Social Cognition Module: Understanding Its Effect on Children with Disruptive Behavior

Abstract

Background:

Disruptive behavior is widely recognized as one of the most prevalent and persistent childhood maladjustment issues. Children exhibiting such behaviors often show biases in social cognitive processes, particularly in social information processing. Research has indicated a strong link between social maladjustments and impaired or biased social cognition. Therefore, applying social cognitive theory as a framework for predicting aggressive behaviors in children is essential when designing and implementing interventions to manage aggression effectively.

Methods:

This study was an attempt to develop the Social Cognition Module (SCM) and to understand the effect of the SCM and Parent Management Training (PMT) among children with disruptive behaviors. A parallel two-arm-randomized controlled trial was conducted to examine the effect of (SCM and PMT) versus PMT alone in children with disruptive behavior. Two groups—with 35 children each and their mothers—were included based on inclusion and exclusion criteria. They completed validated psychometric scales: Reading Mind in Eyes Test, Empathy Quotient Scale, and Child Behavior Checklist. This study allows for the comparison of new treatment with treatment as usual. The quantitative outcome measure was used to evaluate the changes in empathy, theory of mind, and disruptive behaviors in pre-post and follow-up periods of the intervention. Two groups repeated measures analysis of variance (ANOVA) was used within and between the groups.

Results:

The results showed that both groups did show significant improvement in social cognition and reduction in disruptive behavior. There is an interaction effect in the theory of mind, empathy, and disruptive behavior, indicating that the experimental group outperformed the control group. While the control group showed some improvement, the experimental group demonstrated a significantly greater positive change.

Conclusion:

This study highlights the importance of incorporating social cognition interventions when treating children with disruptive behaviors.

Keywords

Child development early childhood social skills parenting parents and families social cognition

Disruptive behaviors (DB) involve actions that can cause harm to oneself or others, like aggression or property damage, and/or result in significant conflicts with societal norms or authority figures.¹ Children with DB are the ones who have trouble controlling their emotions and behavior. These behaviors are easily recognized, as they involve behaviors that are readily seen such as temper tantrums, physical aggression, excessive argumentativeness, stealing, resistance to authority, and impulsivity. Attention-deficit/hyperactivity disorder (ADHD), conduct disorder (CD), and oppositional defiant disorder (ODD) are the main disorders which come under DB.^2,3

A child who consistently displays disruptive or rule-breaking behavior is prone to persisting with these actions throughout childhood and even into adulthood.⁴ A child’s social cognition refers to their ability to understand the thoughts of others, which shapes their unique perspective on the world. When a child fails to understand the feelings and behaviors of others, it results in the child having behavioral problems. Happé and Frith⁵ study investigated whether the social impairments in CD might have a similar root. Several studies have shown the role of social cognition in developing or maintaining psychopathology, particularly DB problems.^6–8A recent study by Wells et al. (2020) found that children with behavioral problems have impairment in identifying others’ emotions as well as intentions.⁹ These social cognitive processes were found to be related to and inversely associated with the severity of behavioral problems. Özbaran et al. (2018) showed that the theory of mind deficits may partly explain emotion dysregulation in children with ADHD.¹⁰

Social cognitive skills are comprised of two main components—empathy (matching the emotional state of another) and theory of mind (ToM; understanding others’ mental states). They are crucial for everyday interactions and cooperation.^11,12 ToM is defined as the cognitive ability to understand that others have minds—with mental states, information, and motivations that may differ from one’s own, allowing an individual to explain, manipulate, and predict others’ behavior. Empathy is known as the ability to feel what others are feeling.¹³ Baron-Cohen and Wheelwright (2004) suggest that empathy comprises both cognitive and affective components, which are distinct yet overlapping.¹⁴ They ascribe ToM to the cognitive component of empathy, which involves understanding others’ mental states and perspectives. This distinction highlights how empathy not only entails sharing others’ emotions (affective empathy) but also requires the cognitive ability to comprehend their thoughts and intentions (cognitive empathy).¹⁵ Children with DBs have biases in social cognitive processes primarily in the area of social information processing.⁵ This includes person perception, causal attributions related to both themselves and others, and the application of social judgments in decision-making, among other factors. Studies have shown that individuals with anger are impaired in cognitive and affective empathy.¹ Another study found evidence for impaired affective but intact cognitive empathy.¹⁵

For young children from the age of 7 to 11, psychotherapy needs to be developmentally appropriate, engaging, and tailored to their specific needs and circumstances. Some of the psychotherapeutic approaches commonly used for this age group to address DB are as follows: Parent Management Training (PMT) is considered the gold standard form of intervention for children with externalizing disorders,¹⁶ Cognitive behavioral therapy (CBT) adapted for children helps in problem-solving, anger management, and building social skills,^17,18 Play therapy is highly effective for young children as it allows them to express their emotions and experiences through play, which is a natural mode of communication for them. Children can act out their inner thoughts and emotions.¹⁹ And nonviolence-resistant program is another treatment program where parents recruit supporters to help them deal with their children’s problematic behaviors. In this treatment, parents develop emotional control means, nonviolent methods, to address and resist the child’s problematic behavior without escalating into an explosive situation.^20,21 There were no studies which tried integrating social cognition into treatment plans, leading to more holistic and effective interventions, addressing the observable behaviors and the underlying cognitive processes contributing to DB.

The rising prevalence of DB among children highlights the urgent need to develop and implement effective interventions for managing aggression. While various studies have identified factors contributing to impaired social cognition in children with DB, a comprehensive understanding of their developmental process remains limited. Notably, previous research indicates that social maladjustments are linked to biased and deficient social cognition. Therefore, incorporating social cognitive theory as a framework for predicting aggressive behaviors in children and adolescents should be a key consideration when designing and implementing intervention strategies. Earlier the specific social adjustment difficulties are detected in younger children, the better the scope of effective treatment or intervention to help children with anger, at the early stage of life itself. Therefore, this study was an attempt to develop the Social Cognition Module (SCM) and to understand the effect of the SCM among children with DB. Research of this nature holds significant potential for the prevention and treatment of externalizing behavior problems. Integrating social cognition considerations into treatment plans can lead to more holistic and effective interventions, addressing the observable behaviors and the underlying cognitive processes contributing to DB. The study’s findings can offer valuable guidance to parents, caregivers, and educators in understanding and supporting children with DB.

Method

A parallel two-arm randomized controlled trial comprised 70 children from the age range of 7 to 11 years, who were recruited from the family clinic using block randomization, and were either self-referred or referred by other doctors, schools, and counsellors to the clinical psychologist. The entire study was conducted by licensed clinical psychologists. The initial screening was done based on the inclusion and exclusion criteria. The inclusion criteria were children meeting the cutoff score for DB—including ADHD, conduct and ODD and age group 7–11 years (latency age). Children with a history of traumatic brain injury, epilepsy, neurological complaint, autism spectrum disorder, who are in the active phase of the physical illness, or with a history of mental illness in parent were excluded. Consent was obtained from parents after briefing about the study and data was collected subsequently. The primary objective of the study was to compare the effect of SCM versus PMT in children with DB. The secondary objective was to examine the efficacy of SCM in maintaining its effect on children with DB. For the purpose of this study, social cognition is measured using Reading Mind in the Eyes Test (Child Version) and Children Empathy Quotient Questionnaire. And children who meet the cutoff score for externalizing disorders in Child Behavior Checklist (CBCL) were considered to understand DB.

To measure changes in efficacy, the following were considered:

Change from baseline to post-phase in DB (CBCL), social cognition (Empathy quotient & Reading Mind in Eyes Test)

Change from baseline to follow-up at one month in DB (in CBCL), social cognition (Empathy quotient & Reading Mind in Eyes Test)

Procedure

Participants completed the initial screening based on the inclusion and exclusion criteria. They were then allocated to two groups through block randomization using software. A sample estimation of 70 participants was decided with two blocks: intervention and control group. Each block contained 35 participants, and they were randomly assigned to the two blocks (Figure 1). The Phase I was the pilot study. The Phase I was the consolidation of ideas and techniques into framing the intervention module through literature reviews and opinion from experts in the field. Mental health experts included psychiatrist, and clinical psychologists who had knowledge and experience in child mental health. All of the experts were professors in the respective fields.

Figure 1.

Randomized Controlled Trial Administered in This Study.

Phase II was actual development of items in the module. Most of the stories were taken from Amar Chitra stories, Jataka, and Panchatantra tales. The characters in the stories were named on culture free basis. The items under each domain of ToM task were sent for face validity and review to the subject expert.

The sample size calculation after the pilot study concluded 35 in the control group and 35 in the intervention group. Parents were asked to fill in sociodemographic information, children’s empathy quotient questionnaire, and a CBCL (CBCL 2001—Achenbach System of Empirically Based Assessment). Children were administered Reading Mind in the Eyes Test (RMET-Child Version). This study used the Empathy QuotientChildren (EQC) Questionnaire by Auyeung et al. (2009)²² to assess empathy. The EQ-C is a parent-report questionnaire comprising 27 items, which is intended to measure how easily one can pick up on other people’s feelings and how strongly one is affected by them. Reading Mind in the Eyes Test (RMET-Child Version) by Cohen et al. in 1997,²³ and (a revised form was published in 2001), was used to assess children’s ToM. The RMET-Child is comprised of 28 images of the eye region of the face, each representing a mental state. Each image is presented with four words and the child labels the emotion. The revised version of the CBCL (2001) is used to understand children from 6 to 18 years. The scale is made up of eight syndrome scales: anxious/depressed, depressed, somatic complaints, social problems, thought problems, attention problems, rule-breaking behavior, and aggressive behavior.

In this study, participants were divided into two groups: an intervention group and a control group. The intervention group comprised of both SCM sessions and PMT sessions, with each session lasting between 1 and 1.5 hours. In contrast, the control group comprised of PMT sessions alone (treatment as usual), with session time of 1 to 1.5 hours. This design aimed to evaluate the impact of the combined intervention in comparison to the standalone PMT sessions.

Intervention Group (SCM and PMT)

Social Cognition Module

This module has mostly incorporated its concepts from the ToM battery, an original work on ToM tasks by Blijd-Hoogewys et al.²⁴ It looks into first-order beliefs (thinking about the thoughts of another person) and second-order beliefs (thinking about the thoughts someone has about the thoughts of a third person). SCM program includes eight individual sessions and one follow-up sessions, at one month after completion. Sessions take place once in every week. The sessions for the intervention group were planned in the following manner:

SCM: Session 1—Explain the purpose of SCM, developing therapeutic alliance, and also to complete the baseline assessment. This session is also to encourage participants to link the concept of social cognition or social thinking to their lived experience.

PMT: Session 1—Welcoming the parents and making them feel comfortable. Discuss about PMT program and what it does in treatment. To do the behavioral analysis assessment in order to understand the ABCs of a target behavior and then to discuss about defining, observing, and recording of a target behavior.

SCM: Session 2—Focus on recognizing the role of emotions in social situations, describing basic emotions, identifying facial expressions corresponding with situations in a short story. In this session, the participant is encouraged to share recent emotional experiences and reflect on how their emotions influenced, and were influenced by, the surrounding social context.

PMT: Session 2—Work on reinforcement and positive incentive chart. The session focused on the importance of praising the child for positive behaviors. This principle helps the child to strengthen his positive behaviors and decrease the problematic behaviors. Time-out principle is also introduced in this session When time out is practiced consistently, it has proven to be extremely effective in decreasing the problematic behavior.

SCM: Session 3—This session focuses on developing the skill of differentiating between physical and mental entities. The child has to understand the reality and imaginations or predictions perceived by the story character and give an understanding of the difference of the working of a physical process and imagination process.

PMT: Session 3—This session helps parents manage minor challenges like whining, complaining, pestering, boredom, loud behavior, pouting, teasing, sibling arguments, and crying. It focuses on two important strategies: attending and planned ignoring. Attending means paying attention when child is behaving well and reinforcing that behavior with positive gestures—like praise, smiles, kind words, engaging conversations, hugs, or a simple pat on the back. Ignoring behaviors are considered as a form of punishment. Planned ignoring involves deliberately withdrawing attention from certain minor attention-seeking behaviors to discourage them. When parents consistently give this kind of positive attention to their children when they are doing a desired behavior, these behaviors will increase. And when they consistently ignore some undesired behaviors, such behaviors will decrease.

SCM: Session 4—This session mainly focuses on understanding that seeing leads to knowing or perception knowledge. Different situations are presented to the child where child has to understand about the connection of seeing or not seeing something and knowing or consequently not knowing something. The child tells the perception of character in story.

PMT: Session 4—This session involves training the parents about the components of shaping and then to apply it to a behavior, so that we get more of the positive behavior. Shaping is a gradual way to teach new behaviors by recognizing and reinforcing small progress along the way. Instead of expecting perfection right away, you break the task into smaller steps and encourage each improvement. Over time, these small successes add up, making it easier to learn and master the full behavior.

SCM: Session 5—This session is on the prediction of behaviors and emotions from desires. There are different situations presented from short stories and then knowledge of desire is used to predict both emotions and actions where desires are either fulfilled or not fulfilled.

PMT: Session 5—This session focuses on reviewing the PMT skills and make necessary changes. And mainly this session helps parents to practice the necessary skills to hypothetical problems which primarily include defining and observing a problem behavior, nature of a problematic behavior, and implementing positive/negative reinforcement and punishments. This session also prepares parents to manage low-frequency behaviors.

SCM: Session 6—This session is for understanding prediction of behaviors and emotions from beliefs. The understanding of fulfilled or not fulfilled beliefs helps in predicting about others beliefs. Different short stories are presented and the cognitions/thoughts/beliefs are interpreted. This session helps in understanding the false belief (FB) of a child mainly to predict the action of a second person, while the child knows that this second person has an incorrect belief about the situation.

PMT: Session 6—This session focuses on observing the interaction between parents and their child. It also serves to reinforce parental consistency, compliance, and positive behavior. Additionally, parents receive feedback on their approach, helping them understand their progress. This allows the researcher to ensure that the programs are being implemented correctly.

SCM: Session 7—This session a social cognition task of picture sequencing where one has to arrange the cards in the correct order so that they show a logical sequence of event. This helps in enhancing the social reasoning of the child. This would help them to understand the order in which a situation can be interpreted.

PMT: Session 7—The seventh session is a family meeting involving the parent(s), child, and researcher. During this session, the researcher goes over the positive behavior and incentive chart with the family. The child is encouraged to explain the chart, reinforcing their understanding and involvement in the process. This session serves as a check-in to review progress. By having the child explain the chart, they take an active role in their behavior management, which boosts their confidence and accountability. The researcher also provides guidance and feedback to help parents continue using the system effectively.

SCM: Session 8—This session is considered mainly for post-assessment. The entire skills are reviewed in this session. And a conclusion of SCM is brought by asking the participants to share their experience in being in the session and explaining how did the skills help them in understanding different situations in their day to day life. A closure and goodbye. Recommendation for booster sessions if required.

PMT: Session 8—This session focuses on teaching parents and children a strategy for resolving conflicts, with an emphasis on effective communication skills and the importance of compromise. Parents are encouraged to reflect on their own and their child’s progress throughout therapy. The session concludes by wrapping up the program and discussing recommendations for potential booster sessions.

Parent Management Training

Control Group (PMT)

The PMT sessions from 1 to 8 are followed with preassessment in the first session and post-session in the eighth session. The PMT sessions include eight individual sessions and one follow-up session at one month after completion (after 8th session). Sessions took place once in every week.

Time period for conducting assessments during the study:

Pretest before starting of module—CBCL, Reading Mind in Eyes Test, Empathy Quotient

Post-test (after 8 sessions): Measures Reading Mind in Eyes Test, Empathy Quotient, CBCL

Follow-up (after one month of post-test): Measures Reading Mind in Eyes Test, Empathy Quotient, CBCL

The outcome variables in the study are as follows:

Change from baseline to post-phase in DB (CBCL), social cognition (Empathy quotient & Reading Mind in Eyes Test)

Change from baseline to follow-up at one month in DB (in CBCL), social cognition (in Empathy quotient & Reading Mind in Eyes Test)

Statistical Analysis

The gathered information was moved to an Excel database and put via SPSS Statistic 23 analysis. The analysis included descriptive statistics, independent t-test, and repeated measure of analysis of variance (ANOVA) and post-hoc analysis.

Results

A total of 70 children and their mothers were included in the study. Out of 70 participants, 37 were boys (52.9%) and 33 were girls (47.1%). Among the 70 children participants, 29 (41.4 %) of them belonged to grade 5, 24 (34.3%) belonged to grade 4, 8 (11.4%) of them in grade 3, 5 (7.1%) in grade 6, 4.3% in grade 2, and one (1.4%) in grade 1. Based on their birth order, 60 (85.7%) of them were first born, 9 (12.9%) were second born, and 1 (1.4%) was third born. Sixteen (22.9%) of them didn’t have siblings, 48 (68.6%) of them had one sibling, 4 (5.7%) had two siblings, and 2 (2.9%) had four siblings. All the children came from nuclear families, 68 (97.1%) of them didn’t have their grandparents staying with them, whereas 2 (2.9%) did have the presence of their grandparents along with them. There was the absence of any family history of mental illness within the family (within three generations).

The data were not normally distributed because of which data was transformed to achieve normal distribution. The SPSS statistical package was utilized for the data analysis.

Independent sample t-test was administered to compare the baseline scores of both experimental and control groups. The results showed that there was no significant difference in TOM, empathy, and DB scores in both groups (Table 1).

Table 1.

Baseline Comparison Using Independent Sample t-test.

Variables	Mean (SD)		t
Variables	Experimental	Control	t
Theory of mind	13.11 (3.12)	14.37 (3.21)	1.67
Empathy	10.44 (6.41)	12.84 (5.34)	1.70
Disruptive behavior	31.74 (7.93)	30.29 (9.86)	0.68

Note: P < .05.

Table 2.

Two-repeated Measures ANOVA Showing the Within-group Difference and Between-group Interaction.

Variables	Groups	Mean (SD)			Within-Group Difference		Between-Group Interaction
Variables	Groups	Pre-test	Post-test	Follow-up	F	h_p²	F	h_p²
Theory of mind	Experimental	13.11 (3.12)	17.74 (2.87)	20.68 (2.45)	164.09**	0.83	21.72**	0.24
Theory of mind	Control	14.37 (3.21)	16.63 (3.08)	18.57 (3.05)	90.61**	0.73
Empathy	Experimental	10.44 (6.41)	21.06 (5.95)	29.13 (6.63)	196.09**	0.85	73.99**	0.52
Empathy	Control	12.84 (5.34)	15.26 (6.29)	17.91 (6.90)	34.48**	0.50
Disruptive behavior	Experimental	31.74 (7.93)	13.25 (7.62)	6.99 (6.95)	179.72**	0.84	66.94**	0.5
Disruptive behavior	Control	29.68 (9.31)	24.32 (8.00)	21.35 (7.70)	96.34**	0.75

Note: SD: Standard deviation; F: Coefficient of ANOVA; η_p²: Partial eta squared

Sphericity not assumed for theory of mind and DB, hence Greenhouse-Geisser F has been shown.

**P < .01.

We used two-way repeated measures ANOVA (Table 2) to test if there is a significant difference in pre-test, post-test, and follow-up scores of social cognition in the experimental and control groups. There was a significant difference in the TOM score within the group, across pre-test phase (M = 13.11, SD = 3.12), post-test phase (M = 17.74, SD = 2.87), and follow-up phase (M = 20.68, SD = 2.45) in the experimental group (F = 164.09, P < .01). Similarly in the control group, there was a significant difference in the TOM within the group across three phases, pre-test (M = 14.37, SD = 3.21), post-test (M = 16.63, SD = 3.08), and follow-up phase (M = 18.57, SD = 3.05) (F = 90.61, P < .01).

There was a significant difference in the empathy score within the group, across the pre-test phase (M = 10.44, SD = 6.41), post-test phase (M = 21.06, SD = 5.95), and follow-up phase (M = 29.13, SD = 6.63) in the experimental group (F = 196.09, P < .01). Likewise, in the control group, a significant difference in empathy scores was observed across the three phases: pre-test (M = 12.84, SD = 5.34), post-test (M = 15.26, SD = 6.29), and follow-up (M = 17.91, SD = 6.90) (F = 34.48, P < .01).

There was a significant difference in the DB score within the group, across pre-test phase (M = 31.74, SD = 7.93), post-test phase (M = 13.25, SD = 7.62), and follow-up phase (M = 6.99, SD = 6.95) in the experimental group (F = 179.72, P < .01). Similarly, the control group showed a significant difference in DB scores across the three phases: pre-test (M = 29.68, SD = 9.31), post-test (M = 24.32, SD = 8.00), and follow-up (M = 21.35, SD = 7.70) (F = 96.34, P < .01).

Bonferroni post-hoc test within-group pairwise comparison during the pre-phase, post-test phase, and follow-up showed that TOM, and empathy of experimental group improved significantly than the control group. There was a significant reduction in DB in the post-phase and follow-up phase in the experimental group compared to the control group.

Table 2 indicates that both groups exhibited a significant between-group interaction effect across all three variables. The experimental group showed a substantial increase in TOM scores (F = 164.09, P < .01), rising from pre-test (M = 13.11, SD = 3.12) to post-test (M = 17.74, SD = 2.87) and follow-up (M = 20.68, SD = 2.45), with a large effect size (ηp² = 0.83). Similarly, the control group demonstrated a significant increase (F = 90.6, P < .01) in the TOM scores from pre-test (M = 14.37, SD = 3.21) to post-test (M = 16.63, SD = 3.08) and follow-up (M = 18.57, SD = 3.05), with a large effect size (ηp² = 0.73).

The experimental group also showed a significant increase in empathy scores (F = 196.09, P < .01), progressing from pre-test (M = 10.44, SD = 6.41) to post-test (M = 21.06, SD = 5.95) and follow-up (M = 29.13, SD = 6.63), with a large effect size (η_p² = 0.85). The control group exhibited a significant increase as well (F = 34.48, P < .01), with scores rising from pre-test (M = 12.84, SD = 5.34) to post-test (M = 15.26, SD = 6.29) and follow-up (M = 17.91, SD = 6.90), with a large effect size (η_p² = 0.50).

Regarding DB, the experimental group showed a significant decrease (F = 196.09, P < .01), with scores dropping from pre-test (M = 31.74, SD = 7.93) to post-test (M = 13.25, SD = 7.62) and follow-up (M = 6.99, SD = 6.95), with a large effect size (η_p² = 0.84). The control group also demonstrated a significant decrease (F = 96.34, P < .01), with scores reducing from pre-test (M = 29.68, SD = 9.31) to post-test (M = 24.32, SD = 8.00) and follow-up (M = 21.35, SD = 7.70), with a large effect size (η_p² = 0.75).

Furthermore, significant between-group interaction effects were observed, with the experimental group outperforming the control group in all measured variables: TOM scores (F = 21.72, P < .01, ηp² = 0.24), empathy scores (F = 73.99, P < .01, η_p² = 0.52), and DB scores (F = 66.94, P < .01, η_p² = 0.50). These results highlight the greater improvements seen in the experimental group compared to the control group (refer to Figure 2).

Figure 2.

Graphs Showing the Interaction Between the Experimental Group and Control Group Through the Pre-, Post-, and Follow-up Phases.

Discussion

The results of our study show that the participants are children aged between 7 and 11 years (in their latency age) and their parents. These children were mainly diagnosed with DB and were included in the study based on the inclusion and exclusion criteria. The two groups were similar based on all sociodemographic variables. The major question addressed in this research project was whether an SCM intervention along with PMT was more promising than PMT for children with DB.

There were no significant differences in the pre-phase scores among the two groups. As per the results, both the groups did show significant improvement in social cognition and reduction in DB. PMT is considered the gold standard method in treating children with externalizing disorder.¹⁶ This study has once again demonstrated its effectiveness in reducing DB. Earlier studies also showed that PMT is effective as it focuses on equipping parents with strategies to address behavior issues and enhance the parent–child relationship.^16,18 The experimental group which has used SCM and PMT showed further more improvement in social cognition and reduced DB. There is an interaction effect in TOM, empathy, and DB which means the experimental group has done better than the control group. The control group had a change but the experimental group had a better change. The findings revealed a significant between-group interaction effect in all measured outcomes, with large effect sizes across TOM, empathy, and DB scores. This indicates that the experimental group consistently outperformed the control group in these areas, demonstrating the intervention’s substantial impact. This shows that social cognition intervention is necessary when treating children with disruptive tendencies. In a study by Lochman et al., the Coping Power Program for children with externalizing disorder considered the components of emotional awareness, perspective taking, social problem solving, and goal setting to reduce the externalizing problems of children and adolescents using a CBT model were incorporated in treating externalizing disorder.²⁵ In this study, the same components were included under the concept of social cognition. Thus, this study has been supported with the previous findings.

One of the components which SCM emphasized was to improve ToM of children with DB. Research also shows that if we increase the ToM, social interaction also improves. ToM is a vital strategy to enhance social communication and interaction skills.²⁶ Apperly also found that better TOM performance enhances social competence, independent of any influence from general cognitive factors.²⁷

The other component which SCM looked into was to enhance empathy. Previous research has demonstrated that empathy is crucial in fostering social skills and maintaining positive relationships.^28,29 When children can share emotions, understand others’ perspectives, and are motivated to provide help or comfort, they establish better social support and do less harm to other people.³⁰ In this study, we can observe the same finding that when empathy increases in a child, DB decreases with the use of SCM along with PMT.

The literature emphasizes that, for both affective and cognitive empathy, the development from emotional contagion to paying attention to others’ feelings and engaging in prosocial behaviors can enhance our understanding of the empathy profiles in children with DB.¹ This finding supports the need for including social cognition along with PMT in the treatment of children with DB. All parents who were in the study reported that these sessions brought new insights for them, by equipping them in learning new strategies to manage their child. The parents felt that they were able to identify behavioral changes in their child.

The effects observed in the study can be attributed to the role of specific intervention which was likely tailored to address specific deficits or challenges faced by participants. This targeted approach ensures a focused and systematic improvement in areas such as TOM, empathy, and DB. By improving participants’ ability to understand others’ perspectives (TOM) and fostering empathy, the intervention may have directly contributed to reducing DB.

The structured and consistent application of the intervention across the experimental group might have provided participants with repeated opportunities to practice and internalize the desired skills and behaviors. A supportive environment during the intervention might have contributed to participants feeling safe and encouraged, facilitating behavioral and cognitive improvements. By addressing both cognitive skills (TOM) and emotional capacities (empathy), the intervention holistically impacted the participants’ ability to manage and improve their behavior. These combined factors might have contributed to the significant positive outcomes observed in the study, in promoting social and emotional development. Addressing all these components highlighted the need for eight sessions for the intervention.

While numerous studies have identified various factors contributing to impaired social cognition in children with DB, a comprehensive understanding of their developmental process remains limited. Specifically, research indicates that social maladjustments are linked to biased and deficient social cognition. Therefore, utilizing social cognitive theory as a framework for predicting aggressive behaviors in children and adolescents should be a key consideration when designing and implementing interventions for managing aggression in children.

Earlier the specific social adjustment difficulties are detected in younger children, the better the scope of effective treatment or intervention to help children with anger, at the early stage of life itself. Therefore, this study was an attempt to understand the effect of social cognition module among children with DB. Accordingly, there are numerous early intervention programs aiming to reduce children’s problem behavior and increase their prosocial behaviors as early as possible. This study shall pave the way to help children in ‘Early intervention’ as an innovative approach to mental health care. It focuses on prevention as well as treatment and aims to help patients and their families intervene before the onset of major psychopathology.

Conclusion

According to the study, there was an effect of SCM and PMT versus PMT in improving behavior and emotions among children with DB. The change in the variables was found to be statistically significant. The improvement was maintained in the experimental group and the control group. Both the groups did show improvement; however, the experimental group did better than the control group. The findings of this study could be used as groundwork for more research in this area.

Limitations and Future Research

The reliance for the most part on parent report measures can be a limitation. Having said that, it is often only parents who will be able to recognize small changes in the functioning of a child. But considering the child also in most of the assessments would be an advantage. This study used two other-reported questionnaires (CBCL and empathy questionnaire) and not performance-based measures. Qualitative data could have been considered as it would have given the readers new insights and more information on this topic. It is important to collect further data on the program for replication purposes and also to conduct trials in other settings (e.g., home and school) administered by parents and teachers to allow for greater dissemination of SCM intervention. This type of research will have important implications for the prevention and treatment of externalizing behavior problems. Future research should prioritize developing interventions that address various factors contributing t o anger in children, incorporating social cognition and parent-mediated approaches. Gaining insights into the risk factors associated with externalizing behaviors in children with behavioral disorders can lead to more effective preventive interventions.

Footnotes

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

Statement of Informed Consent and Ethical Approval

The study was accorded Ethical Committee Approval vide Ethics Committee of Amrita Institute of Medical Sciences (No: ECASM-AIMS-2021-371) Date: 16.11.2021. Written Informed Consent was taken from all the participants. The study was carried out in accordance with the principles as enunciated in the Declaration of Helsinki.

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