Emotional or Behavioral Disorders

Ekornås Self-Perception of Social Acceptance Journal of Social and Clinical Psychology, Vol. 30, No. 6, 2011, pp. 570-582 Primary School Children s Peer Relationships: Discrepancies in Self-Perceived Social Acceptance in Children with Emotional or Behavioral Disorders Belinda Ekornås University of Bergen, Norway; Centre for Child and Adolescent Mental Health, Bergen, Uni Health, Norway Mikael Heimann Linköping University, Sweden; Centre for Child and Adolescent Mental Health, Bergen, Uni Health, Norway; The Swedish Institute of Disability Research, Linköping, Sweden Tomas Tjus University of Gothenburg, Sweden Sonja Heyerdahl Centre for Child and Adolescent Mental Health, Oslo, Norway Astri J. Lundervold University of Bergen, Norway; Centre for Child and Adolescent Mental Health, Bergen, Uni Health, Norway This population-based study investigated self-perception of social acceptance in children with emotional or behavioral disorders, and whether their perceptions were in line with parent/teacher reports of peer relationship problems. Children with behavioral disorders (n = 145) emotional disorders (n = 118), and a comparison group (n = 4,344) were selected from an 11 13-years-old population (n Address correspondence to B. Ekornås, Centre for Child and Adolescent Mental Health, Box 7800, 5020 Bergen, Norway; E-mail: Belinda.Ekornas@uni.no 2011 Guilford Publications, Inc. 570

SELF-PERCEPTION OF SOCIAL ACCEPTANCE 571 = 5073). Children with emotional disorders reported poorer social acceptance than children with behavioral disorders, also when adjusted for parent/teacher ratings of peer problems, confirming the negative self-perception reported in previous clinical studies. Self-perceptions of children with behavioral disorders were lower than in the comparison group and not inflated according to parent/teacher reports. The results emphasize the importance of peer-relations in both disorder groups. An overoptimistic self-perceived social acceptance has been associated with behavioral disorders in early and middle childhood (David & Kistner, 2000; Edens, Cavell, & Hughes, 1999). In contrast, children who suffer from emotional disorders commonly display a negative self-perception of social acceptance (Chansky & Kendall, 1997; Ekornås, Lundervold, Tjus, & Heimann, 2010). The participants in previous studies examining the association between selfperceived social acceptance and psychopathology in youth have mainly been recruited from clinical and case-control samples. The aim of the current study was to extend earlier findings by including a nonreferred sample from a general population of Norwegian children. Children and their parents and teachers have expectations and make judgements about the quality of peer interactions. Children who fail to meet such social expectations may be at risk of developing symptoms of a psychiatric disorder (Masten, 2005). Self-perceptions of social acceptance among children with behavioral disorders, such as Attention Deficit Hyperactivity Disorder (ADHD) and conduct disorder, tend to be more positive than the ratings given by observers (Evangelista, Owens, Golden, & Pelham, 2008; Hughes, Cavell, & Grossman, 1997). Owens and Hoza (2003) conceptualized the inflated self-perceptions reported by children with ADHD as a positive illusory bias. The association between externalizing disorders and overly positive self-perceptions was emphasized by a study showing that children with ADHD and disruptive behavioral disorders tend to report significantly higher self-perception than children with ADHD and internalizing disorders (Bussing, Zima, & Perwien, 2000). Emotional disorders in youth are associated with and probably maintained by what has been referred to as a negative cognitive bias, characterized by misinterpretations of social situations and critical views of the self (Kendall & Treadwell, 2007; Rapee & Heimberg,

572 ekornås 1997). Moreover, negative perception of social acceptance have been more directly linked to depressed children s psychological functioning than actual dislike by classmates (Zimmer-Gembeck, Hunter, & Pronk, 2007). Studies of emotional disorders and social acceptance have mainly included adolescents. Negative interpretations of social acceptance among anxious adolescents are commonly found (Miers, Blote, Bogels, & Westenberg, 2008), and predict subsequent social anxiety and fear of negative evaluation (Teachman & Allen, 2007). The few studies conducted among children with emotional disorders show that they also tend to perceive themselves as less likely to be liked and accepted by peers (Chansky & Kendall, 1997; Ekornås et al., 2010). The current study examines if discrepancies in self-perception can be confirmed in a population-based sample of primary school children with behavioral and emotional disorders. The hypothesis of positively biased self-perception led us to predict that perceptions of social acceptance among children with behavioral disorders would be inflated compared to perceptions in a comparison group and reports of peer relations from their parents/teachers. In contrast, perceptions of social acceptance among children with emotional disorders were expected to be poorer compared to others ratings, in accordance with theories of negative self-perceptions in these children. Methods The Bergen Child Study (BCS) is a longitudinal total population study of children who attended 2nd 4th grade in all schools in Bergen (Norway) in October 2002 (see Heiervang et al., 2007). The present study included 11 13-years-old children from the second wave of the BCS. The target population compromises all participants with parent consent from the first wave of the BCS (n = 7,007). In 5,073 (72.4%) children, parent, teacher, and self-reports of behavioral and emotional difficulties were available (see Figure 1). Instruments Strengths and Difficulties Questionnaire (SDQ; Goodman, 1997) is a brief questionnaire with parent, teacher, and self-report forms for 11- to 16-years-old children. Five subscales are generated from a

SELF-PERCEPTION OF SOCIAL ACCEPTANCE 573 Figure 1. Flowchart, describing sample selection in the current study (see text for details). total of 25 items: hyperactivity and inattention, emotional symptoms, conduct problems, peer relationship problems, and pro-social behaviour. A recent Norwegian study confirmed Goodman s 5-factor model for both parent and teacher forms (Sanne, Torsheim, Heiervang, & Stormark, 2009). The SDQ includes an impact score and computerized algorithms exist for predicting psychiatric disorders by bringing together information from multiple informants (Goodman, Renfrew, & Mullick, 2000). The predictive algorithm generates unlikely, possible or probable ratings for conduct disorders, emotional disorders, hyperactivity disorders, and any psychiatric disorder. In the present study, the predictive SDQ-algorithm was used to select children to the disorder groups. The subscale peer relationship problem, which is not included in the predctive algorithm, was used to assess peer relationships.

574 ekornås Characteristics Table 1. Demographic Characteristics in Children With an Emotional or Behavioral (HI/CD) Disorder Emotional (E) Behavioral (B) N (%) 118 (2.6) 145 (3.1) 4344 (94.3) Comparison Group (C) **p <.001 Boys, % (n) 36 (43) 84 (122) 45 (1959) 1 B > C > E** Family income, % (n) 2 C > E, B** High* 55.8 (63) 52.9 (74) 69.8 (2887) Medium 31.0 (35) 39.3 (55) 28.1 (1161) Low* 13.3 (15) 7.8 (11) 2.1 (87) Family type, % (n) 1 C > E > B** Married or cohabitant 59.3 (70) 45.5 (66) 72.7 (3160) Other 40.7 (48) 54.5 (79) 27.3 (1184) Note. 1 = Chi square analysis, 2 = ANOVA. *High = Very good and good income, Low = Poor and very poor income. The Self-Perception Profile for Children Revised (SPPC-rev) assesses children s global self-worth and perceived competence in five domains: Scholastic Competence, Social Acceptance, Athletic competence, Physical Appearance, and Behavioral Conduct (Harter, 1985). The current study used a Norwegian version, with one statement for each item in accordance with the revised Self-Perception Profile for Adolescents (Wichstrom, 1995). The children are asked to rate how well liked and popular they are compared to children of their own age. The scores range from one to four and are converted to mean scores for each subscale, higher scores indicate higher self-perceived social acceptance. The SPPC has been widely used with satisfactory reliability and good internal consistency (Muris, Meesters, & Fijen, 2003). Participants in the Present Study The SDQ algorithm (Goodman et al., 2000) was used to define any probable psychiatric disorder (n = 279) and unlikely psychiatric disorder (n = 4344). The first group was divided into two subgroups: (1) A behavioral disorder group (n = 145) including children with a probable conduct disorder (CD) and/or hyperactive/inattentive disorder (HI) but no emotional disorder, and (2) an emotional dis-

SELF-PERCEPTION OF SOCIAL ACCEPTANCE 575 Table 2 A and B. Parent/Teacher Rated Peer Relationships Problems (SDQ) in Children with an Emotional or Behavioral (HI/CD) Disorder Emotional (E) Behavioral (B) Comparison (C Peer Relationship Problems M n M n M n **p <.001 η 2 2 A Unadjusted Parent ratings M (SD)) 3.1 (2.4) 118 3.0 (2.6) 142.8 (1.3) 4326 C < E, B** 0.12 Teacher ratings M (SD)) 2.4 (2.6) 118 3.3 (2.5) 145.6 (1.2) 4338 C < E < B** 0.16 2 B Combined Parent/Teacher ratings z-score M (SD) 1.3 (1.4) 118 1.6 (1.5) 142-1.0(.7 ) 4326 C < E < B** 0.19 Adjusted for: Gender M (SD) 1.3 (1.4) 118 1.6 (1.5) 142-1.0(.7 ) 4326 C < E < B** 0.13 Family type and income M (SE) 1.2 (.1) 113 1.4 (.1) 138 -.9 (.0) 4126 C < E, B** 0.12

576 ekornås order group (n = 118) including children with a probable emotional disorder but no behavioral disorders (CD/HI). Children with both disorders (n = 16) were excluded. The comparison group (n = 4,344) included children unlikely to have any psychiatric disorder (Figure 1). Results Confounding Variables The present study included variables that yielded an increased risk of psychopathology in the first BCS wave (Heiervang et al., 2007): (1) family type (married/cohabitant or single/divorced), (2) gender, and (3) family income (self-reported information: very good, good, medium, poor, or very poor). A chi-square test showed that the family type was significantly different between the three groups, (χ 2 (n = 4,607) = 60.0; p <.001). Children in the behavioral disorder group were mostly from single parent or divorced families, while more than half the children in the emotional disorder group and nearly three quarters of the children in the comparison group lived with married or cohabitant parents. The group-difference in gender was also significant; more than three quarters of the children with behavioral disorders and less than half of the children with emotional disorders were boys. An ANOVA showed that parents of children in the two disorder groups described similar levels of family income, but a significantly, F(2, 4387) = 21.4; p <.001 poorer income than parents of children in the comparison group (Table 1). Peer Relationship Problems. An ANOVA, using the model Group, Gender, and Group Gender, showed that the teacher ratings of peer relationship problems were higher in the behavioral than in the emotional disorder group. This group difference was not found in the parent ratings (Table 2A). The parent and teacher reports of peer relationship problems were transformed to z-scores and the aggregated mean score was higher for children in both disorder groups than in the comparison group (Table 2B). The parent/teacher peer relationship problems score was significantly higher in the behavioral disorder group than in the emotional disorder group (p =.02). When introducing the confounders (family income and family type), the difference between the disorder

SELF-PERCEPTION OF SOCIAL ACCEPTANCE 577 Table 3 A and B. Self-Perceived Social Acceptance (SPPC-rev) in Children with an Emotional or Behavioral (HI/CD) Disorder, Adjusted for Parent/Teacher Rated Peer Relationship Problems Emotional (E) Behavioral (B) Comparison (C) Social acceptance: M n M n M n **p <.001 η 2 3 A Children s ratings Unadjusted (SD) 2.4 (.70) 118 2.9 (.70) 140 3.3 (.50) 4314 C > B > E** 0.08 Adjusted for: Gender (SD) 2.5 (.70) 118 2.8 (.70) 140 3.3 (.50) 4314 C > B > E** 0.07 All Confounders (SD) a 2.5 (.05) 113 2.9 (.06) 136 3.3 (.01) 4115 C > B > E** 0.06 3 B Adjusted for: Peer relationship Problems (SE) 2.8 (.05) 118 3.3 (.04) 138 3.3 (.01) 4303 C, B > E ** 0.02 All confounders (SE) a 2.9 (.05) 113 3.3 (.06) 134 3.3 (.01) 4106 C, B > E ** 0.02 Note. a Family type and income, and gender.

578 ekornås groups was not retained (Table 2B). No significant effects of gender or interaction between gender and group were found on the combined parent/teacher score of peer relationship problems. Self-Perceived Social Acceptance. The group of children with emotional disorders reported significantly poorer self-perceived social acceptance than children with behavioral disorders. Both disorder groups rated themselves significantly poorer than the comparison group (see Table 3A). A significant effect of gender (p =.01) and an interaction between gender and group (p =.03) was found in the children s perception of social acceptance, but the effect sizes calculated using the partial η 2 were very small (η 2 =.001 and η 2 =.002). The differences between the three groups were retained when the confounders (gender, family income, and family type) were included in an ANCOVA (Table 3A). Self-Perceived Social Acceptance (SPPC-rev) Adjusted for Peer Relationship Problems (SDQ). An ANCOVA with social acceptance as the dependent variable, and groups as the independent variable and peer relationship problems as a covariate, revealed differences between the groups on self-rated social acceptance, when adjusting for parent/teacher rated peer problems, F(2, 4558) = 40.1; p <.001. Self-perceived social acceptance was still poorer in children with emotional disorders compared to children in the comparison group (Table 3B). However, the difference in reports of self-perceived social acceptance between children in the behavioral disorder and comparison groups was lost when adjusting for parent/teacher ratings of peer problems. Self-perceived social acceptance was significantly different between children in the emotional and behavioral disorder groups, with poorer self-perceptions among children with emotional disorders, even when adjusting for parent/teacher ratings of peer problems, and all the confounding variables (Table 3B). Discussion The present population-based study confirmed the negative selfperceptions of social acceptance described in earlier clinical studies of adolescents with emotional disorders, but not the expected inflated self-perceptions in children with behavioral disorders. Both parents and teachers reported more peer problems in the disorder

SELF-PERCEPTION OF SOCIAL ACCEPTANCE 579 groups, but only teachers reported less peer problems in children with emotional than behavioral disorders. Our study did not confirm the previously documented positive illusory bias or inflated self-perceptions in children with behavioral disorders (Owens & Hoza, 2003). Their reports of social acceptance were poorer than children in the comparison groups, and the selfperception was consistent with parents and teachers reports of their peer problems. These results indicate that peer problems faced by children with behavioral disorders have an impact on their self-perception. Hence, our findings extend previous knowledge by suggesting that perception of social acceptance is negatively affected in both children with emotional and behavioral disorders. The behavioral disorder group primarily included children with a probable conduct disorder according to Goodman s algorithm. This may have affected the results, since the theory of positive illusions is mainly based on clinical samples, where children with an ADHD diagnosis often have a comorbid conduct disorder. Further, the rate of behavioral problems is lower in Norwegian children compared to British children (Heiervang, Goodman, & Goodman, 2008). Our group may thus have a lower level of functional impairment than children included in foreign or clinical samples. This calls for future studies examining the effect of functional impairment on the presence of inflated self-perceptions among children with behavioral disorders. The overly negative perceptions of social acceptance in primary school children with emotional disorders support models arguing that negatively distorted social perception are involved in the cognitive developmental processes linked to emotional disorders (Chansky & Kendall, 1997; Rapee & Heimberg, 1997). Moreover, our results are in line with a study arguing that social acceptance is a predictor associated with anxiety in children during the transition from elementary to middle school (Grills-Taquechel, Norton, & Ollendick, 2010). Teachers reported more peer problems in children with behavioral disorders than in children with emotional disorders. This suggests that it may be easier for teachers to observe the overt (physical aggression or verbal threats) and reputational (i.e., rumor spreading) peer victimization associated with behavioral disorders than the more covert relational peer victimization associated with emotional disorders (La Greca & Harrison, 2005).

580 ekornås Strengths and Limitations The present study is part of the BCS, a large-scale prospective longitudinal population-based study using multi-informants, making the results more appropriate for generalization than observations based on clinical or case-control samples. Moreover, confounding factors were included as covariates in the analyses of the main factors. SDQ has limitations with regard to the accuracy of the prediction of psychopathology. A clinical diagnostic interview would probably enhance the precision of the diagnostic categories in the clinical groups. A cross-sectional design, as the one used in the present study, does not allow any causal explanations, hence, longitudinal population-based studies of self-perceived social acceptance among children are warranted. Clinical Implications Children with emotional disorders report overly negative self-perceived social acceptance. Negative perceptions of social acceptance may be one of the factors involved in avoidance of social activities among children with emotional disorders, and should be considered when planning treatment toward this group. The realistic perception of social acceptance shown by children with behavioral disorders emphasizes the importance of peer relations in both disorder groups. Differences in parent and teacher ratings support the importance of considering information from both informants when screening for peer problems. References Bussing, R., Zima, B. T., & Perwien, A. R. (2000). Self-esteem in special education children with ADHD: Relationship to disorder characteristics and medication use. Journal of the American Academy of Child and Adolescent Psychiatry, 39, 1260-1269. Chansky, T. E., & Kendall, P. C. (1997). Social expectancies and self-perceptions in anxiety-disordered children. Journal of Anxiety Disorders, 11, 347-363. David, C. F., & Kistner, J. A. (2000). Do positive self-perceptions have a dark side? Examination of the link between perceptual bias and aggression. Journal of Abnormal Child Psychology, 28, 327-337.

SELF-PERCEPTION OF SOCIAL ACCEPTANCE 581 Edens, J. F., Cavell, T. A., & Hughes, J. N. (1999). The self-systems of aggressive children: A cluster-analytic investigation. Journal of Child Psychology and Psychiatry and Allied Disciplines, 40, 441-453. Ekornås, B., Lundervold, A. J., Tjus, T., & Heimann, M. (2010). Anxiety disorders in 8 11-year-old children: Motor skill performance and self-perception of competence. Scandinavian Journal of Psychology, 51, 271-277. Evangelista, N. M., Owens, J. S., Golden, C. M., & Pelham, W. E. (2008). The positive illusory bias: Do inflated self-perceptions in children with ADHD generalize to perceptions of others? Journal of Abnormal Child Psychology, 36, 779-791. Goodman, R. (1997). The Strengths and Difficulties Questionnaire: A research note. Journal of Child Psychology and Psychiatry, 38, 581-586. Goodman, R., Renfrew, D., & Mullick, M. (2000). Predicting type of psychiatric disorder from Strengths and Difficulties Questionnaire (SDQ) scores in child mental health clinics in London and Dhaka. European Child & Adolescent Psychiatry, 9, 129-134. Grills-Taquechel, A. E., Norton, P., & Ollendick, T. H. (2010). A longitudinal examination of factors predicting anxiety during the transition to middle school. Anxiety, Stress & Coping: An International Journal, 23(5), 493-513. Harter, S. (1985). Manual for the self-perception profile for children. Denver: University of Denver. Heiervang, E., Goodman, A., & Goodman, R. (2008). The Nordic advantage in child mental health: Separating health differences from reporting style in a crosscultural comparison of psychopathology. Journal of Child Psychology and Psychiatry, 49, 678-685. Heiervang, E., Stormark, K. M., Lundervold, A. J., Heimann, M., Goodman, R., Posserud, M. B., et al. (2007). Psychiatric disorders in Norwegian 8- to 10-yearolds: An epidemiological survey of prevalence, risk factors, and service use. Journal of the American Academy of Child and Adolescent Psychiatry, 46, 438-447. Hughes, J. N., Cavell, T. A., & Grossman, P. B. (1997). A positive view of self: Risk or protection for aggressive children? Development and Psychopathology, 9(1), 75-94. Kendall, P. C., & Treadwell, K.R.H. (2007). The role of self-statements as a mediator in treatment for youth with anxiety disorders. Journal of Consulting and Clinical Psychology, 75, 380-389. La Greca, A. M., & Harrison, H. M. (2005). Adolescent peer relations, friendships, and romantic relationships: Do they predict social anxiety and depression? Journal of Clinical Child & Adolescent Psychology, 34, 49-61. Masten, A. S. (2005). Peer relationships and psychopathology in developmental perspective: Reflections on progress and promise. Journal of Clinical Child & Adolescent Psychology, 34, 87-92. Miers, A. C., Blote, A. W., Bogels, S. M., & Westenberg, P. M. (2008). Interpretation bias and social anxiety in adolescents. Journal of Anxiety Disorders, 22, 1462-1471. Muris, P., Meesters, C., & Fijen, P. (2003). The self-perception profile for children: Further evidence for its factor structure, reliability, and validity. Personality and Individual Differences, 35, 1791-1802. Owens, J. S., & Hoza, B. (2003). The role of inattention and hyperactivity/impulsivity in the positive illusory bias. Journal of Consulting and Clinical Psychology, 71, 680-691.

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