(i.e. poor peer relationships) may be reduced.Additionally, one of the main components ofrecreation therapy or leisure activity often in-volves some form of social interactions withothers; therefore the development of socialcompetency is vital for recreation therapy(Stumbo, 1995).

The Leisure Ability Model, one of thedelivery service models in recreation therapy,is an appropriate delivery point for social skilldevelopment in practice. The Leisure AbilityModel consists of three components (func-tional intervention, leisure education, recre-ation participation). The functional interven-tion phase addresses physical, cognitive,emotional as well as social functioning abili-ties of the individual (Peterson & Stumbo,2000; Stumbo & Peterson, 2004). Servicesprovided during this component help decreaselimitations (i.e. poor social skills) that may


hinder one's ability to learn leisure-relatedawareness, knowledge, skills, abilities, and in-volvement (Stumbo & Peterson).

The second component of the model isleisure education, which includes leisureawareness, social skills, leisure skill develop-ment, and leisure resources. One of the majorcontent areas of leisure education is the teach-ing of social interaction skills, which is con-cerned with promoting effective social skills invarious leisure environments (Peterson &Gunn, 1984; Sylvester, Voelkel, & Ellis, 2001;Stumbo & Peterson, 2004). Individuals withdisabilities often have inadequate social skillsthat can create barriers to full leisure partici-pation (Stumbo & Peterson). Lastly, the rec-reation participation component allows theparticipants to practice their newly learnedsocial skills in leisure activities.

Social Skills Effectiveness andRecreation Therapy

Social interactions during the leisure expe-rience are often more important than the ac-tivity itself (Iso-Ahola, 1980; Peterson &Gunn, 1984; Stumbo, 1995). When individualsdo not have the appropriate social interactionskills, the leisure experience is not as reward-ing as it could be. The social acceptance ofothers during recreation participation may de-termine if the leisure experience is meaningfulfor the individuals with a disability (Sylvester,et al., 2001). Leisure experiences provided inclinical settings help transfer social skillslearned during recreation therapy interventionsto daily interactions within the community.

Social skills are an essential prerequisite toan appropriate leisure lifestyle (Peterson &Gunn, 1984; Sneegas, 1989; Stumbo, 1995;Stumbo & Peterson, 2004), and, thereforeshould be included as a goal in recreationtherapy services. For a goal in social compe-tency to be met, children must be aware ofwhat skills are appropriate in various socialsituations. One factor that contributes to thedevelopment of adjusting to various situationsthrough-out life is identifying personal goals

for social interactions that lead to social com-petence (Erdley & Asher, 1999). For example,a personal goal for social interactions could beto take turns going first or to share their sup-plies for the activity. Creating appropriate so-cial interactions in childhood that can be re-ferred back to with other children whodisplayed positive behaviors can help preventfurther developmental problems because chil-dren with negative social behaviors tend toaffiliate with other children who display thesebehaviors (Erdley & Asher; Farmer & Hollow-ell, 1994). When children become older, thepriorities of the social goals they have setbecome more difficult to change; therefore, itis important to intervene with children atyounger ages, rather than when they enteradolescence (Mize & Ladd, 1990; Erdley &Asher). Individuals who demonstrate socialcompetency have the ability and knowledge torespond appropriately in a variety of situations(Sylvester, et al., 2001).

Recreation therapy facilitates and teachespositive social skills essential for these leisureexperiences (Sneegras, 1989) to occur amongchildren with behavior disorders. Sneegrasstates social interactions with others are asimportant as the leisure experience itself. Yet,adolescents are among many of the popula-tions receiving therapeutic recreation serviceswho display a deficit in social skills (Austin,2001; Sneegras). If an individual cannot so-cially engage with peers, family members, andfriends, the leisure experience cannot be expe-rienced to the fullest. On the other hand, whenan individual is exhibiting acceptable socialbehaviors individuals are able to engage inconversations, problem solve, support others,and attend and listen to what is going onaround them (Austin, 2004; Stein & Cutler,1998).

Social skills training is often identified asone of the key components of a therapeuticrecreation program (Austin, 2004; Bullock &Mahon, 2001; Sylvester, et al., 2001), andespecially a component of leisure education(Dattilo, 2000). During social skills trainingthe therapist utilizes various facilitation tech-


niques with participants to emphasize appro-priate social interactions. These include, butare not limited to: demonstration of the skill,discussion, and active participation bothwithin and outside of the group. Dattilo indi-cates role playing in various leisure situationscan help reinforce appropriate interactions.Social skills training supports the LeisureAbility Model in that the aim of social skillstraining is directed toward improvement insocial functioning (Austin; Duck, 1998) andworking towards the individual being as inde-pendent as possible in various social environ-ments.

Sneegas (1989) and Austin (2001) haveidentified specific steps to follow for socialskill training to be effective in therapeuticrecreation settings. This includes: assessmentof the problem area; task analysis of the be-havioral components necessary to achieve thesocial skill; introduction to the social skill as arationale for the learning of the social skill aregiven to the client; demonstration and model-ing of specific social behaviors; practice andrehearsal of the new behavior; provision offeedback and reinforcement of the behavior;and generalization to a variety of situations(Sneegas). When examining each of thesesteps, one can relate each of them back to thetherapeutic recreation process implemented inprograms.

Therapeutic recreation and social skillstraining has been largely discussed as a facil-itation technique in therapeutic recreation(Austin, 2004; Stumbo & Peterson, 2004), yetlittle research has been conducted in this area.More specifically, social competency has beenseen as a goal of therapeutic recreation foryears (Austin). Providing social skills effec-tiveness in therapeutic recreation environ-ments allows individuals to gain new skillsreinforcing one's social competency (Austin).This includes individuals being accepted, val-ued, and included in community settings (Dat-tilo, 2000).

It is critical that services for children withmental illness, specifically behavior disorders,are developed in a manner that attempts to stop

or reverse the negative impact of such condi-tions on the developmental process. Specifi-cally, maintenance and enhancement of socialcompetence should be a primary targeted out-come. Recreation therapy services have aninherent potential for achieving such outcomesdue to the fact that social skills are a basiccomponent of leisure skills and behaviors.This connection is illustrated by the LeisureAbilities Model, which also proposes that so-cial skills be a primary aspect of recreationtherapy services. Based on this rationale, aprogram for enhancing social skills in childrenwith behavior disorders was developed andlater evaluated. It was hypothesized that chil-dren who participated in at least 10 days of thetreatment program would experience signifi-cant increases in overall social competence, aswell as in interpersonal, self-management, andacademic sub-domains of social competence.The evaluation process was implemented andis presented here because it allows for infor-mation to be collected and analyzed to gener-ate knowledge concerning ethics, efficiency,or equity of a product (Sylvester, et al., 2001).This applied approach to understanding phe-nomenon allows for issues of both practice andresearch to be addressed.

Methods

Participant InformationParticipants for this study were children

ages 5-12 years with a mental illness diagno-sis and behavioral disorders currently receiv-ing outpatient treatment services. Criteria forinclusion in the study included: a current med-ical diagnosis of mental illness, age 5 to 12years, and completion of the 2-week treatment.Participants who did not complete the 2-weektreatment were excluded from the study. Theaverage age of the participants was 10 yearsold and 7 out of the 15 participants werefemales. Although there were over 30 poten-tial participants, only 15 participants qualifiedfor the study from February 2003 to October2003.


InstrumentationThe School Social Behavior Scales (SSBS)

designed by Merrell (2001) were used for thisevaluation. The SSBS is comprised of twoscales: Social Competence and Antisocial Be-havior. These two concepts, social competenceand antisocial behavior, are not dichotomous,but are related. Although these concepts arelinked (i.e. poor social competency morelikely to engage in antisocial behaviors), thenature of the relationship is unknown, thus,they are measured in two different scales.These scales use a five-point Likert-type scaleranging form 1 (never) to 5 (frequently). Thisscale was tested with over 800 participants inkindergarten through high school and had aChronbach's alpha reliability of .94.

The Social Competency scale includes 32positively worded questions divided into threesubscales (interpersonal skills, self-manage-ment skills, and academic skills). Interpersonalskills consists of 14 items that measure socialskills needed for establishing positive relation-ships with and gaining acceptance amongpeers (i.e. "invites other students to participatein activities"). Self-management includes tenitems that measure social skills related to self-restraint, cooperation, and compliance toschool rules and expectations (i.e. "respondsappropriately when corrected by teacher").The third scale is academic skills and consistsof eight items that measure competent perfor-mance and engagement of academic tasks (i.e."completes individual seatwork without beingprompted").

The Antisocial Behavior Scale includes 33items divided into three subscales (hostile-irritable, antisocial-aggressive, disruptive-de-manding). Hostile-Irritable consists of 14items that describe behaviors considered to beself-centered, irritating, and annoying andlikely to lead to rejection of peers (i.e. "willnot share with other students"). Antisocial-Aggressive consists of 10 behavioral descrip-tors that relate to violation of school rules andharm or threats to others (i.e. "takes things thatare not hers/his"). Disruptive-Demanding in-

cludes nine items that reflect ongoing schoolactivity and place inappropriate demands onothers (i.e. "is overly demanding of teacher'sattention").

The participants also completed a "work-book" that asked how they would respond tovarious social situations. Using the workbookallowed documentation of participants' per-spectives on how they would behave and/orrespond to familiar social situations. This al-lowed the recreation therapist to assess eachparticipant's progress and to also discuss theworkbooks with the participants. Table 1 is thelist of questions from the workbook. Theworkbook was not given on the first day oftreatment because the participants had to learna significant amount of rules, meet severalpeople, and adjust to their new setting, thus,time did not allow. These open-ended ques-tions were used in addition to the standardizedsurvey to either confirm or disconfirm theresults of the questionnaire with another levelof data. There were approximately 13 ques-tions and it took about 10-15 minutes tocomplete.

SettingThe outpatient treatment program in this

study utilized an interdisciplinary approach.This included a child psychiatrist, psycholo-gist, social worker, educational specialist, rec-reation therapist, and psychiatric technician.The treatment focused on helping the childrento develop adaptive coping skills, strongerinterpersonal/social relationships, increasedself-esteem, greater autonomy, and educa-tional progress. The treatment team formallymet once a week to discuss each of the partic-ipants, but there were continuous informaldiscussions that occurred. Also, if there wereissues that arose such as outbursts, progress inan area of concern, withdrawal, or moodchanges, more informal discussions occurredwithin the treatment team. This programplaced a tremendous amount of effort on com-munication among the treatment team becauseof its importance for helping each participant.


Table 1.

Workbook Questions

1. What would you do if you were watching T.V. and someone grabbed the remote andchanged the channel?

2. If I don't win at something, I usually . . . .3. Name three ways to be a good friend.4. When I am angry, I usually . . . .5. The best way to make a new friend is to . . . .6. Being a good friend means . . . .7. Circle the best ideas for handling your anger (Scream and yell, Talk to someone, Throw

a tantrum, Run away, Take a break, Go for a walk).8. Someone pushes you in line at the drinking fountain. You handle it by . . . .9. Name three ways to handle your anger.

10. Name three things you look for in a friend . . . .11. What would you do if you and a friend both wanted to play a different game?12. You come home from school and find your little brother in your stuff. You say to him13. Is it OK to be angry? Why or why not?

The participants were referred to this pro-gram by community mental health organiza-tions after severe disruptions in the schooland/or home settings. Some of the behaviorsaddressed in this program included extremeaggressiveness or withdrawal, hyperactivity,short attention spans, soiling clothes, defianceof authority, mood swings, learning disability,problematic family and peer relationships, andpoor reality testing. The length of the programwas approximately 14 to 21 days, but atten-dance fluctuated significantly. Participantswere often moved back to their living settingonce parents believed they had learned basicsocial skills to deal with their social environ-ment or were moved to inpatient services.When the participants were enrolled, theywere removed from their present school andtemporarily enrolled in the accredited schoolassociated with the hospital.

The participants enrolled in the programwere kept in one group throughout the day(8:00 am to 5:00 pm), except for individualmeetings with the child's therapists. The groupsize can range from 1 participant to 10 partic-ipants. A psychiatric technician performed thedaily maintenance of the milieu such as safety

concerns during unstructured play time andtransportation of participants to and from treat-ment sessions, and was the only individual thatremained with the participants throughout theday. The participants attended school in themorning and, after lunch, participated in rec-reation therapy, physical activity, and socialwork groups. Recreation therapy was the onlyprogram the participants attended everyday.

Data Collection ProceduresData collection of the evaluation included

both quantitative and qualitative methods toassess change in the participants' social com-petence during their treatment. Emphasis inthis evaluation was placed on the quantitativecomponent because of the extensive testing ofthe instrument. The purpose of adding a qual-itative component (open-ended workbook)was to either confirm, or disconfirm the resultsof the scales, and to obtain a different level ofdata (Tashakkori & Teddlie, 2003). After com-pletion of one day of the program, the psychi-atric technician completed the SSBS for eachparticipant, and also completed the SSBS onthe participant's final day of treatment. The


workbook was completed by the participantsafter their last recreation therapy session.

TreatmentThe recreation therapy program in this

study had three main areas of focus: socialskills, leisure education, and self-esteem. Self-esteem was also addressed with the socialworker, but social skills and leisure educationwere only formally addressed through the rec-reation therapy program. The participants at-tended the recreation therapy program once aday for 1 hour. During their entire length ofstay, the participants attended at least oneleisure education session and one self-esteemsession, but attended a minimum of six socialskills sessions.

- The type of activities the recreation therapycomponent focused on were typical social ex-periences that occurred in the participants'daily lives. The recreation therapist asked theparticipants what type of social experiencesthey engaged in at home and school, andresponses included games, physical activities,creative outlets, and sharing. One example of asocial skills lesson included a common boardgame that is played by the participants withtheir friends. Participants engaged in the activ-ity, but were given prompts every turn abouttheir behavior such as "Nice job waiting pa-tiently for your turn," or "Now, we know youhave to start over, but that is not playingfriendly when you pout or cry. What is a betterway to handle this?" Another example waswhen the participants shared stories throughart projects about happy experiences they hadwith others at school as well as bad experi-ences. Each of the experiences was talkedabout and ways the participants had power tomake the situation better.

Data Analysis and ResultsThe data were collected over a 9-month

period starting in February 2003 and ending inOctober 2003. The data were scored accord-ingly to the directions of the SBSS manual andentered into SPSS. The alpha was set at <.10

since this was an exploratory evaluation of therecreation therapy program with a limitedsample size. A one-way multivariate analysisof variance (MANOVA) was implementedbased on the use of the multiple dependentvariables. This procedure controls for the in-flation of Alpha that occurs when multipleunivariate tests are conducted. It determinesthe significance of differences between thepre- and post-test using each subscale and theoverall scales as the different dependent vari-ables (pretest-posttest single group design).Table 2 outlines the descriptive statistics fromthe analysis, which appear to support the re-search hypothesis. MANCOVA results con-firmed support for the hypothesis by revealingsignificant Omnibus F (A = .45, F (6, 23.0) =4.7, p < .01, multivariate rf = .55; Pillai'sTrace = .55, F(6, 23.0) = 4.7, p < .01,multivariate rf = .55). In addition, significantimprovements from pretest to posttest werefound for the subscale Interpersonal Skills(F = 7.26, p < .01) and the overall SocialCompetency Scale (F = 3.37, p = .08). Allother univariate comparisons were nonsignifi-cant at the .10 level. Table 3 outlines theresults from the MANOVA.

After the last recreation therapy session,participants completed the "workbook" com-prised of open-ended questions about how theparticipants would respond to various socialsituations. The data obtained from the "work-book" were coded into one of two categories(appropriate social responses and inappropri-ate responses). The data was coded by one ofthe researchers. Another researcher reviewedthe coding and indicated agreement or dis-agreement with the coding of each of theresponses. There was no disagreement by thesecond researcher.

Most of the answers appeared to supportthe positive results (89%) of the Social Com-petency Scale. For example, the participantsindicated that being a friend means "sharing,being nice, helping, no fighting, and telling thetruth." Another example was the responses forthe question about appropriate ways to handlenot winning included, "say that it is okay, be


Table 2.

Descriptive Statistics of the Results from the School Social Behavior Scales (N = 15)

Social Competence ScaleSubscales:

Interpersonal SkillsSelf-Management SkillsAcademic Skills

Antisocial Behavior ScaleSubscales:

Hostile-IrritableAntisocial-AggressiveDemanding-Disruptive

Pre-Test

Mean

99.93

39.9333.0726.93

63.93

29.5315.9318.47

S.D.

14.90

6.527.034.27

21.55

11.555.935.53

Post-Test

Mean

110.27

46.4734.6029.20

72.93

34.4018.4720.07

S.D.

15.92

6.766.364.35

18.61

9.635.614.92

Differences

BetweenTests

10.33*

6.54**1.532.27

9.00

4.872.531.60

*p < .10 (two-tailed)**p < .05 (two-tailed)

happy, maybe next time, play again, and saygood job." Yet, there were also examples ofinappropriate responses that included "yelling,fighting, screaming, blow-up, make my facered hot, and slam my door."

Upon further analysis of the descriptiveanalysis of qualitative data, a sub-categoryemerged from the appropriate responses cate-gory. There appears to be "rehearsed" re-sponses (21%) by the participants in the ap-

Table 3.

Multivariate Analysis of variance for School Social Behavior Scales (N = 15)

Social Competence ScaleSubscales:

Interpersonal SkillsSelf-Management SkillsAcademic Skills

Antisocial Behavior ScaleSubscales:

Hostile-IrritableAntisocial-AggressiveDemanding-Disruptive

SS

800.83

320.1317.6338.53

177.6348.1319.20

df

1

111

111

F

3.37

7.26.39

2.08

1.571.45.70

P

.077*

.012*

.536

.161

.220

.239

.409

*p < .10 (two-tailed)


propriate response category. For example,when an 8-year old is asked how she/he wouldrespond if someone was not being nice or notplaying fairly, it does not seem completelyreasonable for her/him to say "self-break."This type of terminology is used frequently inthe recreation therapy sessions and in the mi-lieu by adults, and tends not to be typicalphrases used by elementary aged children.Some of the other rehearsed responses to ques-tions from the workbook (i.e. getting pushed inline, or a sibling going in their room withoutasking) included "problem-solve," "compro-mise," "cooperate," and "take a self-break."

DiscussionThe overall consensus was that the recre-

ation therapy program had a positive impacton the social skills of the participants. Thegeneral direction of mean score changes frompretest to posttest supported this assertion withall social skills subscales and the overall testscore showing improvement. This was sup-ported by the significance of the Social Com-petency Scale (p = .07) and the InterpersonalSubscale of the Social Competency Scale (p <.01), as well as the high percentage of appro-priate responses in the "workbooks."

On all three subscales of the Social Com-petence Scale there were increases in socialskills, but the least amount of improvementobserved was in Self-Management Skills. Theparticipants rarely were given the opportunityto manage themselves due to the structure ofthe program and therefore, this area was notreadily addressed. Academic skills showed thesecond highest gain in improvement and thehighest amount of improvement by the partic-ipants was in Interpersonal Skills. This wasexpected since the program heavily addressessocial skills which are needed to help make thetransition back into their own school/homeenvironment.

The results were also supported by theresponses of the participants in the "work-books.' The "workbooks" asked open-endedquestions about how the participants would

react in certain social situations that are com-mon in both participant's home and schoolenvironment (i.e. What would you do if youfind your brother/sister in your room playingwithout asking?). Approximately 89% of theresponses were coded as appropriate responsesrather than inappropriate responses. Yet,within the appropriate response category, asub-category appeared to be "rehearsed" re-sponses by the participants (21%). For exam-ple, when a six year old says she/he would"compromise" when asked how they wouldrespond if a friend wanted to go first in thegame, it does not indicate understanding. Al-though this word is used and demonstrated inthe program, it makes it difficult to interpretwhat is actually learned. She/he may be re-sponding by how she/he has been told torespond without knowing how to act. Moreconcrete examples such as "let her/him go firstthis time and you can go first next" instead of"compromise" may want to be employed toincrease the potential for understanding by theparticipants.

All three subscales on the Antisocial Be-havior Scale had non-significant increases.Observed increases in antisocial behaviorscores were unexpected, but may be associatedwith the intensive therapy environment and theassociated psychosocial processes. Also, im-provements in social skills do not necessarilyinclude decreases in antisocial behavior. For-mally addressing social skills can help de-crease antisocial behavior, but the relationshipbetween these two concepts is complex andantisocial behavior may need to be addresseddirectly in conjunction with social skill devel-opment.

There are several possible explanations forthe observed increase on the Antisocial Behav-ior Scale. This program is an intense experi-ence for children this age and forces them tosocially interact with others all day long. Thiscan be a tiring experience and may increasethe occurrence of these behaviors. Addition-ally, the pre-test was completed on the end ofthe participant's first day in which they stillmay have been on their best behavior because


the environment was still novel. Conductingthe pre-test after a couple of days in the pro-gram may have given a more realistic score.Furthermore, many of the children do not wantto leave the program, and try to misbehave atthe end of their treatment in hopes of staying.The program is only 2 weeks, which is arelatively short amount of time and every issuecan not be addressed within this time period.Lastly, there are other issues occurring in achild's life that influences her/his behavior thatare outside the scope of this evaluation.

Social skills development through recre-ation therapy is a necessary component forhelping children with mental illness. Recre-ation therapy takes into account the socialcontext of treatment that other mental healthtreatments do not address (Long, 2004). Withsocial skills recognized as one of the mostimportant aspects of the leisure experience aswell as long-term developmental concerns ofchildren with mental illness, this is an influ-ential area for recreation therapy. All threecomponents of the Leisure Ability Model ad-dressed social skills (Stumbo & Peterson,2004), and social skills directly related to so-cial peer acceptance, which is a necessarycomponent for child development and forlong-term behaviors and relationships. There-fore, recreation therapy programs that addresssocial skill development may be one of themost important interventions for children withmental disorders.

In addition, the recreation therapy sessionswere enjoyed by the participants throughouttheir treatment. Enjoyable leisure experiencesfor children with other peers are important inthe development of social goals that affectlater social competence. By using a format thatis familiar and fun to the participants, andactivities they would like share with friends,can be a readily recognized goal and increaseunderstanding of why they are receiving treat-ment. In recreation therapy, participants en-joyed similar activities before their treatmentand using them during their treatment mayhelp them to better understand behaviors theywere engaging in beforehand as acceptable or

non-acceptable. Thus, contributing to their so-cial development, and therefore, may have agreater potential for influence. Also, duringthis difficult time (treatment), activities theyperceive as fun may encourage the participantsto be more attentive as well as serve as anoutlet. The recreation therapy component al-lows participants to learn and practice appro-priate social skills that are applicable to theparticipants' own lives. This will hopefullyhelp facilitate the transfer from the recreationtherapy setting to their own lives.

LimitationsThe small number of participants is a se-

vere limitation to this study. In particular,concerns for statistical power and generaliz-ability are associated with the current sample.The length of stay necessary for eligibilitycontributed to the small sample size, and thenature of the program made it impossible torandomly select or assign participants for theprogram. Another limitation of this study isthe recreation therapy program teaches the"formal" social skills classes, but social skillsare reinforced throughout the entire program.It is impossible to isolate the impact of therecreation therapy program alone on socialskills or competencies; however, it is also thecase that recreation therapy served a signifi-cant role in the delivery of the social skillstraining and other agencies could implement asimilar approach. In addition, as with anyevaluation program, the measurements mayshow change, but the strength of this change,and how long any changes may last is un-known. Two weeks is a relatively short periodof time for an intervention and this is an areaof functioning that needs more sophisticatedand in-depth methods of evaluation to fullyexplain the cause of these changes. Utilizationof a larger sample, randomization, additionalcomparison groups isolating various aspects ofthe program, and further documentation ofpotential extraneous factors are recommendedfor future studies in this area.


Implications and RecommendationsThrough this evaluation, improvements of

social skills were supported. This was ob-served by the significant increase of meanchanges scores on the subscale InterpersonalSkills and the overall Social CompetencyScale. As such, the first implication of thesefindings is that it appears that interpersonalskills can be enhanced through recreation ther-apy modalities and that recreation therapy pro-fessionals, with the guidance of the LAM, canwork with the treatment team to develop anddeliver such a program throughout the milieu.The recreation therapy program may also wantto foster more emphasis on teaching formalself-management skills. Although there weregains in this area, they were not significant.The development of self- management skillsappear to compliment and enhance any gainsin social skills and can help foster a bettertransition when the participants leave the pro-gram.

Another implication was derived from the"workbooks" that were completed by the par-ticipants. Some of the responses appeared tobe verbatim responses from the recreationtherapist such as "compromise," "problemsolve" and "take a self-break." Although theirmeaning was not assessed, for a child less than10 years to be utilizing this language appearsunorthodox. The recreation therapist may wantto use concrete examples that will enhance thatunderstanding for a wider range of cognitiveabilities. Also, using terminology that otherchildren this age would not normally use mayhinder peer acceptance and their transitionback to their old school environment.

Several recommendations can come fromthis evaluation. First, this evaluation couldserve as a baseline for future research studies.There is a need for the standardization of suchprograms through the development of treat-ment protocols that identify specific contentand mechanisms for consistent delivery ofsuch programs. A standardized mechanism fordelivery of practices can further develop rec-reation therapy as a means for social skill

development among children with mental ill-ness and/or behavioral disorders. The stepsoutlined in the recreation therapy literature forsocial skill training may be an appropriate startfor this protocol (Austin, 2004; Sneegas,1989). Additionally, although this program isgrounded in the Leisure Ability Model, inter-ventions specifically designed using the Lei-sure Ability Model for developing a protocolfor social skills interventions would be bene-ficial. Lastly, with significant amount of em-phasis on social skill effectiveness within rec-reation therapy, more research is needed tobetter understand the potential impact of rec-reation therapy on the development of socialcompetency for children with behavioral dis-orders.

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