social competence among children with central nervous system

Journal of Pediatric Psychology, Vol. 22, No. 6, 1997, pp. 771-793

Social Competence Among Children with CentralNervous System-Related Chronic Health Conditions:A Review1

Jack H. Nassau2

Rhode Island Hospital/Brown University School of Medicine

Dennis Drotar

Case Western Reserve University School of Medicine

Received December 7, 1995; accepted January 27, 1997

Reviewed empirical studies of social competence among children with centralnervous system (CNS)-related chronic health conditions published since 1975.The overwhelming majority of studies evaluated social competence at the level ofsocial adjustment; the domains of children's social performance and social skillswere relatively neglected (Cavell, 1990). Findings are critiqued with respect toconceptualization of social competence among children with CNS conditions andmethodological considerations. Directions for future research include expandingthe conceptualization of social competence in this population to include socialdemands and competencies specific to children with CNS conditions and utilizingexplicit theoretical frameworks that allow for competing hypotheses to be tested.

KEY WORDS: social competence; chronic illness; epilepsy; cerebral palsy; spina bifida.

Cerebral palsy, epilepsy, and spina bifida are among the most prevalent chronichealth conditions involving the central nervous system (CNS) affecting children

'This research is supported in part by National Institute of Mental Health Grants 18830 and 19927,and was conducted while the first author was a doctoral candidate at Case Western Reserve Univer-sity and a postdoctoral fellow at Rhode Island Hospital/Brown University School of Medicine. Wethank Carolyn levers, Elizabeth McQuaid, Tonya Mizell, Charisse Peoples, Kristin Riekert, andJane Robinson for their thoughtful comments during preparation of this manuscript.

2A1I correspondence should be sent to Jack H. Nassau, Department of Child and Family Psychiatry,Rhode Island Hospital, 593 Eddy Street, Providence, Rhode Island 02903.

771

0146-8693/97/1200-0771$!2 50/0 © 1997 Plenum Publishing Corporation

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772 Nassau and Drotar

and adolescents in the United States (Gortmaker & Sappenfield, 1984). Althougha variety of other chronic health conditions (and/or their treatments) may haveimportant implications for the CNS, they are either less prevalent (e.g., braintumors) or not defined by CNS involvement (e.g., sickle cell disease). Thus,although cerebral palsy, epilepsy, and spina bifida are not exhaustive of theconditions with CNS implications, they may be considered representative ofconditions that are defined primarily by CNS dysfunction. Cerebral palsy refersto a variety of disorders of movement and posture caused by a nonprogressiveinjury of the immature brain (Batshaw & Perret, 1986; Eicher & Batshaw, 1993)and has an estimated prevalence of 2.5/1,000 children and adolescents in theUnited States (Boyle, Decoufle, & Yeargin-Allsop, 1994). Epilepsy is defined asthe presence of recurrent seizures that are not provoked by fever or cerebral insult(Batshaw & Perret, 1986). Prevalence estimates among children and adolescentsin the United States range from 3.5/1,000 (Gortmaker & Sappenfield, 1984) to8.9/1,000 (Boyle et al., 1994). Spina bifida, defined as a spinal deformitycaused by an incomplete closure of one or more vertebrae, occurs in approx-imately 1/1,000 live births (Gortmaker, 1985; Varni & Wallander, 1988) and hasan estimated prevalence of 0.4/1,000 children and adolescents in the UnitedStates (Gortmaker & Sappenfield, 1984).

Children with CNS-related chronic health conditions are at increased riskfor developing emotional and behavioral problems when compared to physicallyhealthy children and to children with non-CNS-related chronic health conditions(e.g., insulin-dependent diabetes mellitus; Breslau, 1985; Cadman, Boyle, Szat-mari, & Offord, 1987). One factor that may account for this increased risk isdifficulty in developing age-appropriate social competence and peer relations. Aswith physically healthy children, peer relationships would be expected to exert asocializing influence on children with CNS conditions by shaping appropriateexpressions of behavior (e.g., aggression and sharing; Hartup, 1989). Peer rela-tionships might also provide a context for children with CNS conditions to giveand receive social support and develop a sense of group membership and inter-personal intimacy (Berndt & Perry, 1986; La Greca et al., 1995; Zarbatany,Hartmann, & Rankin, 1990). Furthermore, some children with CNS conditionsface a number of unique social demands (e.g., coping with stigma, teasing, andsocial isolation; developing social outlets and activities within the constraintsimposed by their condition; and communicating with others about their condi-tion) that might pose significant psychological burden. Attainment of age-appro-priate social competence and peer relations may moderate the psychologicaladjustment of these children by enhancing their adaptation to their condition andincreasing their self-esteem (La Greca, 1990; Wallander & Varni, 1989).

Children with CNS conditions may have special problems developing age-appropriate social competence and peer relations. First, some children with CNSconditions have cognitive impairments (e.g., in intelligence, memory, attention,or problem solving) that could hinder their social understanding and, thus, ad-

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Social Competence in CNS Conditions 773

versely affect their social competence (Crick & Dodge, 1994; Dodge & Price,1994). Approximately one third of children with spina bifida have below averageintelligence and approximately 60% of children with cerebral palsy have mentalretardation (Batshaw & Perret, 1986; Eicher & Batshaw, 1993). Although ap-proximately 50% of children with epilepsy have normal intelligence (Batshaw &Perret, 1986), specific cognitive deficits appear to be associated with earlier ageof seizure onset and seizure type (Seidenberg, 1989). In addition, antiepilepticmedications may have cognitive effects that impact on social competence (Bin-nie, 1994). Second, the overt manifestations of these conditions (e.g., theirvisibility, disruptiveness, and/or visually disturbing quality) could lead to thesechildren being stigmatized by their peers and, thus, adversely affect their devel-opment of social competence by reducing opportunities to engage in age-appro-priate peer activities (La Greca, 1990). Children with cerebral palsy or spinabifida may have physical handicaps that require assistive devices (e.g., braces,wheelchair) to help with movement and posture and include impaired bowel andbladder control. Depending on seizure type and response to medication, childrenwith epilepsy may be stigmatized when visually disturbing seizures occur in thepresence of peers. The episodic and unpredictable course of epilepsy may makethe occurrence of seizures especially frightening to peers.

For all of the above reasons, the impact of CNS conditions on children'ssocial competence is important. However, with the exception of including chil-dren with epilepsy, previous reviews of social competence and peer relationsamong children with chronic health conditions (e.g., Spirito, DeLawyer, &Stark, 1991) have excluded studies of children with CNS conditions. Conclu-sions that children with non-CNS-related chronic health conditions do not, as awhole, experience poorer peer relations than their healthy peers may not general-ize to children with CNS conditions who experience additional problems includ-ing impaired cognitive functioning and social stigma. Moreover, children withCNS conditions may experience the very factors (e.g., physical limitations) thatappear to be associated with the most significant disruptions in social compe-tence and peer relations in children with non-CNS-related chronic health condi-tions. To our knowledge, no previous literature review has focused on the socialcompetence of children with CNS conditions. To address this need, this reviewhas two aims: (a) to describe and critique studies that have empirically evaluatedthe social competence of children with CNS conditions; and (b) to present impor-tant directions for future research.

LITERATURE SEARCH

Two strategies were used to identify peer-reviewed studies of social com-petence among children with CNS-related chronic health conditions. First,PSYCHLIT, MEDLINE, and CINAHL databases were searched by computer for

Dow



Tab

le I

. St

udie

s In

clud

ed i

n R

evie

w"

Ref

eren

ceSa

mpl

e (a

ge)

SCM

easu

re(s

)C

ontr

olFi

ndin

gsSt

reng

ths

(S);

Wea

knes

ses

(W)

Am

mer

man

,V

an H

asse

lt,

Her

sen,

&M

oore

(19

89)

And

erso

n(1

979)

Apt

er e

t al

.(1

991)

Bre

slau

(19

85)

Bre

slau

&M

arsh

all

(198

5)

Cen

ter

& W

ard

(198

4)

SB (

n =

25)

(K =

10

-17-

\A

— i

"3 a

\M

=

Ij.o

)

CP

(n =

89)

SB (

n =

30)

15 +

, st

uden

ts

EP

(n =

26)

(M =

14

.9)

CP

(« =

98)

SB (

n =

63)

(R =

3-

18)

CP

(n =

82)

SB (

n =

50)

age

as a

bove

CP

(n

=

101)

(R =

6-

16)

SA SS SA SA SA SA SA

Pare

nt:

Chi

ld B

e-ha

vior

Che

ck-

list,

Soci

alC

ompe

tenc

eSc

ale

(CB

CL

-SC

S)O

bser

vatio

n: R

PT3-

poin

t sc

ale

ofqu

ality

of

soci

allif

e

Mot

her:

CB

CL

-SC

S

Mot

her:

Psy

chi-

atri

c Sc

reen

ing

Inve

ntor

y (P

SI),

Isol

atio

n su

b-sc

ale

Mot

her:

PSI

, Is

o-la

tion

subs

cale

Tea

cher

: so

cial

ac-

cept

ance

rat

ing

Peer

: So

ciom

etri

cs

Yes

(V

I, n

= 2

5;N

onha

ndic

appe

d,n

= 2

5)

Yes

, fo

r th

e 1/

3 in

ordi

nary

sch

ools

Yes

(A

st.,

n -

26;

Hea

lthy,

n =

90)

Yes

(C

F, n

= 6

5;H

ealth

y, n

=35

9)

Yes

(C

F, n

= 5

6)

No

CB

CI^

SCS

in n

oncl

inic

alra

nge;

SB

sub

ject

s le

ss c

om-

pete

nt t

han

cont

rols

on

CB

CL

SC

S;

nona

mbu

lato

rySB

sub

ject

s le

ss c

ompe

tent

;no

dif

fere

nces

on

RPT

21%

(vs

. 94

% o

f co

ntro

ls)

had

"sat

isfa

ctor

y so

cial

liv

es";

com

pete

nce

of t

eens

in

ordi

-na

ry s

choo

ls b

ette

r th

an t

hat

of t

hose

in

spec

ial

scho

ols

EP

subj

ects

les

s co

mpe

tent

tha

nhe

alth

y co

ntro

ls o

n al

l bu

tSc

hool

sub

scal

e; E

P bo

ys l

ess

com

pete

nt t

han

asth

ma

con-

trol

s on

Soc

ial

subs

cale

Chi

ldre

n w

ith C

P or

SB

mor

eis

olat

ed t

han

cont

rols

ind

e-pe

nden

t of

men

tal

reta

rdat

ion

(MR

); c

hild

ren

with

MR

mor

e is

olat

ed t

han

thos

ew

ithou

tT

ime

1 an

d T

ime

2 Is

olat

ion

scor

es c

orre

late

d .5

2; n

om

ean

chan

ge f

rom

Tim

e 1

toT

ime

2; c

ontin

uity

in

scor

esin

depe

nden

t of

MR

30%

of

CP

sam

ple

in i

nteg

rate

dcl

assr

oom

s so

cial

ly u

nacc

ept-

able

or

bord

erlin

e; t

hose

in

spec

ial

clas

sroo

ms

mor

e ac

-ce

pted

S: >

1 co

ntro

l gr

oup,

inf

orm

ant,

soci

al c

ompe

tenc

e do

mai

n;IQ

con

trol

led;

fun

ctio

nal

sta-

tus

cons

ider

ed;

W:

nonc

lini-

cal

scor

es c

ompa

red;

RPT

psyc

hom

etri

cs;

no h

ypot

hese

sst

ated

S: S

ampl

e si

ze;

>1

CN

S gr

oup;

func

tiona

l st

atus

con

side

red;

W:

Mea

sure

des

crip

tion,

psy

-ch

omet

rics

; C

NS

grou

ps n

otan

alyz

ed s

epar

atel

y; n

o hy

-po

thes

es s

tate

dS:

>1

cont

rol

grou

p; C

BC

Lsu

bsca

les

anal

yzed

; ge

nder

cons

ider

ed;

W:

Non

clin

ical

scor

es c

ompa

red;

no

hypo

the-

ses

stat

edS:

Sam

ple

size

; >

1 C

NS

grou

p;de

mog

raph

ics

cont

rolle

d;m

enta

l re

tard

atio

n co

nsid

ered

;hy

poth

eses

sta

ted;

W:

Com

-pe

tenc

e m

easu

re

S: 5

yea

r fo

llow

-up

of B

resl

au(1

985)

; pa

rtic

ipat

ion

rate

s;W

: C

ompe

tenc

e m

easu

re;

nohy

poth

eses

sta

ted

S: >

1 in

form

ant,

mea

sure

; W

:S

ampl

e, m

easu

re d

escr

iptio

n;m

easu

re p

sych

omet

rics

; no

hypo

thes

es s

tate

d

Dow



Eis

er,

Hav

er-

man

s, P

an-

cer,

& E

iser

(199

2)H

erm

ann

(198

2)

Hir

st (

1989

)

Hos

okaw

a,K

itaha

ra,

&N

akam

ura

(198

5)H

owe,

Fei

n-st

ein,

Rei

ss,

Mol

ock,

&B

erge

r(1

993)

Lan

dry,

Rob

in-

son,

Cop

e-la

nd,

&G

amer

(199

3)L

ord,

Var

zos,

Beh

rman

,W

icks

, &

Wic

ks (

1990

)

EP (n = 35)

(R =

4-14;

M = 9.4)

EP (n = 50)

(R = 8-12)

CP (n =

89)

SB (n = 30)

(R =

15-19)

CP (n = 52)

(R =

7-16;

M = 11)

CP (n = 24)

SB (n = 19)

EP (n = 19)

(M =

14.3)

SB (/i =

15)

(R =

6-12;

M = 8.1)

SB (n = 31)

(R =

12-19)

SA SA SA SP SP SA SA

Pare

nt:

CA

AP,

Peer

Rel

atio

nssu

bsca

le

Pare

nt:

CB

CL

-SC

S

3-po

int

"qua

lity

ofso

cial

lif

e" r

at-

ing

scor

ed f

rom

inte

rvie

wT

aken

shik

i So

cial

Mat

urity

Sca

le,

Inte

rper

sona

lSk

ills

fact

orPa

rent

: A

uton

o-m

ous

Func

tion-

ing

Che

cklis

t,So

cial

Ini

tiativ

esu

bsca

leSe

lf:

SS

P,

Peer

Acc

epta

nce

sub-

scal

e

Self

: R

evis

edU

CL

A L

onel

i-ne

ss S

cale

Pare

nt:

PIC

, S

o-ci

al S

kills

sub

-sc

ale

Yes

(A

st.,

n =

53;

IDD

M,

n =

144

;L

euk.

, n

= 1

7;C

ard.

, n

= 1

6)N

o

No

No

Yes

(C

F,

n =

25;

IDD

M,

n =

25;

JRA

, n

= 2

1;

VI,

n =

14;

Hea

lthy,

n =

49)

Yes

(H

ealth

y, n

=15

)

No

Chi

ldre

n w

ith e

pile

psy

leas

tw

ell

adju

sted

acc

ordi

ng t

om

othe

rs,

but

not

fath

ers

Chi

ldre

n w

ith "

good

neu

rops

y-ch

olog

ical

(N

P)

func

tioni

ng"

mor

e co

mpe

tent

tha

n th

ose

with

"po

or N

P f

unct

ioni

ng"

40-4

3% h

ad "

very

res

tric

ted"

soci

al l

ives

; fu

nctio

nal

limita

-tio

ns r

elat

ed t

o qu

ality

of

so-

cial

life

Old

er c

hild

ren

had

bette

r in

ter-

pers

onal

ski

lls;

no d

iffe

renc

eby

gen

der,

cog

nitiv

e sk

ills

, or

mot

or s

kills

Ado

lesc

ents

with

CN

S c

ondi

-tio

ns (

as a

gro

up)

disp

lay

less

soci

al i

nitia

tive

than

chi

ldre

nw

ith n

on-C

NS

cond

ition

s (a

sa

grou

p) a

nd h

ealth

y co

ntro

lsN

o di

ffer

ence

in

perc

eive

d pe

erac

cept

ance

bet

wee

n ch

ildre

nw

ith S

B a

nd c

ontr

ols

SB h

ad p

oore

r so

cial

ski

lls a

ndgr

eate

r lo

nelin

ess

than

nor

ms;

plac

emen

t in

spe

cial

cla

ss-

room

ass

ocia

ted

with

poo

rer

outc

ome

S: >

1 in

form

ant;

hypo

thes

esst

ated

; W

: C

ompe

tenc

e m

ea-

sure

S: L

imite

d ag

e ra

nge;

NP

sta

tus

cons

ider

ed;

W:

CB

CL

sub

-sc

ales

not

ana

lyze

d; n

o hy

-po

thes

es s

tate

dS:

Con

cept

ual

mod

el;

func

tiona

lst

atus

con

side

red;

W: M

ea-

sure

des

crip

tion,

psy

cho-

met

rics

S: D

emog

raph

ics,

fu

nctio

nal

stat

us c

onsi

dere

d; W

: No

hypo

thes

es s

tate

d

S: >

1 c

ontr

ol g

roup

; de

mo-

grap

hics

con

trol

led;

hyp

othe

-se

s st

ated

; W

: IQ

dif

fere

nces

not

cont

roll

ed;

CN

S g

roup

sno

t an

alyz

ed s

epar

atel

yS:

Age

-, I

Q-m

atch

ed c

ontr

ols;

>1

info

rman

t; co

ncep

tual

mod

el;

W:

Sam

ple

size

S: >

1 in

form

ant,

mea

sure

;fu

nctio

nal

stat

us c

onsi

dere

d;W

: C

ompa

riso

n to

nor

ms;

IQ

diff

eren

ces

not

cont

rolle

d; n

ohy

poth

eses

sta

ted

(con

tinu

ed)

Dow



Tab

le I

. (C

onti

nued

)

Ref

eren

ceSa

mpl

e (a

ge)

SCM

easu

re(s

)C

ontr

olFi

ndin

gsSt

reng

ths

(S);

Wea

knes

ses

(W)

McA

ndre

w(1

979)

Silla

npaa

(199

2)

Stor

es (

1978

)

Tew

& L

aw-

renc

e (1

985)

Tho

mps

on,

Kro

nen-

berg

er,

John

-so

n, &

Whi

ting

(198

9)T

in &

Tea

sdal

e(1

984)

Van

Has

selt,

Am

mer

man

,H

erse

n, R

ei-

gel,

& R

ow-

ley

(199

1)

SB (

n =

39)

(R =

14

-25;

M =

19.

2)

EP

(n =

86)

(R =

8-

19)

EP

(n =

70)

(M =

10

-11)

SB (

n =

44)

10 y

ear

olds

SB (

n =

50)

fO

—

1 17

-(K

=

j—

1 /,

M =

10

.7)

SB (

n =

8)

(R =

5th

-7th

grad

e)

SB (

n =

26)

(R =

7-9

; M

=

7.2)

SA SA SA SA SA SP SA SS

Self

: Se

mi-

stru

ctur

ed i

nter

-

view

Fam

ily:

Inte

rvie

w

Tea

cher

: C

onne

r'sR

atin

g Sc

ale,

Soci

al I

sola

tion

fact

orSe

lf: R

oger

s Pe

r-so

nal

Adj

ust-

men

t In

vent

ory,

Soci

al M

alad

-ju

stm

ent

Scal

e

Pare

nt:

Miss

ouri

Chi

ldre

n's

Be-

havi

or C

heck

-lis

t, So

ciab

ility

Fact

or

Obs

erva

tion:

Freq

uenc

y of

soic

al i

nter

ac-

tions

Pare

nt:

CB

CL

-SC

S

Obs

erva

tion:

RPT

No

Yes

(H

ealth

y, n

316)

Yes

(n

= 1

03)

Yes

(H

ealth

y, n

52)

No

Yes

(H

ealth

y, n

8)

Yes

(H

ealth

y, n

29)

Onl

y 3

subj

ects

had

no

clos

efr

iend

s an

d 2/

3 w

ere

rare

lyor

nev

er l

onel

y; 1

/2 d

escr

ibed

as "

soci

ally

iso

late

d"12

% o

f ch

ildre

n w

ith E

P (v

er-

sus

1% o

f co

ntro

ls)

had

"so-

cial

int

egra

tion

hand

icap

"(i

.e.,

few

er h

uman

con

tact

s)B

oys

in 3

/4 E

P gr

oups

mor

e so

-ci

ally

iso

late

d th

an c

ontr

ols;

no d

iffe

renc

e be

twee

n E

Pgi

rls

and

cont

rols

SB c

hild

ren

mor

e so

cial

ly m

al-

adju

sted

tha

n co

ntro

ls;

chil

-dr

en w

ith s

hunt

edhy

droc

epha

lus

less

com

pete

ntth

an t

hose

with

out

shun

ted

hydr

ocep

halu

s2%

had

low

soc

ial

skill

s pr

o-fi

le,

32%

had

soc

iabl

e pr

o-fi

le;

fam

ily

func

tioni

ngpr

edic

ted

vari

ance

in

soci

abili

ty f

acto

r be

yond

de-

mog

raph

ic a

nd C

NS

vari

able

sSB

chi

ldre

n m

ore

ofte

n al

one

and

few

er i

nter

actio

ns t

han

cont

rols

; co

ntro

ls i

nitia

ted

few

er i

nter

actio

ns w

ith S

Bch

ildre

n th

an w

ith o

ther

pee

rsA

ccor

ding

to

fath

ers

(but

not

mot

hers

), c

hild

ren

with

SB

less

com

pete

nt t

han

cont

rols

only

on

Scho

ol s

ubsc

ale;

no

diff

eren

ces

on R

PT

S: D

escr

iptio

n; W

: M

easu

reps

ycho

met

rics

; so

cial

iso

la-

tion

defi

nitio

n un

clea

r; n

o hy

-po

thes

es s

tate

dS:

Sam

ple

unse

lect

ed,

size

; W

:SE

S no

t co

ntro

lled

; so

cial

hand

icap

def

initi

on u

ncle

ar,

no h

ypot

hese

s st

ated

S: S

ampl

e si

ze;

mat

ched

con

-tr

ols;

sei

zure

typ

e co

nsid

ered

;W

: C

ompe

tenc

e m

easu

re;

nohy

poth

eses

sta

ted

S: U

nsel

ecte

d sa

mpl

e; d

emo-

grap

hics

, fu

nctio

nal

stat

usco

nsid

ered

; W

: IQ

dif

fere

nces

not

cont

roll

ed;

mea

sure

psy

-ch

omet

rics

; no

hyp

othe

ses

stat

edS:

Sam

ple

size

, de

scri

ptio

n; >

1IV

; co

ncep

tual

mod

el;

W:

Des

crip

tion

of p

rofi

les,

soci

abili

ty f

acto

r

S: M

atch

ed c

ontr

ols;

obs

erva

-tio

nal

data

; W

: Sa

mpl

e si

ze;

mea

sure

, in

terr

ater

rel

iabi

lity;

no h

ypot

hese

s st

ated

S: L

imite

d ag

e ra

nge;

>1

info

r-m

ant,

soci

al c

ompe

tenc

e do

-m

ain;

CB

CL

sub

scal

esan

alyz

ed;

IQ d

iffe

renc

es c

on-

trol

led;

W:

Sam

ple

desc

rip-

tion D

ownloaded from

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/jpepsy/article/22/6/771/920536 by guest on 17 January 2022

Wal

land

er,

Fel

dman

, &

Vam

i (1

989)

Wal

land

er,

Hub

ert,

&V

arni

(19

88)

Wal

land

er,

Var

-ni

, B

aban

i,B

anis

, D

e-H

aan,

&W

ilcox

(198

9)W

alla

nder

, V

ar-

ni,

Bab

ani,

Ban

is,

&W

ilcox

(198

8)W

alla

nder

, V

ar-

ni,

Bab

ani,

Ban

is,

&W

ilcox

(198

9)W

estb

rook

,B

aum

an,

&Sh

inna

r(1

992)

Whi

tman

, H

er-

man

n, B

lack

,&

Chh

abri

a(1

982)

SB (

n =

61)

(R =

4-

16;

M =

9.

3)

CP

(n

= 27

)SB

(n

= 23

)

(R =

6-1

1;M

=

7.9)

CP

(n

= 27

)SB

(n

= 23

)

(R =

6-

11)

SB (

n =

77)

CP

(TI

=

19)

(R =

4-

16;

M =

10

.3)

SB (

n =

17)

CP

(n

= 17

)

(R =

4-

16;

M =

10

.4)

EP

(n

= 64

)

(R =

12

-20;

M =

16

.1)

EP

(TI

= 83

)(R

=

6-16

)

SA

Mot

her:

CB

CL

- N

oSC

S

SA

Mot

her:

CB

CL

- N

oSC

S

SA

Mot

her:

CB

CL

- N

oSC

S

SA SA SA SP SA

Mot

her:

CB

CL

-SC

S

Mot

her:

CB

CL

-SC

S

Self:

im

pact

of

EP

on p

eer

rela

-tio

ns;

"dis

-cl

osur

em

anag

emen

t"M

othe

r: C

BC

L-

SCS

Yes

(ID

DM

, TI

=80

; H

emop

hilia

,TI

= 4

0; J

RA

, TI

= 19

; Obe

sity

, TI

= 30

)Y

es (

IDD

M,

TI =

74;

JRA

, n

= 23

;O

besi

ty,

TI =

22)

No

No

CB

CL

-SC

S in

non

clin

ical

rang

e; 2

3% "

mal

adju

sted

"; n

odi

ffer

ence

s as

fun

ctio

n of

dis

-ea

se s

ever

ityL

ess

com

pete

nt t

han

norm

s;m

ore

com

pete

nt o

n So

cial

subs

cale

; SB

mor

e co

mpe

tent

than

CP;

chi

ld a

nd m

ater

nal

IVs

pred

ict

com

pete

nce

52%

"m

alad

just

ed";

mor

e co

m-

pete

nt o

n So

cial

sub

scal

e; S

Bm

ore

com

pete

nt t

han

CP;

IQan

d ad

aptiv

e fu

nctio

ning

con

-tr

ibut

ed t

o co

mpe

tenc

e

CP

sub

ject

s le

ss c

ompe

tent

tha

nSB

sub

ject

s an

d co

ntro

ls;

nodi

ffer

ence

bet

wee

n SB

sub

-je

cts

and

cont

rols

CP

sub

ject

s le

ss c

ompe

tent

tha

nSB

sub

ject

s an

d co

ntro

ls;

nodi

ffer

ence

bet

wee

n SB

sub

-je

cts

and

cont

rols

2/3

repo

rt E

P d

oes

not

impa

ctpe

er r

elat

ions

; yo

unge

r su

b-je

cts

repo

rt g

reat

er im

pact

;1/

2 so

met

imes

or

ofte

n ke

epE

P s

ecre

tD

emog

raph

ic a

nd s

ever

ity v

ari-

able

s di

d no

t pr

edic

t si

gnifi

-ca

nt v

aria

nce

in s

ocia

lco

mpe

tenc

e

S: S

ampl

e si

ze;

dise

ase

seve

rity

cons

ider

ed;

W:

Com

pari

son

to n

orm

s; C

BC

L s

ubsc

ales

not

anal

yzed

S: >

1 C

NS

grou

p, I

V;

CB

CL

subs

cale

s an

alyz

ed;

conc

ep-

tual

mod

el;

W:

Com

pari

son

to n

orm

s; r

egre

ssio

n an

alys

isno

t co

ncep

tual

ly d

rive

nS:

>l

CN

S gr

oup,

IV

; C

BC

Lsu

bsca

les

anal

yzed

; co

ncep

-tu

al m

odel

; W

: C

ompa

riso

nto

nor

ms

S: >

1 C

NS

grou

p; s

ampl

e si

ze;

W:

Age

ran

ge;

CB

CL

sub

-sc

ales

not

ana

lyze

d; n

oncl

ini-

cal

scor

es c

ompa

red;

no

hypo

thes

es s

tate

dS:

Mul

tiple

CN

S co

nditi

ons;

conc

eptu

al m

odel

; W

: A

gera

nge;

CB

CL

sub

scal

es n

otan

alyz

ed;

nonc

linic

al s

core

sco

mpa

red

S: M

ultip

le s

ocia

l co

mpe

tenc

edo

mai

ns;

illne

ss-s

peci

fic s

o-ci

al c

ompe

tenc

e; c

once

ptua

lm

odel

S: D

emog

raph

ic a

nd d

isea

seva

riab

les

cons

ider

ed;

W:

Com

pete

nce

mea

sure

; no

hy-

poth

eses

sta

ted

°SC

: So

cial

Com

pete

nce

Dom

ain;

SA

: So

cial

Adj

ustm

ent;

SP:

Soc

ial

Perf

orm

ance

; SS

: So

cial

Ski

lls;

SB:

Spin

a B

ifida

; C

P: C

ereb

ral

Pal

sy;

EP:

Epi

leps

y; V

I:V

isua

lly I

mpa

ired

; A

st.:

Ast

hma;

CF:

Cys

tic F

ibro

sis;

ID

DM

: In

sulin

-dep

ende

nt D

iabe

tes

Mel

litus

; L

euk.

: L

euke

mia

; C

ard.

: Car

diac

; JR

A: J

uven

ile R

heum

atoi

dA

rthr

itis;

M:

Mea

n (in

yea

rs);

R:

Ran

ge (

in y

ears

); R

PT: R

ole

Play

Tes

t; C

AA

P: C

hild

and

Ado

lesc

ent

Adj

ustm

ent

Prof

ile;

SSP

: Har

ter

Self-

Per

cept

ion

Prof

ile f

orC

hild

ren;

PIC

: Pe

rson

ality

Inv

ento

ry f

or C

hild

ren;

SE

S: S

ocio

econ

omic

sta

tus;

IV

: In

depe

nden

t V

aria

ble.

Dow




studies published after 1975. The search was limited to studies published after1975 because a comprehensive review of adjustment to chronic childhood disor-ders (Pless & Pinkerton, 1975) was published in that year. Articles containingeither the words cerebral palsy, epilepsy, or spina bifida combined with phrases(gleaned from the databases' thesauruses) reflecting some aspect of social behav-ior (e.g., social competence) or peer relations (e.g., social acceptance) in eitherthe title, abstract, or key words were requested. Second, reference lists of previ-ously located studies were reviewed for articles published after 1975.

Studies were included in the review if they met the following criteria: (a)inclusion of children or adolescents with cerebral palsy, epilepsy, or spina bifida;(b) inclusion of at least one measure of children's social competence that wasanalyzed separately from other dependent measures; and (c) separate analysis ofsocial competence data from children with at least one CNS condition (i.e.,cerebral palsy, epilepsy, and/or spina bifida). Using these criteria, 43 articleswere initially reviewed, of which 27 met the above criteria. At least one empiri-cal study evaluating some aspect of children's social competence or peer rela-tions was found for each of the CNS conditions listed above; 10 studies containedmore than one of the CNS conditions under consideration. Reviewed articles arelisted alphabetically by author in Table I and are marked with an asterisk in theReferences.

REVIEW OF LITERATURE

General Conceptual Model of Children's Social Competence

For the following reasons, Cavell's (1990) model of children's social com-petence provides a useful framework within which to describe and critique stud-ies of the social competence of children with CNS conditions. First, Cavell'smodel is sensitive to a wide range of issues (e.g., peer relationship development,communication) in children's social development that may be affected by thepresence of a CNS condition. Furthermore, the model considers domains ofsocial competence that may be differentially sensitive to the effects of CNSconditions. These domains include (a) social adjustment (e.g., are children withCNS conditions accepted by their peers or socially withdrawn compared to otherchildren?); (b) social performance (e.g., how do children with CNS conditionsactually behave in typical peer situations such as entering a peer group?); and (c)social skills (e.g., do children with CNS conditions possess the basic skills, suchas the ability to evaluate nonverbal cues, necessary to behave competently intypical peer situations?).

The overwhelming majority of studies (24/27) assessed social competence

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at the level of social adjustment as defined by Cavell (1990). Only 3 of 27 studiesassessed these children's social performance and only 2 studies assessed theirsocial skills. Two studies (Ammerman, Van Hasselt, Hersen, & Moore, 1989;Van Hasselt, Ammerman, Hersen, Reigel, & Rowley, 1991) assessed both thesocial adjustment and social skills of these children.

Study Designs

Two basic study designs were utilized to study social competence amongchildren with CNS conditions: (a) comparison of the social competence of chil-dren with CNS conditions to either normative data or to control samples of eitherchildren with non-CNS-related chronic health conditions or physically healthychildren; and (b) description of the relationships between independent variablesand social competence among children with CNS conditions. Studies reportinggroup comparisons in social competence (n = 20) are discussed separately fromthose reporting relationships between independent variables and social compe-tence (w = 13). Within the section on group differences, the review is organizedin accord with Cavell's (1990) model (i.e., findings regarding children's socialadjustment, social performance, and social skills are discussed separately). Thesection on correlates of social competence is organized according to the indepen-dent variable(s) used in analyses.

Group Differences in Social Competence

Social Adjustment of Children with CNS-Related Chronic Health Conditions

Eighteen studies assessed the social adjustment of children with CNS condi-tions through comparisons between the study sample and either normative data (n= 4) or a control group (n = 14). Physically healthy children served as controlsin 8 studies, whereas children with non-CNS-related chronic health conditionsserved as controls in 4 studies; 2 studies included both types of control groups.

Evaluations of children's social adjustment generally involved summary orglobal assessments of social functioning. Taken together, available findings indi-cated that children with CNS conditions were less socially competent comparedto normative data, physically healthy children, or children with non-CNS-relatedchronic health conditions. However, it is important to note that the strength of thefindings depended on how social adjustment was operationalized and measured.In 4 studies that employed the Total Social Competence Scale of the ChildBehavior Checklist (CBCL; Achenbach, 1979; Achenbach & Edelbrock, 1983)children with CNS conditions were less socially competent than either a norma-tive sample of non-clinic-referred children (Wallander, Feldman, & Varni, 1989;

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Wallander, Hubert, & Varni, 1988; Wallander, Varni, Babani, Banis, DeHaan, &Wilcox, 1989) or a physically healthy control group (Ammerman et al., 1989;Apter et al., 1991). In 2 studies that employed a control group of children withnon-CNS-related chronic health conditions (Wallander, Varni, Babani, Banis, &Wilcox, 1988, 1989), children with cerebral palsy were less competent thanthese controls, but children with spina bifida were not.

Similarly, in all 5 studies that utilized measures of social isolation that wereeither derived from larger instruments of child behavior (e.g., Conners TeacherRating Scale, Conners, 1969; Psychiatric Screening Inventory, Langner, Ger-sten, McCarthy, & Eisenberg, 1976) or through interviews, children with CNSconditions were reported to be less socially competent (i.e., more socially iso-lated) than either physically healthy children (Anderson, 1979; Breslau, 1985;Sillanpaa, 1992; Stores, 1978) or children with non-CNS-related chronic healthconditions (Breslau, 1985; Breslau & Marshall, 1985). In one descriptive studythat did not include a comparison group (McAndrew, 1979), approximately 50%of children with spina bifida were socially isolated according to self-reports on asemistructured interview. In the only study that addressed children's social com-petence at two points in time (Breslau & Marshall, 1985) mothers' reports on thePsychiatric Screening Inventory indicated that children with CNS conditionswere more socially isolated than children with non-CNS-related conditions atboth an initial assessment and at an assessment 5 years later.

Furthermore, in an additional 3 out of 4 studies that assessed social adjust-ment using subscales from larger inventories (e.g., the Peer Relations subscale ofthe Child and Adolescent Adjustment Profile; Ellsworth, 1979), children withCNS conditions were less socially competent (i.e., had poorer peer relations)compared to norms (Lord, Varzos, Behrman, Wicks, & Wicks, 1990), physicallyhealth children (Tew & Lawrence, 1985), or children with non-CNS-relatedchronic health conditions (Eiser, Havermans, Pancer, & Eiser, 1992). OnlyLandry, Robinson, Copeland, and Garner (1993), who utilized the Peer Accep-tance subscale of the Harter Self-Perception Profile (Harter, 1985) found nodifferences between children with a CNS condition (i.e., spina bifida) and physi-cally healthy controls.

Only one study (Center & Ward, 1984) utilized sociometric procedures tomeasure the social adjustment of children with CNS conditions. Sociometricprocedures have the distinct advantage of gathering data concerning social accep-tance directly from children's peers. In their study, children with cerebral palsywho were integrated into regular classrooms were less socially accepted thantheir healthy peers, with 30% considered socially unacceptable.

Inconsistent findings emerged from studies that assessed more specific do-mains of social adjustment. For example, after finding differences between chil-dren with CNS conditions and control groups on the Total Social CompetenceScale of the CBCL (Achenbach, 1979; Achenbach & Edelbrock, 1983), twostudies (Ammerman et al., 1989; Apter et al., 1991) separately analyzed each of

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the three subscales (i.e., Activities, School, and Social) that constitute the scale.Compared to physically healthy controls, Ammerman et al. (1989) reported thatchildren with spina bifida were less competent on each of the three subscales,whereas Apter et al. (1991) reported that adolescents with temporal lobe epilepsywere less competent on the Activities and Social subscales, but not on the Schoolsubscale. Van Hasselt et al. (1991) reported that children with spina bifida wereless competent than physically healthy children only on the School subscale. Inthe one study that also included a control group of participants with a non-CNS-related chronic health condition, Apter et al. (1991) reported that adolescent boyswith temporal lobe epilepsy were less socially competent than those with asthmaonly on the Social subscale.

Six studies of children's social adjustment included children with differentCNS conditions (e.g., children with cerebral palsy and children with spina bi-fida) and compared these children's social competence. In each of 4 studies usingthe CBCL, Wallander and colleagues (Wallander, Hubert, et al., 1988; Wal-lander, Varni, Babani, Banis, DeHaan, et al., 1989; Wallander, Vami, Babani,Banis, & Wilcox, 1988, 1989) reported that children with cerebral palsy wereless competent than children with spina bifida. However, Breslau (1985) andHirst (1989) did not report differences in isolation between these groups.

Social Performance of Children with CNS-Related Chronic Health Conditions

Only 2 studies assessed the social performance (i.e., children's behavior indiscrete peer situations) of children with CNS conditions through comparisonswith a control group. Physically healthy children served as controls in one study,whereas both physically healthy children and children with non-CNS-relatedchronic health conditions served as controls in the other study.

Both Howe, Feinstein, Reiss, Molock, and Berger (1993) and Tin andTeasdale (1985) reported that children with CNS conditions were less sociallycompetent than either physically healthy children or children with non-CNS-related chronic health conditions. Using parents' reports on the AutonomousFunctioning Checklist (Sigafoos, Feinstein, Damond, & Reiss, 1988), Howe etal. (1993) found that children and adolescents with CNS conditions exhibitedless autonomous social initiative than either physically healthy children or chil-dren with non-CNS-related chronic health conditions.

In a particularly informative assessment of children's social performanceusing observational data of peer interactions, Tin and Teasdale (1985) comparedchildren with spina bifida attending regular schools to physically healthy childrenmatched individually on age, gender, race, socioeconomic status, and academicability. Children's social performance was assessed through observations of inter-personal interactions during lunch and on the playground; these observationsyielded frequency counts which were entered into seven categories including

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total amount of interaction and source of interaction (i.e., did the subject or apeer initiate the interaction). Results indicated that children with spina bifida hadfewer interactions with peers and were more frequently alone compared to con-trols. However, whereas there were no differences in the amount of interactioninitiated by children with spina bifida and controls, peers initiated significantlyfewer interactions with children with spina bifida than with controls. Thus,children with spina bifida initiated interactions with peers, but were neglected bypeers compared to physically healthy children (controls).

Social Skills of Children with CNS-Related Chronic Health Conditions

Only 2 studies assessed the social skills, defined as abilities in variousspecific components of peer situations, of children with CNS conditions. VanHasselt and colleagues (e.g., Ammerman et al., 1989; Van Hasselt et al., 1991)compared the social skills of children and adolescents with spina bifida to thoseof physically healthy children and adolescents. In each of these studies, subjectscompleted a role-play test with a confederate during which they were rated onverbal (e.g., speech duration, hostile statements) and nonverbal (e.g., smiles,gaze, physical gestures) indices of social skill. The role-play tests covered theinterpersonal tasks of initiating a conversation and making friends, negativeassertion (e.g., responding to a situation by denying unreasonable requests) andpositive assertion. In both studies, the level of social skill demonstrated bychildren and adolescents with spina bifida did not differ from that demonstratedby physically healthy children and adolescents.

Correlates of Social Competence Among Children with CNS-RelatedChronic Health Conditions

Studies of factors that influence individual variation are important becausethey may provide insight into processes that underlie the development of socialcompetence among children with CNS conditions. Eight studies determinedwhether subgroups of children with CNS conditions (e.g., boys vs. girls) differedin social competence, whereas 5 studies used correlational or multiple regressionprocedures to determine the amount of variance in social competence accountedfor by various independent variables. All but 1 of these 13 studies (Hosokawa,Kitahara, & Nakamura, 1985) assessed children's social adjustment.

Severity of Condition

Seven studies, of which all but 1 employed a group difference analyticstrategy, evaluated the influence of condition severity on social competence.Using various measures of social adjustment (i.e., the Social Competence Scale

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from the CBCL (Achenbach, 1979; Achenbach & Edelbrock, 1979, 1983), So-cial Maladjustment Scale from the Rogers Personal Adjustment Inventory(Rogers, 1961), Social Skills Scale from the Personality Inventory for Children(Wirt, Lachar, Klinedinst, & Seat, 1984), and unstandardized ratings of qualityof social life), 6 studies found that children with more severe presentations wereless socially competent than those with less severe presentations. Comparablefindings were obtained regardless of whether severity was operationalized asdegree of medical intervention (e.g., children with spina bifida and shuntedhydrocephalus vs. those without hydrocephalus; Tew & Lawrence, 1985), func-tional impairment (e.g., ambulatory vs. nonambulatory; Ammerman et al.,1989; Hirst, 1989), neuropsychological impairment (Hermann, 1982), or type ofschool placement (e.g., special vs. mainstreamed classrooms; Anderson, 1979;Lord et al., 1990; Wallander, Hubert, et al., 1988).

For example, Hirst (1985) found that adolescents with three or more severeimpairments were more likely to have very restricted social lives than those withfewer than three impairments. In an analysis of combinations of different impair-ments, he concluded that almost any combination of severe functional impair-ments could lead to restrictions in social life, but that combinations including IQless than 85, walking problems, and obesity had a more negative effect onadolescents' social lives than other combinations of functional impairments notincluding these characteristics. Only Wallander, Feldman, et al. (1989), whostudied the influence of a variety of severity parameters including lesion level,number of shunt surgeries, ambulation status, and bladder function among chil-dren with spina bifida, reported no differences in children's social competence asa function of condition severity.

Demographic Characteristics

Three studies evaluated the influence of demographic characteristics on thesocial competence of children with CNS conditions. Of the 2 studies that as-sessed the influence of age on children's social adjustment, one (Westbrook,Bauman, & Shinnar, 1992) reported that older children with CNS conditionswere more socially competent (i.e., reported less perceived stigma) than youngerchildren, whereas the other (Wallander, Hubert, et al., 1988) reported no differ-ences in social competence (as measured by the CBCL; Achenbach & Edelbrock,1983). In the one study that assessed the influence of age on children's socialperformance, Hosokawa et al. (1985) reported that older children with CNSconditions were more socially competent than younger children as measured byan instrument similar to the Vineland Social Maturity Scale (Doll, 1953). In 2studies of children's social adjustment, no differences in social competence werereported as a function of gender (Wallander, Hubert, et al., 1988) or ethnicity(Westbrook etal. , 1992).

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Combinations of Independent Variables

Using multiple regression procedures, 4 studies evaluated the percentage ofvariance in children's social competence accounted for by demographic, condi-tion severity, and child and family functioning independent variables separatelyand in combination. All of these studies assessed children's social adjustment.

Whitman, Hermann, Black, and Chhabria (1982) reported that a combina-tion of demographic and severity variables did not significantly predict the socialcompetence of children with epilepsy as measured by the CBCL (Achenbach,1979). However, Thompson, Kronenberger, Johnson, and Whiting (1989) re-ported that a combination of demographic, severity, and family functioningvariables explained a significant amount of variance in the social competence ofchildren with spina bifida as measured by the Missouri Children's BehaviorChecklist (Sines, Pauker, Sines, et al., 1969). Furthermore, using the CBCL(Achenbach & Edelbrock, 1983), Wallander, Hubert, et al. (1988) reported thatchild and maternal temperament variables explained a significant portion ofvariance in the social competence of children with CNS conditions, and Wal-lander, Varni, Babani, Banis, DeHaan, et al. (1989) reported that children'sadaptive functioning significantly added to the variance accounted for in socialcompetence beyond that accounted for by intelligence.

In summary, the reviewed studies of individual differences in children'ssocial competence indicate that measures of functional severity (e.g., cognitiveimpairment, restricted mobility) are associated with social competence in chil-dren with CNS conditions, such that children with poorer functional status areless socially competent. Conclusions concerning the impact of demographic(e.g., age) and family variables (e.g., family functioning) are less clear largelydue to the fact that only a few studies included these variables in analyses.

CRITIQUE

Although group comparison and correlational studies have contributed im-portant initial findings regarding social competence among children with CNS-related chronic health conditions, the conclusions that can be drawn from thereviewed studies are limited by several important methodological problems andconceptual issues.

Conceptualization of Social Competence

One major problem of the reviewed literature is that only 8 studies presentedan explicit theoretical model of how children's social competence might beaffected by the presence of a CNS-related chronic health condition. Three studies

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employed implicit conceptual models (i.e., stated hypotheses) without providinga clear rationale for the hypotheses. Sixteen studies did not state a priori hypothe-ses that would indicate an implicit conceptual model. Consequently, competinghypotheses were generally not proposed and most results were described andinterpreted without a priori attention to the mechanisms (variables) that mightaccount for or explain the results. Thus, the manner in which several causal ormoderating factors may either contribute to or interfere with the development ofsocial competence in children with CNS conditions has not been well describedby the reviewed research. Moreover, the absence of a priori hypotheses to guidestatistical analyses also increased the likelihood of obtaining spurious findings,especially when multiple comparisons were made (Wallander, 1992).

The lack of attention to the development of specific conceptual modelsdescribing how children's social competence may be affected by the presence ofa CNS condition has promoted a view of social competence for this populationthat has focused almost exclusively on children's social adjustment and hasneglected other potentially important domains of social competence (e.g., socialperformance and social skills). In addition, unique social demands (e.g., manag-ing stigma, disclosure and explanation about their condition) faced by childrenwith CNS conditions, but not physically healthy peers, have been largely over-looked.

Measurement of Social Competence

The manner in which children's social competence was operationalized andmeasured also poses significant problems. Social adjustment was operationalizedmainly in terms of social activity (e.g., rates and quality of children's participa-tion in various peer activities) and by measures that were originally designed toassess psychological, rather than social, functioning. Specific instruments em-ployed (with the number of studies using them) included the CBCL (10; Achen-bach, 1979, 1991; Achenbach & Edelbrock, 1979, 1983), Psychiatric ScreeningInventory (2; Langner et al., 1976), Child and Adolescent Adjustment Profile (1;Ellsworth, 1979), Conners Teacher Rating Scale (1; Conners, 1969), Harter Self-Perception Profile (1; Harter, 1985), Missouri Children's Behavior Checklist (1;Sines et al., 1969), Personality Inventory for Children (1; Wirt et al., 1984), andRogers Personal Adjustment Inventory (1; Rogers, 1961). These instrumentsgenerally comprise several scales, of which only one actually assesses any do-main of social competence. For example, the CBCL (Achenbach, 1979, 1991;Achenbach & Edelbrock, 1979, 1983) contains 138 items, 20 of which form theSocial Competence Scale. The Social Competence Scale itself is divided intothree subscales labeled Activities, School, and Social. Respectively, these sub-scales reflect judgments of rates and quality of children's participation in various

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sports, hobbies, and organizations; school performance (i.e., grades); and in-volvement and behavior with peers.

Several factors hinder the validity of findings obtained from the above-mentioned measures. First, all of these instruments were originally designed toassess physically healthy children's functioning and may not be valid for childrenwith CNS conditions. The psychometric properties of these instruments, whenused in samples of children with CNS conditions, have not been well established.Second, because most of these instruments were designed to detect psychopath-ology as opposed to variations within the normal range of functioning, thesignificance of findings regarding group differences between children with CNSconditions and comparison samples is difficult to interpret (Perrin, Stein, &Drotar, 1991). For example, the CBCL (Achenbach, 1979, 1991; Achenbach &Edelbrock, 1979, 1983) employs T scores and a cutoff beyond which children'ssocial competence would be considered deviant. However, the validity and clini-cal significance of statistically significant differences within the normal range offunctioning are not clear. Third, results based on such operational definitions ofchildren's social competence are misleading when studying children with CNSconditions because they may reflect direct consequences of the children's condi-tion on their ability to participate in social activities as opposed to deficits inchildren's social competence per se (Drotar, Stein, & Perrin, 1995; Perrin et al.,1991). For example, consider a child with cerebral palsy who requires the use ofa wheelchair. This child's rate of engagement in the types of peer activitiesmeasured by the CBCL may be reduced because of access and transportationdifficulties and not because of any lack of social ability or interest.

The remaining 7 studies of children's social adjustment operationalizedsocial adjustment as either peer acceptance or quality of social life through theuse of sociometric procedures or unstandardized rating scales derived from con-currently collected interview data. A clear benefit of sociometric procedures,through which children with CNS conditions were nominated by their peers asfriends (or not) and ascribed various social qualities, is that data are gatheredfrom children's peers as opposed to from parents or teachers as is often the casewith questionnaires. The validity of results from studies that used unstandardizedrating scales is threatened because these scales lack psychometric data.

Study Design

Four studies did not collect data from control samples, but instead relied oncomparisons with normative data to obtain results. However, Lavigne and Faier-Routman (1992) showed that comparisons to normative data tend to overestimatepsychosocial deficits in samples of children with a variety of chronic healthconditions. Comparisons to normative data may overestimate deficits in childrenwith CNS conditions because normative samples are typically selected to exclude

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children with mental retardation or serious adjustment problems and, thus, arenot representative of the general population of children (Perrin et al., 1991).

Of the 15 controlled studies, 8 collected data from healthy children, 4collected data from children with non-CNS-related conditions, and 3 collecteddata from both. Generally speaking, where differences in social competencewere reported, children with CNS conditions were less competent regardless ofthe type of control group employed. However, inferences that can be drawndiffer depending on the type of control group used. Although more difficult torecruit, employing children with non-CNS-related conditions as controls is prob-ably preferable because it allows for results to be discussed with respect to thespecific effects of CNS conditions on social competence; when only healthychildren are employed as controls, it is impossible to conclude whether differ-ences in competence are a result of having any chronic condition or of having aCNS condition.

Sample Characteristics

Eleven studies utilized samples of children whose ages varied by 10 or moreyears (e.g., 4-14 years old). However, only 3 of these studies controlled for theeffects of age on children's social outcomes. The inclusion of children andadolescents of vastly different ages makes the clinical significance of findingsdifficult to interpret given the varied developmental tasks facing children ofdifferent ages (Perrin & Gerrity, 1984). This is a particular problem because thefunctions of children's peer relationships, and thus what constitutes sociallycompetent behavior, are hypothesized to undergo significant developmentalchanges. For example, whereas peer relationships in middle childhood are gener-ally characterized by the underlying theme of defining a peer group, self-explora-tion through self-disclosure is a dominant theme in adolescent peer relations(Parker & Gottman, 1989). The peer relations of children and adolescents withCNS conditions may undergo similar broad developmental processes.

In addition, too many studies (see Ammerman et al., 1989; Breslau, 1985;Landry et al., 1993; Van Hasselt et al., 1991, for exceptions) paid insufficientattention to potential differences in cognitive functioning between children withCNS conditions and comparison groups. Because CNS conditions may impactaspects of cognitive functioning (e.g., attention, memory) that are important forthe development of social competence (Crick & Dodge, 1994; Dodge & Price,1994) it is imperative to know whether differences in social competence areexplained by differences in cognitive functioning. Of the 4 studies that controlledfor intellectual differences between CNS and control groups, 3 reported differ-ences in social competence. However, no studies reported data on specific cogni-tive functions (e.g., attention).

Finally, all but a few studies were conducted at a single site. Unfortunately,

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single-site research projects are almost always hindered by the relatively smallpopulations of children with any one CNS condition available for study, espe-cially if researchers limit their study to a particular age group. Because of theinherent small samples and idiosyncratic characteristics of any one research site,results from such studies may not generalize to the broader population of childrenwith CNS conditions.

DIRECTIONS FOR FUTURE RESEARCH

Future research concerning social competence among children with CNS-related chronic health conditions would benefit from (a) reconceptualization ofwhat constitutes socially competent behavior in this population and (b) the use oftheoretical models to generate hypotheses about how social competence may beenhanced or disrupted. In addition, future research must address the fact thatsocial competence may vary as a function of specific CNS conditions (e.g.,children with cerebral palsy vs. those with epilepsy), dimensions that are com-mon to different diagnoses (e.g., degree of cognitive impairment), as well asnormative issues (e.g., children's gender or developmental level; Holden,Chmielewski, Nelson, Kager, & Foltz, 1997).

A situational analysis such as that outlined by Cavell (1990) and Di-Girolamo, Quittner, Ackerman, and Stevens (1997) would be a useful way toelucidate relevant social demands and conceptualize socially competent behavioramong children with CNS conditions. In such a process, measures of relevantsocial demands and strategies (i.e., competencies) used to cope with them wouldbe developed out of interviews with children and their parents. The strength ofthis approach lies in its ability to define developmentally appropriate socialdemands and competencies within specific CNS conditions. Because relevantsocial demands would be expected to vary as the goals of social behavior changeas a function of developmental level (Parker & Gottman, 1989; Perrin & Gerrity,1984), a situational analysis would allow researchers to directly examine devel-opmental changes in social competence. In addition, rather than focusing onnormative social demands (e.g., social acceptance), future research should con-centrate on elucidating social demands that are specific to CNS conditions as awhole (e.g., disclosing and/or explaining their condition in response to peers'questions, managing stigma) and those that are specific to particular CNS condi-tions (e.g., developing social outlets within the context of physical limitations).Empirical comparisons of social demands across CNS conditions would enableresearchers to determine which demands are common to children with CNSconditions as a group and which are specific to particular CNS conditions.

After developmentally appropriate social demands have been defined, in-vestigations of social competence should concentrate on assessments of chil-

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dren's social performance and social skills. These domains have been neglectedby the reviewed research. In fact, current findings beg the question, "why arechildren with CNS conditions less socially adjusted than controls?" Althoughcurrent findings indicate that children with CNS conditions are less sociallyadjusted than their peers, the 2 studies that examined social skills (Ammerman etal., 1989; Van Hasselt et al., 1991) did not report social skill deficits in thesechildren. Several appropriate strategies are available to assess social performanceand social skills. Observational measures of children's social behaviors in natu-ralistic environments reflecting developmentally appropriate social demandswould be a useful way of measuring these children's social performance (Cavell,1990). Laboratory measures (e.g., Dodge, Petit, McClaskey, & Brown, 1986)that identify specific social information-processing deficits (e.g., in children'sability to attend to and encode nonverbal social cues) encountered during devel-opmentally appropriate social demands would be a useful way of measuringthese children's social skills. The combination of these social performance andsocial skill assessments would enable researchers to first characterize socialbehaviors that are relatively effective versus those that are relatively ineffectiveand, second, to describe the social skill competencies that underlie these socialbehaviors.

This reconceptualization of social competence paves the way for theoreticalmodels to predict social competence among children with CNS conditions. Twomodels that appear especially useful for generating hypotheses with respect tosocial competence in this population are the social information-processing modeldescribed by Crick and Dodge (1994) and Wallander and Hubert's (1987) modelthat delineates environmental factors related to the development of social compe-tence. The relevance of Crick and Dodge's (1994) model lies in its microlevelanalysis of the individual's cognitive processes (e.g., encoding and interpretingsocial cues; clarifying social goals; and developing, choosing, and enactingsocial behavior) that underlie social behavior. Wallander and Hubert's (1987)model is an important adjunct because it includes environmental factors (e.g.,opportunity to learn and display social behavior) that influence the developmentof social competence.

Within the structure of these two models, several specific important re-search questions concerning the processes by which social competence is en-hanced or disrupted among children with CNS conditions may be forwarded. Themodels allow for research that addresses potential differences both within andacross different CNS conditions. For example, research has yet to determine thespecific effects of cognitive impairment (a dimension that varies within specificCNS conditions and cuts across different CNS conditions) on social competencein this population. Within the framework of the social information-processingmodel, studies examining (a) accuracy of encoding and interpretation of nonver-bal (e.g., facial) social cues and/or (b) generation of alternative behavioral

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responses among subgroups of children with cognitive deficits would help toclarify the link between cognitive impairment and social competence amongchildren with CNS conditions. In such studies, attempts should be made torecruit subjects with specific cognitive deficits in attention and/or memory asthese specific abilities appear to be especially crucial for encoding and interpret-ing social cues and accessing alternative behavioral responses (Crick & Dodge,1994). One would hypothesize that among children with different CNS condi-tions, those with weaknesses in attention and/or memory would be more likely toinaccurately encode and interpret social cues and generate fewer response alter-natives than would those without such weaknesses.

Wallander and Hubert's (1987) model is probably most useful for answeringquestions that specifically focus on environmental factors that influence thedevelopment of social competence. For example, research has yet to determinethe specific effects of social stigma on these children's opportunities to learn anddevelop appropriate social behaviors. One hypothesis is that children's perceivedstigma leads to their avoidance of developmentally appropriate activities and thusreduces their opportunities to learn and develop appropriate social behaviors. Analternative hypothesis is that social stigma leads peers to avoid children withCNS conditions and thus reduces their opportunities to learn and develop appro-priate social behavior.

Reconceptualizing the meaning of social competence among children withCNS conditions and utilizing theoretical models to further study their social skillsand social performance will enhance the value of future research. Our knowledgewill be advanced by elucidating developmentally appropriate social demands,differentiating aspects of social competence that are common to children withCNS conditions as a whole from those that are specific to particular CNS condi-tions and, consequently, identifying specific areas of intervention.

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