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Coping styles and locus of control as predictors for psychological adjustment of adolescents with a chronic illness
Social Science a Medicine 54 (2002) 1453–1461
Coping styles and locus of control as predictors for psychological adjustment of adolescents with a chronic illness Susan A. Meijera,*, Gerben Sinnemaa, Jan O. Bijstrab, Gideon J. Mellenberghc, Wim H.G. Woltersa a
Department of Pediatric Psychology, The Wilhelmina Children’s Hospital, University Medical Center Utrecht, (KA.00.004.0), P.O. Box 85090, 3508 AB Utrecht, The Netherlands b Department of Developmental Psychology, Groningen University, The Netherlands c Department of Psychological Methods, University of Amsterdam, The Netherlands
Abstract This study examines the way coping styles and locus of control contribute to the prediction of psychosocial adjustment in adolescents with a chronic illness. Psychosocial adjustment of 84 adolescents aged 13–16 years with a chronic illness was assessed with measures of social adjustment, global self-esteem and behavior problems. Linear regressions were performed with demographic factors (age and gender) and stress-processing factors (coping style and locus of control) as predictor variables. Results indicated that coping styles were related to most aspects of social adjustment. The coping styles ‘seeking social support’ and ‘confrontation’ were important predictors for positive social adjustment; the coping style ‘depression’ was a predictor for poor adjustment, viz. low social self-esteem and high social anxiety. Avoidance and locus of control were not strongly associated with psychosocial adjustment. Clinical implications of these findings were discussed in terms of preventive interventions for adolescents with a chronic illness. r 2002 Elsevier Science Ltd. All rights reserved. Keywords: Adolescence; Coping style; Chronic illness; Chronic behavior checklist; Social skills; Netherlands
Introduction A chronic illness may interfere with the developmental tasks of adolescents by making them more vulnerable to psychological and social problems (e.g. Gortmaker, Walker, Weitzman, a Sobol, 1990; Lavigne a FaierRoutman, 1992). However, there is wide variation in the psychosocial functioning of adolescents with a chronic illness (Lavigne a Faier-Routman, 1993). The majority of these adolescents function quite well, but a substantial subgroup develop clinically significant psychological or social problems. Several models have been developed to identify factors that contribute to this variation (e.g. Garmezy, Masten, a Tellegen, 1984; Pless a Perrin, 1985; Stein a Jessop, 1982). Wallander, *Corresponding author. Tel.: +31-30-2504111; fax: +31-302505325. E-mail address: [email protected] (S.A. Meijer).
Varni, Babani, Banis, and Wilcox (1989), who put mediating factors in psychosocial adjustment in a riskresistance framework elaborated one of the most detailed models. They identified disease/disability parameters, functional dependence and psychosocial stressors as risk factors, while resistance factors included intrapersonal factors (e.g. temperament, problem solving ability), social-ecological factors (e.g. family environment, family members’ adaptation, social support), and stress processing factors (cognitive appraisal and coping strategies). Resistance factors are thought to moderate the negative effects of risk factors on psychosocial adjustment besides their direct relation with psychosocial adjustment. Therefore, resistance factors are key parameters in preventing adjustment problems of chronically ill adolescents. This is confirmed in a meta-analysis carried out by Lavigne and Faier-Routman (1993), who found that resistance factors such as family/parent or
0277-9536/02/$ - see front matter r 2002 Elsevier Science Ltd. All rights reserved. PII: S 0 2 7 7 - 9 5 3 6 ( 0 1 ) 0 0 1 2 7 - 7
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child measures were stronger predictors in relation to child adjustment than disease/disability parameters were. As identified in the model of Wallander et al. (1989), increasing attention is being paid to the relationship between stress-processing factors and the psychosocial adjustment of children and adolescents with a chronic disease. Lavigne and Faier-Routman (1993) illustrated the importance of coping as a mediating factor by reporting relatively high correlations between coping and adjustment. The mediating effect may vary between coping strategies. This was demonstrated by Spirito, Stark, Williams, Stamonlis, and Alexan (1988), who found that children with a chronic disease who were referred for adjustment problems used coping strategies that differed from those of children with a chronic disease and no apparent adjustment problems. Children with adjustment problems were more likely to use social withdrawal and wishful thinking than children without apparent adjustment problems were. Within this context, researchers have discussed categories of coping strategies that reflect effective coping. People with effective coping styles generally deal directly with the stressor by using active coping strategies. For example, Jorgensen and Dusek (1990) demonstrated in a healthy sample that optimally adjusted adolescents exhibited a higher percentage of active coping efforts (i.e. making decisions, seeking social support, and talking about problems with friends) than psychosocially less adjusted peers. Active coping is also associated with better illnessrelated adjustment (Gil, Williams, Thompson, a Kinney, 1991; Grey, Cameron, a Thurber, 1991). Avoidance or depressive coping behaviors characterizes people with less effective coping styles. Frank, Blount, and Brown (1997) found that avoidance coping and depressive attitudes predicted the risk for adjustment difficulties, that is depression and anxiety, in children with cancer. Likewise, Grey et al. found that avoidance was correlated with worse adjustment in children and adolescents with diabetes mellitus. In sum, the results of studies of coping in pediatric populations generally have favored the efficacy of more active efforts over more passive coping. In addition to coping strategies, the appraisal of stress is a stress-processing factor that mediates between risk factors and adjustment. Specifically, expectations of control over one’s environmentFthe locus of control (LOC)Fseem to be a mediator in adaptation. Research suggests that persons with an internal LOC are better adjusted than persons with an external LOC are (e.g. Benson a Deeter, 1992; Steinhausen, Schindler, a Stephan, 1983). Also, an internal LOC seems to be predictive for illness-related adjustment (e.g. Jacobson et al., 1990; Miles, Sawyer, a Kennedy, 1995). Although relevant research has been done with regard to coping and LOC as resistance factors in relation to
psychosocial adjustment, several methodological problems limit the conclusions of these investigations. First, research specifically pertaining to adolescents is scarce. In most studies, results are presented for a group of children and adolescents with a broad age-range. Consequently, developmental differences in cognitive appraisal and in the use of coping strategies are masked. These stress-processing factors develop with age: coping strategies of children differ from coping strategies of adolescents (Carlson, Ricci, a Shade-Zeldow, 1990; Compas, Malcarne, a Fondacaro, 1988; Reid, Dubow, a Carey, 1995). Second, as far as we know, social adjustment has been outside the scope of most studies regarding resistance factors in chronically ill adolescents. Usually, psychological maladjustment factors such as behavior problems or depression are studied, but social maladjustment factors, such as social anxiety or social skills, have been rarely included. Finally, literature on coping in chronic illness focuses mainly on coping with illness-specific situations. Less attention has been given to the general coping styles of chronically ill adolescents. General coping styles may be more predictive for the psychosocial development of chronically ill adolescents than illness-related coping, because these styles reflect how the adolescents cope with developmental tasks. Moreover, ‘‘no current research suggests that children cope differently with illnessrelated stressors than with general stressors’’ (cited from Ryan-Wenger, 1996). Therefore, the purpose of this study is to examine the contribution of two relevant resistance factors in the prediction of psychological and social adjustment of chronically ill adolescents: coping styles and LOC. The age-range is restricted to 13–16 years. In addition to psychological functioning variables, i.e. behavior problems and global self-esteem, we included several social adjustment variables: social activities, social self-esteem, social anxiety, and social skills. Adolescents with a variety of chronic conditions were included in the current study. Generally, investigators have failed to find an association of psychosocial functioning with diagnosis; the chronicity of the condition appears to be the common factor associated with psychosocial maladjustment (Siefert, Wittman, Farquar, a Talsma, 1992; Stein a Jessop, 1989; Wallander et al., 1989).
Method Participants All adolescents who were under medical care of the Wilhelmina Children’s Hospital for a chronic physical condition and who met our inclusion criteria, be described elsewhere in this section, were
S.A. Meijer et al. / Social Science a Medicine 54 (2002) 1453–1461 Table 1 Descriptive statistics for predictor and adjustment variables
Predictor variables Demographic factors Gender Boys Girls Age Stress-processing factors Confrontation Seeking social support Depression Avoidance Locus of control Adjustment variables Social adjustment Social activities Social self-esteem Social skills Adequate skills Inadequate skills Assertive behavior Social anxiety Global self-esteem Behavior problems Internalizing Externalizing Total
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Procedure
n
Mean
SD
37 47 84
14.5
1.2
83 83 83 83 84
15.8 12.7 11.9 17.0 28.4
3.4 3.5 3.1 3.8 4.6
82 83
5.7 44.4
1.6 6.7
84 84 84 84 83
64.4 34.0 149.5 75.3 15.0
6.8 6.5 23.2 18.2 3.3
83 83 83
7.1 6.7 21.2
6.2 7.0 17.4
approached to participate in our study. A group of 124 adolescents and their parents got a letter about our study and were asked to participate. Within 2–4 weeks, we phoned to ask their reaction. Six families could not be traced, and 34 families did not want to participate. The main reasons for non-participation were lack of interest (48%), lack of time (30%), or unwillingness to be confronted with the disease more than necessary (8%). Four adolescents with serious psychosocial problems (serious psychopathology or family problems, for which they received psychological treatment at the time of our study) were excluded to avoid overburdening them. Data were collected for 84 adolescents, which indicates a participation rate of 68%. Inclusion criteria were: age between 13 and 16 years, sufficient command of the Dutch language, and diagnosed at least 1 year prior with one of the following chronic physical conditions: asthma (n ¼ 31), cystic fibrosis (CF; n ¼ 23), constitutional eczema (CE; n ¼ 15), or juvenile chronic arthritis (JCA; n ¼ 15). Mean age was 14.5 years, SD 1.2 (Table 1). The group consisted of 37 boys and 47 girls. Mean illness duration since diagnosis was 11.2 years (SD 4.6).
Data were gathered using parent-reported and childreported questionnaires. In addition, the parents were administered a short interview concerning demographic information (nationality, family composition, education of their children and themselves), the social functioning of their children, disease-related aspects (duration of the disease, age of onset/diagnosis, number of hospitalizations, school absence), and information about the use of mental health care. In nearly all cases (95%), the mother was the informant. Data were collected as part of a research project concerning the psychosocial functioning of children and adolescents with a chronic illness. Participation in this project implied that the participants filled in a series of questionnaires. The adolescents and their parents came to the hospital and filled in questionnaires simultaneously but separately. It took about 2 h to fill in the questionnaires and to finish the interview. Most adolescents completed the questionnaires by themselves, but if they had any questions, they could ask the skilled interviewer, who was present during the entire session. The Research and Ethics Committee of the University Hospital for Children and Youth approved the protocol of the study. All adolescents and their parents gave informed consent. Materials Predictor variables Coping styles were measured with the Utrecht Coping List for Adolescents: UCL-A (Bijstra, Jackson, a Bosma, 1994). This self-report questionnaire was originally developed for adults (Schreurs, van de Willige, Tellegen, a Brosschot, 1988), but it has been adapted for adolescents. Adolescents indicate on forty seven 4point scale items how they would react when they are confronted with a problem (e.g. ‘‘I wait for better times’’, or ‘‘I ask somebody for help’’). The UCL-A measures seven behavioral coping styles, of which we used four in this study: ‘confrontation’ and ‘seeking social support’ were selected to represent active coping, while avoidance and depressive reactions were selected to represent passive coping. Bijstra et al. (1994) reported internal consistencies of 0.77 (confrontation), 0.81 (seeking social support), 0.68 (avoidance), and 0.63 (depressive reactions), while Cronbach’s alphas in our study are 0.75, 0.81, 0.75, and 0.67, respectively. LOC was measured with the Nowicki–Strickland internal and external locus of control scale: LOC (Nowicki a Strickland, 1973; van Broeck, 1986). It is a self-report questionnaire which uses forty yes/no items to measure the degree to which adolescents attribute the course of events to their own actions instead of attributing it to external causes (e.g., ‘‘When people
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are unfriendly to you, do you think that this is without any reason?’’). A high score indicates a high internal LOC. Psychometric properties of the LOC have not been determined for a Dutch population, but the reliability of the scale for adolescents within this study was sufficient with a KR-20 of 0.72. Psychosocial adjustment variables Social activities were assessed with a subscale of the child behavior check list, completed by the parents: CBCL (Achenbach, 1991; Verhulst, van der Ende, a Koot, 1996). The social competence section consists of twenty questions subdivided into three categories: recreational activities, social activities and school competence. Of the social competence section, only the category social activities was used in the present study. This scale measures adolescents’ behavior with friends, siblings, and adults. A high score on the social activities scale means that the adolescent is actively involved in social contacts. The test-retest correlation of the social activities scale of the Dutch version is 0.79 (Verhulst et al., 1996). Social and global self-esteem were measured with the self perception profile for adolescents (SPPA, Harter, 1988; Straathof a Treffers, 1988). The scale measures with forty 4-point scale items how adolescents perceive their own functioning in eight relevant domains. In this study, we used the global self-esteem subscale (e.g. ‘‘Some youngsters are happy with themselves’’), and a combination of three social subscales (peer friendships, romantic friendships and social acceptance). A high score on the social subscales means that the adolescents perceive themselves as being accepted by their peers (e.g. ‘‘Some adolescents feel they are accepted by many peers’’). The factor structure of the Dutch version of the SPPA differed from the original version in that the three social scales did not form three separate factors (Straathof a Treffers, 1988). Therefore, we decided to combine them into one social scale after we had confirmed that the scores on these scales were significantly correlated (Pearson r varied from 0.44 to 0.59, po0:01). The internal consistency of the three separate subscales is good: Cronbach’s alpha for ‘peer friendships’ and for ‘romantic friendships’ is 0.76, and for ‘social acceptance’ 0.81; the internal consistency of the combined social scale in this study is 0.86. The internal consistency of the global self-esteem scale is 0.84 (Straathof a Treffers, 1988). In our study, this was 0.86. Social anxiety of the adolescents was measured by means of a Dutch self-report questionnaire (Bijstra a Oostra, 1995), originally developed for adults, called the scale of interpersonal behavior for adolescents (SIG-A, Arrindell, De Groot, a Walburg, 1984; Arrindell, Sanderman, a Ranchor, 1990). The items on the SIGA consist of 47 social situations that are evaluated by the adolescents on two dimensions. First, they judge on a 4-
point scale how much anxiety they experience in a particular situation (e.g. ‘‘give an opinion that is different from the opinion of the person you are talking with’’), and second, they judge on a 5-point scale how frequently they find themselves in that particular situation. There is a total score for social anxiety and a total score for frequency of assertive behavior. Cronbach’s alphas for both the social anxiety dimension and the assertive behavior dimension are high at 0.96 and 0.95, respectively (Bijstra a Oostra). In our study this was 0.95 and 0.93, respectively. Social skills of the adolescents were assessed with two self-reports. First, the frequency scores of the SIG-A were used to indicate assertive behavior (for a description of this questionnaire we refer to the section ‘social anxiety’). Second, adolescents reported their social skills on the Matson Evaluation of Social Skills with youngsters (MESSY, Matson, Rotatori, a Helsel, 1983; Blonk, Prins, a Sergeant, 1993). The MESSY consists of 62 5-point scale items, measuring the frequency of two types of behavior in a range of social situations, viz. adequate social skills and inadequate social skills. A high score on ‘adequate social skills’ means that the adolescents report to react with positive/friendly behavior in social situations (e.g. ‘‘I join other youngsters to talk with them’’); a high score on ‘inadequate social skills means that the adolescents report to react with aggressive behavior in social situations (e.g. ‘‘I pick on other youngsters to make them angry’’). Answers are ranging from ‘never’ to ‘always’. The internal consistency of the Dutch version is good with Cronbach’s alpha for adequate social skills 0.81, and for inadequate social skills 0.82. In our study, this was 0.83 and 0.79, respectively. The original American version also has good psychometric properties (Matson, Macklin, a Helsel, 1985; Matson et al., 1983; Spence a Liddle, 1990), and correlated well with other measures of social skills, such as direct observations of the child’s social behavior and a teacher nomination measure of social competence (Matson, Esveldt-Dawson, a Kazdin, 1983) Behavior problems were assessed with the CBCL (Verhulst et al., 1996). Mothers (and in a few cases the father) rated the severity of each symptom as expressed by their child on a 113-item behavior problem scale, with internalizing and externalizing symptomatology, and a total score of behavior problems. The CBCL has been used in a wide range of studies, and has good psychometric properties. The 3–4 week test-retest correlation of the Dutch version was 0.84 for the internalizing problem scale, 0.78 for the externalizing scale, and 0.84 for the total problem score (Verhulst et al., 1996). Data analysis In a preliminary analysis we investigated our premise that diagnosis is not associated with psychosocial
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S.A. Meijer et al. / Social Science a Medicine 54 (2002) 1453–1461 Table 2 Correlations between predictor variables and adjustment variables
Social activities Social self-esteem Adequate skills Inadequate skills Assertive behavior Social anxiety Global self-esteem Internalizing pr. Externalizing pr. Total behavior pr. a b
Confrontation
Social support
Depression
Avoidance
Locus of control
0.09 0.35a 0.40a –0.21 0.33a –0.28b 0.10 –0.22b –0.21 –0.16
–0.03 0.15 0.44a 0.08 0.35a 0.08 –0.12 –0.02 0.20 0.10
–0.09 –0.18 0.11 0.24b 0.11 0.39a –0.49a 0.21 0.15 0.18
0.07 –0.22 0.00 0.20 0.11 0.21 –0.09 –0.15 –0.24b –0.18
–0.07 0.02 0.00 –0.20 0.08 –0.04 0.13 –0.18 –0.26b –0.30a
po0:01. po0:05.
adjustment. This was done by adding three of the four diagnosis groups (CF, JCA, CE, and asthma) as dummy-variables in the regression analysis, and by comparing these results with regression analyses that were conducted without diagnosis as predictor. The correlations between the variables were computed. The correlations between the stress-processing variables and the adjustment variables are reported in Table 2. To study the contribution of the five stress-processing variables (confrontation, depressive reactions, seeking social support, avoidance, and LOC) to the prediction of adjustment, two regression models were specified per adjustment variable: (1) the regression of the adjustment variable on age (in years), gender (dichotomous variable), and the block of five stress-processing variables (full regression model), and (2) the regression of the adjustment variable on only age and gender. The block of five stress-processing variables does not contribute to the prediction of an adjustment variable if the explained variance (R2) of the full and restricted regression models is equal to each other. Therefore, the null hypothesis that the difference in R2 between full and restricted regression models is 0 was tested for each of the ten adjustment variables at the 5% significance level. The power of this test for the situation of 82 patients is about 0.75 and 0.99 for medium and large effect sizes, respectively (Cohen, 1988, Chapter 9). The null hypothesis was tested for each of the ten adjustment variables. If each of a number of true null hypotheses is tested at the 5% significance level, it is expected that 5% of these true null hypotheses will be rejected. Multivariate statistical tests can be used to prevent this type of chance capitalization. A number of well-known multivariate tests, such as MANOVA, make strong assumptions on the distribution of the variables, whereas other tests, such as the Bonferroni-Holm (Bonferroni) procedure (Seaman, Levin, a Serlin, 1991) make less
stringent assumptions. Therefore, the Bonferroni procedure was preferred above MANOVA for simultaneously testing the ten null hypotheses (one per adjustment variable) of no difference in R2 between full and restricted regression models. A null hypothesis, which was rejected by the Bonferroni procedure, was interpreted. A null hypothesis, which was rejected by the univariate test, but was not rejected by the Bonferroni procedure, was considered to be an interesting result that should be replicated in a new study before it can be interpreted. To study the contribution of each of the five stressprocessing variables separately, the standardized regression (beta-) coefficients were used. The null hypothesis that a beta-coefficient is 0 was tested at the 5% significance level per stress-processing variable within the full regression model of each of the ten adjustment variables. The power of this test for the situation of 82 patients is above 0.92 and 0.99 for medium and large effect sizes, respectively (Cohen, 1988, Chapter 9). The null hypothesis was tested ten times (one test for each of the ten adjustment variables) per stress-processing variables. To prevent chance capitalization the Bonferroni procedure was applied to the ten tests per stressprocessing variables.
Results Preliminary analyses Comparison of regression analyses with and without diagnoses showed that the inclusion of diagnosis as dummy variables did not affect the interpretation of our results, that is, it did not affect the predictive value of the stress-processing variables for psychosocial adjustment. Therefore, subsequent analyses collapse across diagnostic group.
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Full regression model Together, age, gender, and stress-processing factors predicted most aspects of psychosocial adjustment (Table 3). Except for social activities, the model significantly explained all social adjustment variables. The model also predicted global self-esteem and externalizing behavior problems. The explained variance of internalizing behavior problems was univariately significant, but not with
Table 3 R2 statistics for the blocked stepwise regression analysesa
Social adjustment Social activities Social self-esteem Social skills Adequate skills Inadequate skills Assertive behavior Social anxiety Global self-esteem Behavior problems Internalizing Externalizing Total
R2 full modelb
Decrease in R2 R2 age+ stress-processingc genderd
0.10 0.27**
0.05 0.19**
0.05 0.09*
0.35** 0.22** 0.25** 0.27** 0.25**
0.25** 0.15* 0.19** 0.24** 0.25**
0.11* 0.07 0.06 0.03 0.00
0.18* 0.24** 0.17
0.15* 0.22** 0.17*
0.03 0.03 0.00
Note: *po0:05; ** p significant with Bonferroni o0.05. R2 for full model (age+gender+coping); df=7, 74. c Decrease in R2 after removal of ‘coping’; df=5, 76. d Remaining R2 for age and gender; df=2, 79. a
b
Bonferroni correction. Social activities and total behavior problems could not be predicted with the predictor variables used in this model.
Stress-processing factors Stress-processing factors contributed significantly to the prediction of social self-esteem, adequate social skills, assertive behavior, social anxiety, global selfesteem, and externalizing behavior problems (Table 3). The decrease in R2 after removal of the block stressprocessing factors was 25% for adequate social skills and global self-esteem, 24% for social anxiety, 22% for externalizing behavior problems, and 19% for social self-esteem and assertive behavior, respectively. The decrease in R2 was univariately significant for total behavior problems, internalizing behavior problems, and inadequate social skills (17%, 15%, and 15%, respectively), but it was not significant with Bonferroni correction. Stress-processing factors did not contribute to the prediction of social activities. Inspection of the Beta-coefficients within the block stress-processing factors in Table 4 showed that the coping style confrontation was an important predictor for social adjustment (std. Beta=0.36 for adequate skills), followed by seeking social support (std. beta=0.37 for adequate skills). Confrontation was also univariately related to social anxiety and assertive behavior, while seeking social support was also univariately related to assertive behavior. Depression was a significant predictor for global self-esteem (std. Beta=– 0.50) and social anxiety (std. Beta=0.37), and it was
Table 4 Standardized Beta coefficients of stress-processing factors
Social adjustment Social activities Social self-esteem Social skills Adequate skills Inadequate skills Assertive behavior Social anxiety Global self-esteem Behavior problems Internalizing Externalizing Total a b
Stress-processing factors Confrontation Social support
Depression
Avoidance
Locus of control
F 0.33a
F F
F F
F F
F F
0.36a F 0.28b –0.29b F
0.37a F 0.31b F F
F F F 0.37a –0.50a
F F F F F
F F F F F
F F F
F F F
0.27b F F
–0.23b –0.23b F
F –0.23b –0.26b
p significant with Bonferroni o0.05. po0:05.
S.A. Meijer et al. / Social Science a Medicine 54 (2002) 1453–1461
univariately related to internalizing behavior problems. Avoidance was not a strong predictor for psychosocial adjustment, but it did have a univariate relationship with internalizing and externalizing behavior problems. LOC was also not a strong predictor; it was only univariately related to total behavior problems and externalizing behavior problems.
Discussion In this study, psychosocial functioning of chronically ill adolescents was significantly related to stress-processing factors. Coping styles were significantly associated with social adjustment, global self-esteem and externalizing behavior problems. The coping style confrontation, characterized by active and purposeful problem-solving, seems to be the most important determinant for positive psychosocial functioning, as reflected in this study by a high social self-esteem, the use of adequate social skills, and, to a lesser extent, the absence of anxiety in social situations and the use of assertive behavior. These findings are in line with results regarding healthy adolescents (Bijstra, Bosma, a Jackson, 1994), and support the hypothesis that confrontation is an effective behavioral coping style. The coping style seeking social support also seems to be effective, but only in relation to social skills. Adolescents who discuss their daily problems with others use adequate social skills more frequently and tend to display more assertive behavior than adolescents who are less inclined to seek social support. The relationship between seeking social support and social skills is probably bi-directional. On one hand, seeking social support may stimulate the development of social skills. On the other hand, adolescents who have adequate social skills and who are assertive may be more inclined to seek social support. If a bi-directional relationship exists, it may be possible to teach adolescents the social skills that facilitate seeking social support. A depressive reaction pattern was negatively associated with psychosocial functioning. Adolescents who react to daily problems with depressive behavior reported low global self-esteem and high social anxiety. This may indicate that adolescents who react with depressive behavior do not cope effectively with stressful social situations. These results have also been found in healthy adolescents (Bijstra et al., 1994; Meijer, Sinnema, Bijstra, Mellenbergh, a Wolters, 2000). Some caution is warranted in the interpretation of our findings. First, due to the cross-sectional design the direction of the relationship between predictor variables and adjustment variables cannot be determined. How-
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ever, it is likely that the relationship between coping and psychosocial adjustment is not one-directional, but rather forms an interactional process (see Jorgensen a Dusek, 1990). A longitudinal design is needed to examine this hypothesis. Second, our results are based on self-report questionnaires with hypothetical reactions. There may be a discrepancy between the reported hypothetical reactions of the adolescents and their actual reactions. Using multiple informants or observational data to assess coping styles and psychosocial adjustment could enhance the validity of the results. However, valid observational methods for assessing social skills or coping are scarce. Finally, we have not specified a particular problem-situation in assessing coping behaviors of the adolescents, while the use of coping strategies may be situation-specific. However, we were primarily interested in the coping styles of adolescents, reflecting a stable pattern of coping with developmental tasks and daily problems. This approach is supported by studies that indicate that youths are relatively consistent in their coping behaviors across situations (see Compas, 1987; Schreurs et al., 1988). Our study has some clinical implications. With regard to coping factors, our study has provided evidence that the coping styles confrontation and seeking social support are related with positive psychosocial functioning. Stimulating the use of these functional coping styles may prevent developmental problems in psychosocial functioning. This may be especially important for adolescents who display depressive behavior in reaction to daily problems. They seem to have difficulties in coping effectively with stressful social situations, which make them vulnerable to developing psychosocial problems. The relationship between the coping style seeking social support and social skills also has implications for preventive intervention. The relevance of social support in psychosocial adjustment has been demonstrated in several studies (e.g. La Greca et al., 1995; Sherbourne, Meredith, Rogers, a Ware, 1992; Wallander a Varni, 1989), indicating that seeking social support may be effective in reducing general and illness-related stress. This coping style can be stimulated by training adequate social skills: in the interactional relationship between social skills and seeking social support, social skills are the most modifiable aspect (see also Katz a Varni, 1993). In conclusion, our study has given more insight into the relative contribution of stress-processing factors to specific aspects of psychological and social functioning in chronically ill adolescents. In addition, the results underline the relevance of including social aspects of adjustment in studies of stress-processing factors. This might be a useful starting point for developing preventive interventions for adolescents with a chronic illness.
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Grey, M., Cameron, M. E., a Thurber, F. W. (1991). Coping and adaptation in children with diabetes. Nursing Research, 40, 144–149. Harter, S. (1988). Manual for the self-perception profile for adolescents. Denver: University of Denver. Jacobson, A. M., Hauser, S. T., Lavori, P., Wolfsdorf, J. I., Herskowitz, R. D., Milley, J. E., Bliss, R., Gelfand, E., Wertlieb, D., a Stein, J. (1990). Adherence among children and adolescents with insulin-dependent diabetes mellitus over a four-year longitudinal follow-up: I. The influence of patient coping and adjustment. Journal of Pediatric Psychology, 15, 511–526. Jorgensen, R. S., a Dusek, J. B. (1990). Adolescent adjstment and coping strategies. Journal of Personality, 58, 503–513. Katz, E. R., a Varni, J. W. (1993). Social support and social cognitive problem-solving in children with newly diagnosed cancer. Cancer, 71, 3314–3319. La Greca, A. M., Auslander, W. F., Greco, P., Spetter, D., Fisher Jr., E. B., a Santiago, J. V. (1995). I get by with a little help from my family and friends: Adolescents support for diabetic care. Journal of Pediatric Psychology, 20, 449–476. Lavigne, J. V., a Faier-Routman, J. (1992). Psychological adjustment to pediatric physical disorders: A metaanalytic review. Journal of Pediatric Psychology, 17, 133–157. Lavigne, J. V., a Faier-Routman, J. (1993). Correlates of psychological adjustment to pediatric physical disorders: A meta-analytic review and comparison with existing models. Developmental and Behavioral Pediatrics, 14, 117–123. Matson, J. L., Esveldt-Dawson, K., a Kazdin, A. E. (1983). Validation of methods for assessing social skills in children. Journal of Clinical Child Psychology, 12, 174–180. Matson, J. L., Macklin, F., a Helsel, W. J. (1985). Psychometric properties of the Matson evaluation of social skills with youngsters (MESSY) with emotional problems and self-concept in deaf children. Journal of Behavioral Therapy and Experimental Psychiatry, 16, 117–123. Matson, J. L., Rotatori, A. F., a Helsel, W. J. (1983). Development of a rating scale to measure social skills in children: The Matson evaluation of social skills with youngsters (MESSY). Behaviour Research and Therapy, 21, 335–340. Meijer, S. A., Sinnema, G., Bijstra, J. O., Mellenbergh, G. J., a Wolters, W. H. G. (2000). Peer interaction in adolescents with a chronic illness. Personality and Individual Differences, 29, 799–813. Miles, A., Sawyer, M., a Kennedy, D. (1995). A preliminary study of factors that influence children’s sense of competence to manage their asthma. Journal of Asthma, 32, 437–444. Nowicki, S., a Strickland, B. R. A. (1973). A locus of control scale for children. Journal of Consulting and Clinical Psychology, 40, 148–154. Pless, I. B., a Perrin, J. M. (1985). Issues common to a variety of illnesses. In N. Hobbs, a J. M. Perrin (Eds.), Issues in the care of children with chronic illness (pp. 41–60). San Francisco: Jossey-Bass. Reid, G. J., Dubow, E. F., a Carey, T. C. (1995). Developmental and situational differences in coping among
S.A. Meijer et al. / Social Science a Medicine 54 (2002) 1453–1461 children and adolescents with diabetes. Journal of Applied Developmental Psychology, 16, 529–554. Ryan-Wenger, N. (1996). Children, coping, and the stress of illness: A synthesis of the research. Journal of the Society of Pediatric Nursing, 1, 127–138. Schreurs, P. J. G., van de Willige, G., Tellegen, B., a Brosschot, J. F. (1988). De Utrechtse Coping Lijst: UCL-handleiding (The Utrecht coping list: Manual of the UCL). Lisse, Netherlands: Swets a Zeitlinger. Seaman, M. A., Levin, I. R., a Serlin, R. C. (1991). New developments in pairwise multiple comparisons. Some powerful and practicable procedures. Psychological Bulletin, 110, 577–586. Sherbourne, C. D., Meredith, L. S., Rogers, W., a Ware Jr., J. E. (1992). Social support and stressful life events: Age differences in their effects on health-related quality of life among the chronically ill. Quality of Life Research, 1, 235–246. Siefert, K., Wittman, D., Farquar, S., a Talsma, F. (1992). Similarities and differences between children with asthma and children with cancer: implications for preventive intervention. The Journal of Primary Prevention, 13, 149–159. Spence, S. H., a Liddle, B. (1990). Self-report measures of social competence for children: an evaluation of the Matson evaluation of social skills for youngsters and the list of social situation problems. Behavioral Assessment, 12, 317–336. Spirito, A., Stark, L. J., Williams, C., Stamonlis, D., a Alexan, D. (1988). Coping strategies utilized by referred and nonreferred pediatric patients and a healthy control group. Poster presented at the Society of Behavioural Medicine Annual Meeting, Boston, MA.
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Stein, R. E. K., a Jessop, D. J. (1982). A noncategorical approach to chronic childhood illness. Public Health Reports, 97, 354–362. Stein, R. E. K., a Jessop, D. J. (1989). What diagnosis does not tell: The case for a non-categorical approach to chronic illness in childhood. Social Science and Medicine, 29, 769–778. Steinhausen, H., Schindler, H., a Stephan, H. (1983). Correlates of psychopathology in sick children: An empirical model. Journal of the American Academy of Child Psychiatry, 22, 559–564. Straathof, M. A. E., a Treffers, Ph. D. A. (1988). Vertaling van de competentiebelevings-schaal voor adolescenten [Translation of the perceived competence scale for adolescents]. Oegstgeest, Netherlands: Academic Center of Psychiatry for Children and Youth Curium (in Dutch). van Broeck, N. (1986). Informatieverwerking en symptoomrapportage (Information processing and symptom-report). Thesis. Gent: University of Gent. Verhulst, F. C., van der Ende, J., a Koot, J. M. (1996). Handleiding voor de CBCL/4–18. (Manual for the CBCL/4– 18). Rotterdam, Netherlands: Department of Child Psychiatry, Sophia Childrens Hospital/Academic Hospital Rotterdam/Erasmus University Rotterdam. Wallander, J. L., a Varni, J. W. (1989). Social support and adjustment in chronically ill and handicapped children. American Journal of Community Psychology, 17, 185–201. Wallander, J. L., Varni, J. W., Babani, L. V., Banis, H. T., a Wilcox, K. T. (1989). Family resources as resistance factors for psychological maladjustment in chronically ill and handicapped children. Journal of Pediatric Psychology, 14, 157–173.
Coping styles and locus of control as predictors for psychological adjustment of adolescents with a chronic illness Susan A. Meijera,*, Gerben Sinnemaa, Jan O. Bijstrab, Gideon J. Mellenberghc, Wim H.G. Woltersa a
Department of Pediatric Psychology, The Wilhelmina Children’s Hospital, University Medical Center Utrecht, (KA.00.004.0), P.O. Box 85090, 3508 AB Utrecht, The Netherlands b Department of Developmental Psychology, Groningen University, The Netherlands c Department of Psychological Methods, University of Amsterdam, The Netherlands
Abstract This study examines the way coping styles and locus of control contribute to the prediction of psychosocial adjustment in adolescents with a chronic illness. Psychosocial adjustment of 84 adolescents aged 13–16 years with a chronic illness was assessed with measures of social adjustment, global self-esteem and behavior problems. Linear regressions were performed with demographic factors (age and gender) and stress-processing factors (coping style and locus of control) as predictor variables. Results indicated that coping styles were related to most aspects of social adjustment. The coping styles ‘seeking social support’ and ‘confrontation’ were important predictors for positive social adjustment; the coping style ‘depression’ was a predictor for poor adjustment, viz. low social self-esteem and high social anxiety. Avoidance and locus of control were not strongly associated with psychosocial adjustment. Clinical implications of these findings were discussed in terms of preventive interventions for adolescents with a chronic illness. r 2002 Elsevier Science Ltd. All rights reserved. Keywords: Adolescence; Coping style; Chronic illness; Chronic behavior checklist; Social skills; Netherlands
Introduction A chronic illness may interfere with the developmental tasks of adolescents by making them more vulnerable to psychological and social problems (e.g. Gortmaker, Walker, Weitzman, a Sobol, 1990; Lavigne a FaierRoutman, 1992). However, there is wide variation in the psychosocial functioning of adolescents with a chronic illness (Lavigne a Faier-Routman, 1993). The majority of these adolescents function quite well, but a substantial subgroup develop clinically significant psychological or social problems. Several models have been developed to identify factors that contribute to this variation (e.g. Garmezy, Masten, a Tellegen, 1984; Pless a Perrin, 1985; Stein a Jessop, 1982). Wallander, *Corresponding author. Tel.: +31-30-2504111; fax: +31-302505325. E-mail address: [email protected] (S.A. Meijer).
Varni, Babani, Banis, and Wilcox (1989), who put mediating factors in psychosocial adjustment in a riskresistance framework elaborated one of the most detailed models. They identified disease/disability parameters, functional dependence and psychosocial stressors as risk factors, while resistance factors included intrapersonal factors (e.g. temperament, problem solving ability), social-ecological factors (e.g. family environment, family members’ adaptation, social support), and stress processing factors (cognitive appraisal and coping strategies). Resistance factors are thought to moderate the negative effects of risk factors on psychosocial adjustment besides their direct relation with psychosocial adjustment. Therefore, resistance factors are key parameters in preventing adjustment problems of chronically ill adolescents. This is confirmed in a meta-analysis carried out by Lavigne and Faier-Routman (1993), who found that resistance factors such as family/parent or
0277-9536/02/$ - see front matter r 2002 Elsevier Science Ltd. All rights reserved. PII: S 0 2 7 7 - 9 5 3 6 ( 0 1 ) 0 0 1 2 7 - 7
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child measures were stronger predictors in relation to child adjustment than disease/disability parameters were. As identified in the model of Wallander et al. (1989), increasing attention is being paid to the relationship between stress-processing factors and the psychosocial adjustment of children and adolescents with a chronic disease. Lavigne and Faier-Routman (1993) illustrated the importance of coping as a mediating factor by reporting relatively high correlations between coping and adjustment. The mediating effect may vary between coping strategies. This was demonstrated by Spirito, Stark, Williams, Stamonlis, and Alexan (1988), who found that children with a chronic disease who were referred for adjustment problems used coping strategies that differed from those of children with a chronic disease and no apparent adjustment problems. Children with adjustment problems were more likely to use social withdrawal and wishful thinking than children without apparent adjustment problems were. Within this context, researchers have discussed categories of coping strategies that reflect effective coping. People with effective coping styles generally deal directly with the stressor by using active coping strategies. For example, Jorgensen and Dusek (1990) demonstrated in a healthy sample that optimally adjusted adolescents exhibited a higher percentage of active coping efforts (i.e. making decisions, seeking social support, and talking about problems with friends) than psychosocially less adjusted peers. Active coping is also associated with better illnessrelated adjustment (Gil, Williams, Thompson, a Kinney, 1991; Grey, Cameron, a Thurber, 1991). Avoidance or depressive coping behaviors characterizes people with less effective coping styles. Frank, Blount, and Brown (1997) found that avoidance coping and depressive attitudes predicted the risk for adjustment difficulties, that is depression and anxiety, in children with cancer. Likewise, Grey et al. found that avoidance was correlated with worse adjustment in children and adolescents with diabetes mellitus. In sum, the results of studies of coping in pediatric populations generally have favored the efficacy of more active efforts over more passive coping. In addition to coping strategies, the appraisal of stress is a stress-processing factor that mediates between risk factors and adjustment. Specifically, expectations of control over one’s environmentFthe locus of control (LOC)Fseem to be a mediator in adaptation. Research suggests that persons with an internal LOC are better adjusted than persons with an external LOC are (e.g. Benson a Deeter, 1992; Steinhausen, Schindler, a Stephan, 1983). Also, an internal LOC seems to be predictive for illness-related adjustment (e.g. Jacobson et al., 1990; Miles, Sawyer, a Kennedy, 1995). Although relevant research has been done with regard to coping and LOC as resistance factors in relation to
psychosocial adjustment, several methodological problems limit the conclusions of these investigations. First, research specifically pertaining to adolescents is scarce. In most studies, results are presented for a group of children and adolescents with a broad age-range. Consequently, developmental differences in cognitive appraisal and in the use of coping strategies are masked. These stress-processing factors develop with age: coping strategies of children differ from coping strategies of adolescents (Carlson, Ricci, a Shade-Zeldow, 1990; Compas, Malcarne, a Fondacaro, 1988; Reid, Dubow, a Carey, 1995). Second, as far as we know, social adjustment has been outside the scope of most studies regarding resistance factors in chronically ill adolescents. Usually, psychological maladjustment factors such as behavior problems or depression are studied, but social maladjustment factors, such as social anxiety or social skills, have been rarely included. Finally, literature on coping in chronic illness focuses mainly on coping with illness-specific situations. Less attention has been given to the general coping styles of chronically ill adolescents. General coping styles may be more predictive for the psychosocial development of chronically ill adolescents than illness-related coping, because these styles reflect how the adolescents cope with developmental tasks. Moreover, ‘‘no current research suggests that children cope differently with illnessrelated stressors than with general stressors’’ (cited from Ryan-Wenger, 1996). Therefore, the purpose of this study is to examine the contribution of two relevant resistance factors in the prediction of psychological and social adjustment of chronically ill adolescents: coping styles and LOC. The age-range is restricted to 13–16 years. In addition to psychological functioning variables, i.e. behavior problems and global self-esteem, we included several social adjustment variables: social activities, social self-esteem, social anxiety, and social skills. Adolescents with a variety of chronic conditions were included in the current study. Generally, investigators have failed to find an association of psychosocial functioning with diagnosis; the chronicity of the condition appears to be the common factor associated with psychosocial maladjustment (Siefert, Wittman, Farquar, a Talsma, 1992; Stein a Jessop, 1989; Wallander et al., 1989).
Method Participants All adolescents who were under medical care of the Wilhelmina Children’s Hospital for a chronic physical condition and who met our inclusion criteria, be described elsewhere in this section, were
S.A. Meijer et al. / Social Science a Medicine 54 (2002) 1453–1461 Table 1 Descriptive statistics for predictor and adjustment variables
Predictor variables Demographic factors Gender Boys Girls Age Stress-processing factors Confrontation Seeking social support Depression Avoidance Locus of control Adjustment variables Social adjustment Social activities Social self-esteem Social skills Adequate skills Inadequate skills Assertive behavior Social anxiety Global self-esteem Behavior problems Internalizing Externalizing Total
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Procedure
n
Mean
SD
37 47 84
14.5
1.2
83 83 83 83 84
15.8 12.7 11.9 17.0 28.4
3.4 3.5 3.1 3.8 4.6
82 83
5.7 44.4
1.6 6.7
84 84 84 84 83
64.4 34.0 149.5 75.3 15.0
6.8 6.5 23.2 18.2 3.3
83 83 83
7.1 6.7 21.2
6.2 7.0 17.4
approached to participate in our study. A group of 124 adolescents and their parents got a letter about our study and were asked to participate. Within 2–4 weeks, we phoned to ask their reaction. Six families could not be traced, and 34 families did not want to participate. The main reasons for non-participation were lack of interest (48%), lack of time (30%), or unwillingness to be confronted with the disease more than necessary (8%). Four adolescents with serious psychosocial problems (serious psychopathology or family problems, for which they received psychological treatment at the time of our study) were excluded to avoid overburdening them. Data were collected for 84 adolescents, which indicates a participation rate of 68%. Inclusion criteria were: age between 13 and 16 years, sufficient command of the Dutch language, and diagnosed at least 1 year prior with one of the following chronic physical conditions: asthma (n ¼ 31), cystic fibrosis (CF; n ¼ 23), constitutional eczema (CE; n ¼ 15), or juvenile chronic arthritis (JCA; n ¼ 15). Mean age was 14.5 years, SD 1.2 (Table 1). The group consisted of 37 boys and 47 girls. Mean illness duration since diagnosis was 11.2 years (SD 4.6).
Data were gathered using parent-reported and childreported questionnaires. In addition, the parents were administered a short interview concerning demographic information (nationality, family composition, education of their children and themselves), the social functioning of their children, disease-related aspects (duration of the disease, age of onset/diagnosis, number of hospitalizations, school absence), and information about the use of mental health care. In nearly all cases (95%), the mother was the informant. Data were collected as part of a research project concerning the psychosocial functioning of children and adolescents with a chronic illness. Participation in this project implied that the participants filled in a series of questionnaires. The adolescents and their parents came to the hospital and filled in questionnaires simultaneously but separately. It took about 2 h to fill in the questionnaires and to finish the interview. Most adolescents completed the questionnaires by themselves, but if they had any questions, they could ask the skilled interviewer, who was present during the entire session. The Research and Ethics Committee of the University Hospital for Children and Youth approved the protocol of the study. All adolescents and their parents gave informed consent. Materials Predictor variables Coping styles were measured with the Utrecht Coping List for Adolescents: UCL-A (Bijstra, Jackson, a Bosma, 1994). This self-report questionnaire was originally developed for adults (Schreurs, van de Willige, Tellegen, a Brosschot, 1988), but it has been adapted for adolescents. Adolescents indicate on forty seven 4point scale items how they would react when they are confronted with a problem (e.g. ‘‘I wait for better times’’, or ‘‘I ask somebody for help’’). The UCL-A measures seven behavioral coping styles, of which we used four in this study: ‘confrontation’ and ‘seeking social support’ were selected to represent active coping, while avoidance and depressive reactions were selected to represent passive coping. Bijstra et al. (1994) reported internal consistencies of 0.77 (confrontation), 0.81 (seeking social support), 0.68 (avoidance), and 0.63 (depressive reactions), while Cronbach’s alphas in our study are 0.75, 0.81, 0.75, and 0.67, respectively. LOC was measured with the Nowicki–Strickland internal and external locus of control scale: LOC (Nowicki a Strickland, 1973; van Broeck, 1986). It is a self-report questionnaire which uses forty yes/no items to measure the degree to which adolescents attribute the course of events to their own actions instead of attributing it to external causes (e.g., ‘‘When people
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are unfriendly to you, do you think that this is without any reason?’’). A high score indicates a high internal LOC. Psychometric properties of the LOC have not been determined for a Dutch population, but the reliability of the scale for adolescents within this study was sufficient with a KR-20 of 0.72. Psychosocial adjustment variables Social activities were assessed with a subscale of the child behavior check list, completed by the parents: CBCL (Achenbach, 1991; Verhulst, van der Ende, a Koot, 1996). The social competence section consists of twenty questions subdivided into three categories: recreational activities, social activities and school competence. Of the social competence section, only the category social activities was used in the present study. This scale measures adolescents’ behavior with friends, siblings, and adults. A high score on the social activities scale means that the adolescent is actively involved in social contacts. The test-retest correlation of the social activities scale of the Dutch version is 0.79 (Verhulst et al., 1996). Social and global self-esteem were measured with the self perception profile for adolescents (SPPA, Harter, 1988; Straathof a Treffers, 1988). The scale measures with forty 4-point scale items how adolescents perceive their own functioning in eight relevant domains. In this study, we used the global self-esteem subscale (e.g. ‘‘Some youngsters are happy with themselves’’), and a combination of three social subscales (peer friendships, romantic friendships and social acceptance). A high score on the social subscales means that the adolescents perceive themselves as being accepted by their peers (e.g. ‘‘Some adolescents feel they are accepted by many peers’’). The factor structure of the Dutch version of the SPPA differed from the original version in that the three social scales did not form three separate factors (Straathof a Treffers, 1988). Therefore, we decided to combine them into one social scale after we had confirmed that the scores on these scales were significantly correlated (Pearson r varied from 0.44 to 0.59, po0:01). The internal consistency of the three separate subscales is good: Cronbach’s alpha for ‘peer friendships’ and for ‘romantic friendships’ is 0.76, and for ‘social acceptance’ 0.81; the internal consistency of the combined social scale in this study is 0.86. The internal consistency of the global self-esteem scale is 0.84 (Straathof a Treffers, 1988). In our study, this was 0.86. Social anxiety of the adolescents was measured by means of a Dutch self-report questionnaire (Bijstra a Oostra, 1995), originally developed for adults, called the scale of interpersonal behavior for adolescents (SIG-A, Arrindell, De Groot, a Walburg, 1984; Arrindell, Sanderman, a Ranchor, 1990). The items on the SIGA consist of 47 social situations that are evaluated by the adolescents on two dimensions. First, they judge on a 4-
point scale how much anxiety they experience in a particular situation (e.g. ‘‘give an opinion that is different from the opinion of the person you are talking with’’), and second, they judge on a 5-point scale how frequently they find themselves in that particular situation. There is a total score for social anxiety and a total score for frequency of assertive behavior. Cronbach’s alphas for both the social anxiety dimension and the assertive behavior dimension are high at 0.96 and 0.95, respectively (Bijstra a Oostra). In our study this was 0.95 and 0.93, respectively. Social skills of the adolescents were assessed with two self-reports. First, the frequency scores of the SIG-A were used to indicate assertive behavior (for a description of this questionnaire we refer to the section ‘social anxiety’). Second, adolescents reported their social skills on the Matson Evaluation of Social Skills with youngsters (MESSY, Matson, Rotatori, a Helsel, 1983; Blonk, Prins, a Sergeant, 1993). The MESSY consists of 62 5-point scale items, measuring the frequency of two types of behavior in a range of social situations, viz. adequate social skills and inadequate social skills. A high score on ‘adequate social skills’ means that the adolescents report to react with positive/friendly behavior in social situations (e.g. ‘‘I join other youngsters to talk with them’’); a high score on ‘inadequate social skills means that the adolescents report to react with aggressive behavior in social situations (e.g. ‘‘I pick on other youngsters to make them angry’’). Answers are ranging from ‘never’ to ‘always’. The internal consistency of the Dutch version is good with Cronbach’s alpha for adequate social skills 0.81, and for inadequate social skills 0.82. In our study, this was 0.83 and 0.79, respectively. The original American version also has good psychometric properties (Matson, Macklin, a Helsel, 1985; Matson et al., 1983; Spence a Liddle, 1990), and correlated well with other measures of social skills, such as direct observations of the child’s social behavior and a teacher nomination measure of social competence (Matson, Esveldt-Dawson, a Kazdin, 1983) Behavior problems were assessed with the CBCL (Verhulst et al., 1996). Mothers (and in a few cases the father) rated the severity of each symptom as expressed by their child on a 113-item behavior problem scale, with internalizing and externalizing symptomatology, and a total score of behavior problems. The CBCL has been used in a wide range of studies, and has good psychometric properties. The 3–4 week test-retest correlation of the Dutch version was 0.84 for the internalizing problem scale, 0.78 for the externalizing scale, and 0.84 for the total problem score (Verhulst et al., 1996). Data analysis In a preliminary analysis we investigated our premise that diagnosis is not associated with psychosocial
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S.A. Meijer et al. / Social Science a Medicine 54 (2002) 1453–1461 Table 2 Correlations between predictor variables and adjustment variables
Social activities Social self-esteem Adequate skills Inadequate skills Assertive behavior Social anxiety Global self-esteem Internalizing pr. Externalizing pr. Total behavior pr. a b
Confrontation
Social support
Depression
Avoidance
Locus of control
0.09 0.35a 0.40a –0.21 0.33a –0.28b 0.10 –0.22b –0.21 –0.16
–0.03 0.15 0.44a 0.08 0.35a 0.08 –0.12 –0.02 0.20 0.10
–0.09 –0.18 0.11 0.24b 0.11 0.39a –0.49a 0.21 0.15 0.18
0.07 –0.22 0.00 0.20 0.11 0.21 –0.09 –0.15 –0.24b –0.18
–0.07 0.02 0.00 –0.20 0.08 –0.04 0.13 –0.18 –0.26b –0.30a
po0:01. po0:05.
adjustment. This was done by adding three of the four diagnosis groups (CF, JCA, CE, and asthma) as dummy-variables in the regression analysis, and by comparing these results with regression analyses that were conducted without diagnosis as predictor. The correlations between the variables were computed. The correlations between the stress-processing variables and the adjustment variables are reported in Table 2. To study the contribution of the five stress-processing variables (confrontation, depressive reactions, seeking social support, avoidance, and LOC) to the prediction of adjustment, two regression models were specified per adjustment variable: (1) the regression of the adjustment variable on age (in years), gender (dichotomous variable), and the block of five stress-processing variables (full regression model), and (2) the regression of the adjustment variable on only age and gender. The block of five stress-processing variables does not contribute to the prediction of an adjustment variable if the explained variance (R2) of the full and restricted regression models is equal to each other. Therefore, the null hypothesis that the difference in R2 between full and restricted regression models is 0 was tested for each of the ten adjustment variables at the 5% significance level. The power of this test for the situation of 82 patients is about 0.75 and 0.99 for medium and large effect sizes, respectively (Cohen, 1988, Chapter 9). The null hypothesis was tested for each of the ten adjustment variables. If each of a number of true null hypotheses is tested at the 5% significance level, it is expected that 5% of these true null hypotheses will be rejected. Multivariate statistical tests can be used to prevent this type of chance capitalization. A number of well-known multivariate tests, such as MANOVA, make strong assumptions on the distribution of the variables, whereas other tests, such as the Bonferroni-Holm (Bonferroni) procedure (Seaman, Levin, a Serlin, 1991) make less
stringent assumptions. Therefore, the Bonferroni procedure was preferred above MANOVA for simultaneously testing the ten null hypotheses (one per adjustment variable) of no difference in R2 between full and restricted regression models. A null hypothesis, which was rejected by the Bonferroni procedure, was interpreted. A null hypothesis, which was rejected by the univariate test, but was not rejected by the Bonferroni procedure, was considered to be an interesting result that should be replicated in a new study before it can be interpreted. To study the contribution of each of the five stressprocessing variables separately, the standardized regression (beta-) coefficients were used. The null hypothesis that a beta-coefficient is 0 was tested at the 5% significance level per stress-processing variable within the full regression model of each of the ten adjustment variables. The power of this test for the situation of 82 patients is above 0.92 and 0.99 for medium and large effect sizes, respectively (Cohen, 1988, Chapter 9). The null hypothesis was tested ten times (one test for each of the ten adjustment variables) per stress-processing variables. To prevent chance capitalization the Bonferroni procedure was applied to the ten tests per stressprocessing variables.
Results Preliminary analyses Comparison of regression analyses with and without diagnoses showed that the inclusion of diagnosis as dummy variables did not affect the interpretation of our results, that is, it did not affect the predictive value of the stress-processing variables for psychosocial adjustment. Therefore, subsequent analyses collapse across diagnostic group.
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Full regression model Together, age, gender, and stress-processing factors predicted most aspects of psychosocial adjustment (Table 3). Except for social activities, the model significantly explained all social adjustment variables. The model also predicted global self-esteem and externalizing behavior problems. The explained variance of internalizing behavior problems was univariately significant, but not with
Table 3 R2 statistics for the blocked stepwise regression analysesa
Social adjustment Social activities Social self-esteem Social skills Adequate skills Inadequate skills Assertive behavior Social anxiety Global self-esteem Behavior problems Internalizing Externalizing Total
R2 full modelb
Decrease in R2 R2 age+ stress-processingc genderd
0.10 0.27**
0.05 0.19**
0.05 0.09*
0.35** 0.22** 0.25** 0.27** 0.25**
0.25** 0.15* 0.19** 0.24** 0.25**
0.11* 0.07 0.06 0.03 0.00
0.18* 0.24** 0.17
0.15* 0.22** 0.17*
0.03 0.03 0.00
Note: *po0:05; ** p significant with Bonferroni o0.05. R2 for full model (age+gender+coping); df=7, 74. c Decrease in R2 after removal of ‘coping’; df=5, 76. d Remaining R2 for age and gender; df=2, 79. a
b
Bonferroni correction. Social activities and total behavior problems could not be predicted with the predictor variables used in this model.
Stress-processing factors Stress-processing factors contributed significantly to the prediction of social self-esteem, adequate social skills, assertive behavior, social anxiety, global selfesteem, and externalizing behavior problems (Table 3). The decrease in R2 after removal of the block stressprocessing factors was 25% for adequate social skills and global self-esteem, 24% for social anxiety, 22% for externalizing behavior problems, and 19% for social self-esteem and assertive behavior, respectively. The decrease in R2 was univariately significant for total behavior problems, internalizing behavior problems, and inadequate social skills (17%, 15%, and 15%, respectively), but it was not significant with Bonferroni correction. Stress-processing factors did not contribute to the prediction of social activities. Inspection of the Beta-coefficients within the block stress-processing factors in Table 4 showed that the coping style confrontation was an important predictor for social adjustment (std. Beta=0.36 for adequate skills), followed by seeking social support (std. beta=0.37 for adequate skills). Confrontation was also univariately related to social anxiety and assertive behavior, while seeking social support was also univariately related to assertive behavior. Depression was a significant predictor for global self-esteem (std. Beta=– 0.50) and social anxiety (std. Beta=0.37), and it was
Table 4 Standardized Beta coefficients of stress-processing factors
Social adjustment Social activities Social self-esteem Social skills Adequate skills Inadequate skills Assertive behavior Social anxiety Global self-esteem Behavior problems Internalizing Externalizing Total a b
Stress-processing factors Confrontation Social support
Depression
Avoidance
Locus of control
F 0.33a
F F
F F
F F
F F
0.36a F 0.28b –0.29b F
0.37a F 0.31b F F
F F F 0.37a –0.50a
F F F F F
F F F F F
F F F
F F F
0.27b F F
–0.23b –0.23b F
F –0.23b –0.26b
p significant with Bonferroni o0.05. po0:05.
S.A. Meijer et al. / Social Science a Medicine 54 (2002) 1453–1461
univariately related to internalizing behavior problems. Avoidance was not a strong predictor for psychosocial adjustment, but it did have a univariate relationship with internalizing and externalizing behavior problems. LOC was also not a strong predictor; it was only univariately related to total behavior problems and externalizing behavior problems.
Discussion In this study, psychosocial functioning of chronically ill adolescents was significantly related to stress-processing factors. Coping styles were significantly associated with social adjustment, global self-esteem and externalizing behavior problems. The coping style confrontation, characterized by active and purposeful problem-solving, seems to be the most important determinant for positive psychosocial functioning, as reflected in this study by a high social self-esteem, the use of adequate social skills, and, to a lesser extent, the absence of anxiety in social situations and the use of assertive behavior. These findings are in line with results regarding healthy adolescents (Bijstra, Bosma, a Jackson, 1994), and support the hypothesis that confrontation is an effective behavioral coping style. The coping style seeking social support also seems to be effective, but only in relation to social skills. Adolescents who discuss their daily problems with others use adequate social skills more frequently and tend to display more assertive behavior than adolescents who are less inclined to seek social support. The relationship between seeking social support and social skills is probably bi-directional. On one hand, seeking social support may stimulate the development of social skills. On the other hand, adolescents who have adequate social skills and who are assertive may be more inclined to seek social support. If a bi-directional relationship exists, it may be possible to teach adolescents the social skills that facilitate seeking social support. A depressive reaction pattern was negatively associated with psychosocial functioning. Adolescents who react to daily problems with depressive behavior reported low global self-esteem and high social anxiety. This may indicate that adolescents who react with depressive behavior do not cope effectively with stressful social situations. These results have also been found in healthy adolescents (Bijstra et al., 1994; Meijer, Sinnema, Bijstra, Mellenbergh, a Wolters, 2000). Some caution is warranted in the interpretation of our findings. First, due to the cross-sectional design the direction of the relationship between predictor variables and adjustment variables cannot be determined. How-
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ever, it is likely that the relationship between coping and psychosocial adjustment is not one-directional, but rather forms an interactional process (see Jorgensen a Dusek, 1990). A longitudinal design is needed to examine this hypothesis. Second, our results are based on self-report questionnaires with hypothetical reactions. There may be a discrepancy between the reported hypothetical reactions of the adolescents and their actual reactions. Using multiple informants or observational data to assess coping styles and psychosocial adjustment could enhance the validity of the results. However, valid observational methods for assessing social skills or coping are scarce. Finally, we have not specified a particular problem-situation in assessing coping behaviors of the adolescents, while the use of coping strategies may be situation-specific. However, we were primarily interested in the coping styles of adolescents, reflecting a stable pattern of coping with developmental tasks and daily problems. This approach is supported by studies that indicate that youths are relatively consistent in their coping behaviors across situations (see Compas, 1987; Schreurs et al., 1988). Our study has some clinical implications. With regard to coping factors, our study has provided evidence that the coping styles confrontation and seeking social support are related with positive psychosocial functioning. Stimulating the use of these functional coping styles may prevent developmental problems in psychosocial functioning. This may be especially important for adolescents who display depressive behavior in reaction to daily problems. They seem to have difficulties in coping effectively with stressful social situations, which make them vulnerable to developing psychosocial problems. The relationship between the coping style seeking social support and social skills also has implications for preventive intervention. The relevance of social support in psychosocial adjustment has been demonstrated in several studies (e.g. La Greca et al., 1995; Sherbourne, Meredith, Rogers, a Ware, 1992; Wallander a Varni, 1989), indicating that seeking social support may be effective in reducing general and illness-related stress. This coping style can be stimulated by training adequate social skills: in the interactional relationship between social skills and seeking social support, social skills are the most modifiable aspect (see also Katz a Varni, 1993). In conclusion, our study has given more insight into the relative contribution of stress-processing factors to specific aspects of psychological and social functioning in chronically ill adolescents. In addition, the results underline the relevance of including social aspects of adjustment in studies of stress-processing factors. This might be a useful starting point for developing preventive interventions for adolescents with a chronic illness.
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