Which peer status includes children who are both actively liked and actively disliked by peers?

Pathways between peer rejection and externalizing problems

Peer rejection and low peer preference have been robustly associated with increases in aggression (e.g., Janssens et al., 2017; Ladd, 2006; Tseng et al., 2013), and antisocial, rule-breaking, and delinquent behaviors (e.g., Di Giunta et al., 2018; Laird et al., 2005; Miller-Johnson et al., 1999; Nelson and Dishion, 2004). For example, one study found that an increase of one standard deviation in first grade social preference was associated with a 35% decrease in the likelihood of meeting criteria for a diagnosis of Oppositional Defiant Disorder or Conduct Disorder in third grade (Miller-Johnson et al., 1999; note that rejection and acceptance were not examined separately from preference). However, some studies have failed to find associations between peer rejection and delinquency (e.g., Allen et al., 2005; Pedersen et al., 2007). Delinquency may be linked to a more chronic form of peer rejection than that which is captured by these studies, or minor delinquency as measured in early to middle adolescence may be broadly normative enough (Moffitt, 1993) that connections with rejection are not as apparent. Supporting this idea, one study (Nelson and Dishion, 2004) found childhood social rejection to be associated with age 24 antisocial behavior, but not with age 15 antisocial behavior.

Disruptiveness (e.g., Pedersen et al., 2007), overt and relational aggression (e.g., Orue and Calvete; 2011; Tseng et al., 2013) and measures of broad externalizing behaviors (e.g., Kim and Cicchetti, 2010) all predict later rejection. Aggression in particular is strongly linked to peer problems (Prinstein et al., 2018), and studies that distinguish between reactive aggression (that which occurs in response to a provocation) and proactive aggression (that which is goal-directed) tend to find that reactive aggression alone predicts peer rejection (Evans et al., 2015; Fite et al., 2007, 2013; Prinstein and Cillessen, 2003). Some studies do not find pathways from aggression to later peer rejection (e.g., Janssens et al., 2017); it is possible that associations between peer rejection and aggression vary across cultures (Prinstein et al., 2018).

Social Skills Training

Peer rejection of children with ADHD is quite common and may lead to serious long-term consequences. Further, children with ADHD who overcome their social problems have better outcomes in the long term than do those children who continue to experience problems with peers. Thus, investigators have focused on designing psychosocial interventions that specifically target peer relationships. Social skills training interventions include instruction in social skills, social problem solving, and behavioral competencies. In addition, the interventions attempt to enhance social competence by encouraging close friendships, and decreasing undesirable and antisocial behaviors. Interestingly, although children with ADHD are less socially effective than are their peers, they typically do not perceive themselves as such. Thus, the primary goal of social skills training is to promote prosocial behaviors that include cooperation, communication, participation, and validation. Social skills training represents the most common approach to treating social problems in children, with groups typically being conducted at a clinic, a summer treatment program, or in school-based settings, and often including parent and teacher participation. The literature shows that combining social skills training with other interventions (e.g., behavior management, parent training) is more effective than is providing it as a stand-alone treatment.

Peer Rejection

Childhood peer rejection and its role in the development of psychopathology has received more attention than any other peer-related topic, in part because of its prevalence—approximately 10% to 15% of children are rejected by their peer group. These children are actively disliked by many of their peers and are liked by few or none of them.

Peer rejection is a global term that encompasses the many behaviors used by children to exclude and hurt one another, including overt forms of control and exclusion and more subtle tactics, such as gossiping and spreading rumors. These methods, whether overt or covert, account for variance in children’s maladjustment and social acceptance above and beyond the effects of aggressive behaviors. It is not simply being the recipient of aggressive acts that is linked to maladaptive outcomes, but being the recipient of coordinated efforts that keep an individual outside the boundaries of the peer group.

The short-term and long-term consequences of peer rejection are quite serious. In the short-term, these children often experience loneliness, low self-esteem, and social anxiety. Long-term consequences include poor academic performance, school dropout, juvenile delinquency, criminal behavior, and mental health problems, particularly externalizing ones, in adolescence and adulthood.

What elicits rejection? Many factors can lead to peer rejection, but the most consistently related factors, especially over the long-term, are aggressive and socially withdrawn behavior. Numerous studies have linked aggressive behavior problems in preschool, middle childhood, and adolescence to rejection from peers. Aggressive play with peers in early childhood is linked to behavioral maladjustment and difficulties with peers in middle childhood. Hostile behavior and withdrawal from social interaction in middle childhood is predictive of antisocial behavior in adolescence, extreme forms of teenage delinquency, externalizing problems in late adolescence, drug use in adulthood, and problems in other social relationships. Aggressive children are more likely to be avoided and actively targeted than nonaggressive children because the larger group seeks to isolate individuals who tend to disrupt normal peer interaction. At the same time, the experience of being rejected serves to perpetuate aggressive and externalizing problems, partly by limiting the amount and quality of the rejected child’s socialization by his or her peers.

Despite clear links between aggression and rejection, not all aggressive children are rejected (Parkhurst and Asher, 1992). Approximately one third of aggressive elementary school–age children and two thirds of aggressive young adolescents are not rejected. Several factors seem to differentiate children who become rejected and children who do not. Aggressive children who are rejected tend to engage in more instrumental aggression or aggression designed to reach a specific goal; they are more likely to instigate and escalate aggressive interchanges; and they are more likely to be argumentative, disruptive, inattentive, off-task, and hyperactive.

Children’s self-perceptions may be important in assessing the likelihood of negative outcomes (Patterson et al, 1990; Reinherz et al, 2000). Many rejected children describe themselves in negative terms—they say that they are less competent socially, they feel more anxious, and they expect less positive social outcomes than other children. Despite these negative self-portrayals, however, rejected children often rate themselves higher on positive indices than parents or peers, perhaps as a face-saving defense tactic. Finally, several more recent studies suggest that self-perceptions of being rejected (whether or not peer rejection is truly present) are significantly implicated in the cause of depression and suicidal ideation in childhood and adolescence.

Peer rejection, including its concomitant and long-term consequences, is an extremely difficult process to derail, in part because of its stability. Almost half of rejected children are rejected 1 year later, and 30% remain rejected after 4 years. In addition, many rejected children quickly become disliked again when put into new groups of children.

Peer rejection, humiliation, and implications for the high-profile school shootings

The role of peer rejection, not merely the lack of peer approval, is telling. In Harter's studies, initial interest in peer rejection began with an analysis of the emerging profiles of the, now, 12 high-profile cases of school shootings by white, middle-class, male older children and adolescents, from small cities or suburbs. They have gone on shooting sprees killing peers, and in a few cases, school officials who were random victims, rather than specifically targeted individuals. What became evident, in the analysis of media reports, is that all of these male youth killers had a history of peer rejection and humiliation. Surprisingly, there is virtually no literature on humiliation. Yet, humiliation is a daily event in most schools and neighborhoods. For the school shooters, extreme feelings of chronic humiliation by peers, due to excessive teasing, taunting, and physical insults eventually led them to psychologically ‘snap,’ provoking random deaths and, in the case of the Columbine teens, to suicide.

An examination of the media accounts of the school shooters made it obvious that many of the determinants in the model could be found in the lives of these adolescents. They displayed inadequacies in the domains of peer acceptance, athletic ability, and scholastic competence. They experienced low peer and parental approach, exhibited low self-esteem, and were hopeless about their future, and often depressed. Some experienced suicidal tendencies. Thus, humiliation can put one at pathological risk for endangering not only others' lives but also one's own.

A critical feature of the humiliation experience is the necessary role of an audience where observers laugh at the victim, often joining in the harassment and mockery. The bullying literature links such harassment directly to revenge and violence. However, a more thoughtful analysis addresses the critical role of humiliation as a key emotional link or mediator between harassment and retaliation.

Contextual Peer Factors

Children with disruptive behaviors are at risk for being rejected by their peers.80 Childhood aggressive behavior and peer rejection are independently predictive of delinquency and conduct problems in adolescence.81,82 Aggressive children who are also socially rejected tend to exhibit more severe behavior problems than do children who are either only aggressive or only rejected. As with bidirectional relations evident between the degree of parental positive involvement with their children and children's aggressive behavior over time,83 children's aggressive behavior and their rejection by their peers affect each other reciprocally.84 Children who have overestimated perceptions of their actual social acceptance can be at particular risk for aggressive behavior problems in some settings.85

Despite the compelling nature of these findings, race and gender may moderate the relation between peer rejection and negative adolescent outcomes. For example, Lochman and Wayland81 found that peer rejection ratings of African American children in a mixed-race classroom were not predictive of subsequent externalizing problems in adolescence, whereas peer rejection ratings of white children were associated with future disruptive behaviors. Similarly, whereas peer rejection can be predictive of serious delinquency in boys, it can fail to be so with girls.86

As children with conduct problems enter adolescence, they tend to associate with deviant peers. We believe that many of these teenagers are continually rejected from more prosocial peer groups because they lack appropriate social skills and, as a result, they turn to antisocial cliques as their only sources of social support.86 The tendency for aggressive children to associate with one another increases the probability that their aggressive behaviors will be maintained or will escalate, because of modeling effects and reinforcement of deviant behaviors.87 The relation between childhood conduct problems and adolescent delinquency is at least partially mediated by deviant peer group affiliation.88

Classroom Peer Acceptance and Rejection

A growing corpus of findings link children's acceptance or rejection by classroom peers with indicators of their school adjustment (see Ladd, 2005). Early peer rejection – at school entry – has been shown to predict problems such as negative school attitudes, school avoidance, and underachievement during the first year of schooling and thereafter (Ladd, 1990; Ladd et al., 1999; Ladd and Burgess, 2001). Later, in the elementary years, peer acceptance has been linked with loneliness (Parker and Asher, 1993), conduct problems (Ladd, 2006), lower emotional well-being (Ladd, 2006), and academic deficits (Ladd et al., 1997).

Researchers have also attempted to distinguish the contributions of peer acceptance and rejection from those of other classroom relationships. Ladd et al. (1997, 1999) found that, even after controlling for other forms of peer and teacher–child relationships, peer rejection predicted children's participation in the classroom which, in turn, was linked to later achievement. In a similar study, Buhs and Ladd (2001) found that children's peer acceptance at school entry predicted changes in classroom participation which, in turn, predicted later academic and emotional adjustment. In general, these results support the premise that peer acceptance promotes social inclusion which, in turn, yields provisions (e.g., sense of belongingness and engagement in learning activities) that enhance children's interpersonal and scholastic adjustment (Buhs et al., 2006).

Outcomes Associated with Peer Rejection

Focusing on both externalizing and internalizing problems, this section briefly reviews research on peer rejection and later adjustment outcomes. Research in this arena has been guided by several theoretical models, proposed to explain how sociometric status, behavior, and later adjustment are related. The “causal model” states that rejected peers interact with their peers in negative manner causing them to receive poorer treatment which eventually leads to subsequent adjustment difficulties. The “incidental model” assumes that peer rejection does not affect later adjustment but is only a by-product of the child's behavioral style and it is behavior, alone, that affects later adjustment. More recently suggested, the “additive model” states that relational risk factors, such as peer rejection, increase the likelihood of later dysfunction beyond the risks associated with behavioral characteristics. Alternatively, the “moderated risk-adjustment model” suggests that relational risks (eg, peer rejection) exacerbate maladjustment among children who are behaviorally at risk. Finally, examining forces outside of the child and the peer group, the “transactional model” proposes that the child's dispositional and biologically-based characteristics, parents' socialization practices, relationships within and outside of the family, and culture, stress, and social support determine both peer relationships and the positive or negative outcomes that follow.

5.11.4.1 Externalizing Disorders

Externalizing disorders are characterized by maladaptive disruptive, impulsive, delinquent, hyperactive, and aggressive behaviors, with symptoms typically emerging in childhood or early adolescence. These disorders are associated with significant functional impairment, including peer rejection, delinquent peer affiliations, academic underachievement, school dropout in childhood and adolescence (Egger and Angold, 2006; Fergusson et al., 2005a; Frick and Dickens, 2006), work-related problems, substance abuse, relationship difficulties, and antisocial or criminal behavior in adulthood (Fairchild et al., 2019; Odgers et al., 2008).

The most common externalizing disorders of childhood and adolescence are Attention-deficit/hyperactivity disorder (ADHD) and oppositional defiant disorder (ODD); fewer youth experience conduct disorder (CD) which also presents during this developmental period. While CD and ODD are more strongly characterized by defiant, impulsive, and, antisocial behaviors, as well as aggression in the case of CD (Hinshaw and Lee, 2003), ADHD is characterized by clinically impairing symptoms of inattention, impulsivity, hyperactivity, and, restlessness (Frick and Lahey, 1991). Children with ADHD can often display aggressive behavior; however, aggression is not recognized as a core construct of the disorder. Global prevalence estimates of ADHD, ODD, and CD are 3.4%, 3.6% and 2.1%, respectively (Fairchild et al., 2019; Polanczyk et al., 2015). There are well described differences in the expression of externalizing disorders by sex, with evidence that compared to girls, boys are more likely to be diagnosed with ADHD (1.5% for boys, 0.3% in girls), ODD (3.1% for boys, 2.1% in girls), and CD (3%–4% for boys, 1%–2% in girls) (Costello et al., 2003). Most diagnoses of these externalizing disorders are made in middle childhood, but rarely are these disorders diagnosed before age 4 years (Dodge, 2007; Fairchild et al., 2019).

Childhood externalizing disorders co-occur substantially, at rates much higher than chance (Hudec and Mikami, 2017) and are more severe variants of the single disorders (Angold et al., 1999). Children with an ADHD diagnosis have 10-fold risk of being diagnosed with either CD or ODD relative to children without ADHD (Angold et al., 1999; Connor et al., 2010), while children with ODD have a 15-fold risk of meeting criteria for CD (Fairchild et al., 2019). In addition to externalizing comorbidities, there is evidence that CD, ADHD, and ODD frequently co-occur with major depressive disorder, particularly in girls (Angold et al., 1999), suggesting there are also strong links between internalizing and behavioral disorders in the childhood years. Externalizing disorders are often experienced over the lifespan; approximately 15%–21% of those with childhood ADHD continue to meet diagnostic criteria for the disorder in adulthood (Agnew-Blais et al., 2016; Faraone et al., 2006), with about 40% of children with CD later diagnosed with antisocial personality disorder in adulthood (Gelhorn et al., 2007). Without effective intervention, negative long-term sequalae of CD and ADHD include the development of internalizing disorders, substance dependence, unemployment, criminal behavior, and excess mortality (Agnew-Blais et al., 2016; Frick and Dickens, 2006; Fairchild et al., 2019; Samek and Hicks, 2014; Moffitt et al., 2002).

Social-Cognitive Correlates of Peer Acceptance and Rejection

Researchers have investigated the social cognitions of children in the different sociometric status groups and of children with different behavioral tendencies. Social information processing (SIP) theories explain online processing and decision-making that occur before, during, and after social interactions. Most SIP models suggest that individuals enter social situations with unique interpersonal histories, which include beliefs, schemas, scripts, and working models, all of which influence how they interpret social interactions and how they behave. Typically, SIP models also outline a series of sequential steps that explain how children attend to, encode, and interpret social information and how they choose, evaluate, and enact both goals and behavioral strategies. Recent revisions of these models also include temperament, emotional regulation, and affective reactions as contributors to cognition and subsequent behavior in social interaction.

Generally, rejected children are less likely than their well-liked counterparts to formulate prosocial goals and generate sophisticated strategies. However, a majority of SIP research has focused on children who are both rejected and aggressive. Typically studied by asking children to respond to vignettes in which they are harmed but is unclear whether the offense was intentional (e.g., someone bumps into you in the cafeteria and your milk is spilled on your shirt), rejected-aggressive children are more likely to judge an ambiguous harm as being intentionally caused and respond in a hostile manner. This tendency has been termed the hostile attribution bias.

Children who are both aggressive and rejected are also more likely to choose aggressive/hostile goals and strategies in social situations. For example, these youth are more likely to endorse revenge and dominance goals as well as aggressive behavioral strategies in both ambiguous situations and very minor conflicts of interest. Aggressive children also view aggression as a more legitimate response in social situations, anticipate greater rewards and fewer consequences for aggression, and they expect that aggression will lead them to feel better about themselves and will be less hurtful to victims.

In comparison, far less research has examined the SIP patterns of withdrawn children. Research that has focused on this group finds that withdrawn children are more likely than aggressive or typical children to anticipate failure in social situations. When withdrawn children do encounter social rejection, they are more likely to attribute it to their own dispositional characteristics rather than to external causes. Additionally, withdrawn children are more likely to suggest adult-dependent and avoidant strategies and less likely to generate assertive social strategies to resolve interpersonal conflicts.

Interpersonal schemas may also predict how children react in peer situations, and ultimately are related to their sociometric status. For example, rejection-sensitivity, defined as the tendency to defensively expect, readily perceive, and overreact to rejection, has been associated with peer rejection and child behavior. First, peer rejection predicts increases in rejection sensitivity over time. Furthermore, angry expectations of rejection are positively associated with teacher-rated aggression and negatively linked with social competence. Moreover, child and young adolescent anxious expectations of rejection have been linked with social anxiety and social withdrawal. While this is still a relatively new topic of investigation, it seems that rejection-sensitivity is a construct that may prove useful in further SIP-guided research.

Parent-Child Communication

It is extremely important for a pediatric health care provider to screen for and to assess how well a child and parent are communicating about the child’s social relationships, school behaviors, and overall psychosocial adjustment. A youth who shows high levels of aggression, peer rejection, or social withdrawal is more at risk if he or she does not have an adult to confide in. Although there are few well-validated and brief assessment tools in this area, several specific screening questions can be asked by pediatric health care providers in the context of an office visit as outlined in Table 40-3. These questions will provide a deep understanding for the pediatric health care provider about the child’s home and school context and can be helpful in the referral and treatment recommendation process.