Development and testing of the school competency assessment scale

Development and Testing of the School Competency Assessment Scale Julia Challinor, PhD, RN, Ida (Ki) Moore, DNS, RN, Robin Kramer, MSN, RN, PNP, Alice Pasvogel, PhD, RN, Kenneth Leung, MD, Michael Amylon, MD, John Hutter, MD, and Katherine Matthay, MD

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n the United States each year, approximately 12,400 children and adolescents younger than 20 years of age are diagnosed with cancer; 31% of these children have acute lymphoblastic leukemia (ALL), the most common pediatric tumor (Ries et al., 1999). Treatment for ALL ranges from 2.5 to 3 years, with treatment intensity determined by the specific leukemia subtype and treatment protocol. The brain is considered a sanctuary site for leukemia cells; therefore, central nervous system (CNS) treatment is essential to prevent CNS relapse. Children who receive treatment for ALL are expected to return to school as soon as their health status is stable. Academic and social success in school is challenging for the majority of children with cancer, especially those who receive CNS treatment with chemotherapy or cranial radiation. During the first year of therapy, school absenteeism and having academic difficulties after CNS treatment have been documented in a number of studies of children previously treated for cancer (Anderson, Smibert, Ekert, & Godber, 1994; Armstrong, Blumberg, & Toledano, 1999; Brown & Madan-Swain, 1993; Brown et al., 1996; Challinor, Miaskowski, Moore, Slaughter & Franck, 2000; Copeland, Moore, Francis, Jaffe, & Culbert, 1996; McCarthy, Williams, & Plumer, 1998; Moore, et al., 2000;

Raymond-Speden, Tripp, Lawrence, & Holdaway, 2000; Smibert, Anderson, Godber, Ekert, 1996; Waber, et al., 1995). Despite numerous reports of school problems experienced by long-term survivors of childhood cancer, information of a comprehensive assessment of a child’s risk and protective factors for school problems is lacking. This information is essential to the development of intervention strategies designed to improve academic abilities and school competency among children with cancer. Sophisticated neuropsychologic instruments are used to characterize specific cognitive and academic deficits in children with cancer, especially those who receive CNS treatment. Typically, a neuropsychologic evaluation is completed after a child has a history of poor school performance. Although neuropsychologic instruments are useful, they do not provide a comprehensive academic risk and protective factor profile of the child with cancer. The purpose of this study was to develop a School Competence Assessment Scale (SCAS) for children with cancer. This instrument is a systematic method for evaluating the child’s risk and protective factors for school problems, and can provide information essential for the development of appropriate individualized intervention strategies.

Theoretical Framework From the University of California San Francisco Division of Pediatric Oncology, San Francisco, CA; the University of Arizona Division of Pediatric Hematology/Oncology, Tucson, AZ; Kaiser Permanente, San Francisco, CA; and Stanford University School of Medicine; Stanford, CA. Reprints not available from the authors. © 2003 by Association of Pediatric Oncology Nurses 1043-4542/03/2002-0003$30.00/0 doi:10.1053/jpon.2003.80

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A theoretical framework describing risk and opportunity (protective) factors in the life of a child that may predict school problems (academic, social, and behavioral) guided the development of the assessment instrument. Risk factors defined as biologic and psychosocial threats that increase the likelihood of a maladaptive

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Development and Testing of the School Competency Assessment Scale

developmental outcome for the child (Garmezy, 1983; Hunter & Chandler, 1999; Ladd, Birch, & Buhs, 1999; Werner, 1985; Youngstrom & Izard, 1999). Opportunity or protective factors, on the other hand, are defined as characteristics that serve to modify or “ameliorate” risk factors (Garmezy, 1983; Rutter, 1992). An example of a protective factor is a high level of maternal emotional maturity and stability and maternal education (Pianta, Egeland, & Sroufe, 1992).

Cancer-related Risk and Protective Factors Cancer treatment that damages the CNS has been repeatedly implicated in a variety of cognitive and academic problems. The type of CNS treatment (e.g., intrathecal chemotherapy alone or in combination with cranial radiation, or systemic intermediate- or high-dose methotrexate), treatment intensity, and age at time of treatment have all been identified as risk factors for these problems (Brown et al., 1996; Challinor et al., 2000; Copeland et al., 1996; Fossen, Abrahamsen, & Storm-Mathisen, 1998; Hill et al., 1998; Kiltie, Lashgord, & Gattamaneni, 1997; Smibert, et al., 1996). Furthermore, the adverse effects of CNS therapies on cognitive and academic abilities often do not become evident until several years after treatment (Copeland, et al., 1996; Jankovic, et al., 1994; Mulhern, Armstrong, & Thompson, 1998; Roman & Sperduto, 1995). A high rate of school absenteeism is one of the most significant school problems children experience as a result of their cancer diagnosis (Armstrong & Mulhern, 1999; Brown & MadanSwain, 1993). Frequent hospitalizations or clinic visits for therapy and complications such as severe neutropenia, infection, and nausea contribute to school day absences. School absence, loss of intellectual ability, and emotional problems have been identified as risk factors that adversely influence school performance (Anderson, et al., 1994; Brown, et al., 1996; Frank, Blount, & Brown, 1997; Mulhern, et al., 1998). Several studies have reported that long-term survivors of childhood cancer experience a greater number of problems in social and behavioral competence than healthy children (Pendley, Dahlquist, & Dreyer, 1997; Sloper,

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Larcombe, & Charlton, 1994; Vannatta, Gartstein, Short, & Noll, 1998). These social and behavioral problems are important because interpersonal skills are critical to every child’s school success (Ladd, et al., 1999; Youngstrom & Izard, 1999). Self-esteem and supportive personal relationships have been noted as important protective factors (Hunter & Chandler, 1999; Rutter, 1992; U.S. Department of Education, 2000). Peers can be relied upon throughout life as “cognitive and emotional resources,” and for the development of social skills (Hartup & Moore, 1990, p.5). During the treatment phase of childhood cancer, many children receive extraordinary peer support from friends and classmates that may serve as a protective factor for behavioral and social problems.

Family Characteristic Risk and Protective Factors Family characteristics, such as socioeconomic index, mother’s education, and single parenting, have been identified as risk factors for cognitive abilities and school competence (Dubow & Luster, 1990; Dunst, 1993; Hunter & Chandler, 1999; Sinclair, 1993; U.S. Department of Education, 2000). A significant risk factor for problems with behavior and school achievement is having a mother who was less than 17 years old at the child’s birth (Dubow & Luster, 1990; U.S. Department of Education, 2001). Childhood cancer survivors with single parents were found to have a two-fold increase in school problems (Mulhern, Wasserman, Friedman, & Fairclough, 1989). A non-English primary language has been demonstrated to decrease knowledge and skills at school entry (U.S. Department of Education, 2000, p.61). Thus the specific aims of this study were to develop a SCAS and examine validity and reliability properties of the SCAS.

Design A cross-sectional descriptive design was used to evaluate the psychometric properties of the SCAS. Data were collected from 82 children receiving cancer treatment at three pediatric oncology treatment centers; data were also collected from parents and teachers. The majority

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of children were Caucasian (60.4%); other ethnic groups included Latino (27.1%), African American (2.1%), Asian (2.1%), Filipino (4.2%), and other (4.2%). The most common diagnosis was ALL (n ⫽ 77); other diagnoses included Hodgkin’s disease (n ⫽ 1), non-Hodgkin’s lymphoma (n ⫽ 2), Wilms’ tumor (n ⫽ 1), and rhabdomyosarcoma (n ⫽ 1). The mean age was 9 years, 11 months (range ⫽ 5 years, 2 months to 16 years, 0 months).

Instruments SCAS The SCAS was developed from pediatric oncology literature describing the previously identified risk factors associated with cancer treatment (i.e., type of CNS treatment, age at the time of CNS treatment), and from educational and psychologic literature describing risk and protective factors associated with developmental outcome and school competency. Items were developed to measure the child’s academic success and social competence. The SCAS includes a parent, teacher, and medical form with yes/no and Likert-type (i.e., forced choice) questions; space is provided for respondents to include comments. Each SCAS form can be completed in approximately 20 minutes. The parent is asked if the teacher has told him or her after the cancer diagnosis that the child is having difficulties in school with reading, math, spelling, or written language. The teacher is asked how the child compares with peers academically, how easily the child makes friends compared with other students in the class, gets along with peers, and compares with peers behaviorally. Other SCAS items measure family risk and protective factors including serious family problems in the past year, parental educational background, and neighborhood safety. The medical form includes items about the child’s cancer treatment, such as type and amount of CNS treatment; complications of CNS treatment (e.g., seizures, encephalopathy, somnolence syndrome); unusual or unexpected physical, emotional or mental health problems during treatment; and body image alterations (e.g., hair loss, amputation).

Deasy-Spinetta Behavioral Questionnaire The Deasy-Spinetta Behavioral Questionnaire (DSBQ) is a forced-choice questionnaire that measures subtle differences in attitude and behavior between children with cancer and other children of the same age and sex (Spinetta & Deasy-Spinetta, 1981). Scores for the total parent and teacher scales range from 0 to 74, with higher scores reflecting more positive behaviors or fewer school problems. The DSBQ has content validity based on extensive interviews and reviews from pediatric oncologists, nurses, parents, and teachers. In this study, the parent and teacher completed the DSBQ on the child with cancer for the purpose of determining construct validity of the SCAS. Behavioral Assessment System for Children The Behavioral Assessment System for Children (BASC) questionnaire is a set of scales that provides a comprehensive behavioral assessment of risk (Internalizing Problems, Externalizing Problems, and School Problems) and protective (Adaptive Skills) factors of children and adolescents (Reynolds & Kamphaus, 1992). The Aggression, Hyperactivity, and Conduct Problems scale scores are combined to form the Externalizing Composite score; and the Anxiety, Depression, and Somatization scale scores are combined to form the Internalizing Problems Composite score. Three different report forms of the BASC questionnaire are available (i.e., teacher form, parent form, and child/adolescent form). The teacher and parent forms include items regarding observations of negative and positive behavioral performance of children or adolescents. The child/adolescent self-report form (ages 8-18) solicits information regarding the child/ adolescent’s self-perception and emotional status. For the BASC scale, higher scores on scales that measure Internalizing Problems (e.g., anxiety, depression, atypicality), Externalizing Problems (e.g., aggression, conduct problems), and School Problems (e.g., attention problems, learning problems) represent negative or undesirable characteristics. However, higher scores on scales that measure personal adjustment or

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adaptive skills (e.g., adaptability, social skills, leadership) represent positive or desirable characteristics. The BASC questionnaire takes parents and teachers approximately 10 to 20 minutes to complete, and children 30 minutes to complete.

scores were correlated with the appropriate scale (or factors) and composite scores from the DSBQ and BASC to obtain an estimate of construct validity.

Procedures

Before using the SCAS with parents, children, and teachers, a panel of pediatric oncologists, pediatric oncology nurse specialists, parents of children with cancer, and teachers and child/ school psychologists with expertise in working with children with cancer reviewed the questionnaire. Minor revisions were made based on the panel’s critique and suggestions. The expert panel also reviewed the final version of the SCAS to establish content validity.

Institutional review board approval was obtained for human subject protection at each of the respective participating medical centers. The attending physician or clinical nurse specialist identified eligible children for the study. Parent and teacher consents were obtained from all adult participants and signed assents from children 7 years and older at University of Arizona. Parents were given instrument packets during routine clinic visits. The instrument packets included the parent and child BASC questionnaires and the parent forms of the DSBQ and SCAS. The completed forms were returned by self-addressed stamped envelope or hand-delivered by the family at the next clinic visit. A recruitment letter and instrument packets with the BASC, DSBQ, and SCAS questionnaires were mailed to the child’s identified teacher. The teacher returned to the clinic the completed questionnaires by self-addressed stamped envelope to ensure privacy of responses. The medical SCAS form was completed by a clinician familiar with the child and his or her family.

Data Analysis Descriptive statistics (mean, standard deviation, range) and frequencies were computed for sample demographic characteristics and for scale and total scores on the SCAS, DSBQ, and BASC questionnaires. Principal-Components Factor Analysis with Varimax Rotation was used to identify conceptual domains within the SCAS. Cronbach’s alpha was used to determine the reliability (internal consistency) of the SCAS scales. There are limited published data on the psychometric properties of the DSBQ. Therefore, factor analysis was also used to identify DSBQ scales, and Cronbach’s alpha was used to determine internal consistency of the scales, as well as the total instrument. Finally, SCAS scale

Results

SCAS Domains Items from the parent and teacher forms of the SCAS were analyzed and resulted in three domains. The domains were Educational Characteristics, Social Abilities, and the Family. Results of the analysis of the items of the medical form of the SCAS were not available for report at this time. Educational Characteristics Domain Factor analysis of the SCAS resulted in an Educational Characteristics Domain (15 items) and Social Abilities Domain (7 items). Examples of Educational Characteristics items include: (1) repeating a grade; (2) home schooling while being treated for cancer; (3) speech, hearing, motor skills, reading, math, or written language problems before diagnosis; (4) identified reading, math, spelling, or written language problems after diagnosis; (5) developing an Individualized Education Plan for the child; (6) attending special day classes; and (7) receiving special education services. Higher scores on these domains indicate more problems before or after the cancer diagnosis. Internal consistency for the 15 items was .82. Social Abilities Domain Example items in the Social Abilities Domain include: (1) makes friends easily; (2) gets along with peers; (3) compares with peers behavior-

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TABLE 1. DSBQ Factors and Items DSBQ Factors Emotional factor Academic factor Social factor

Examples of DSBQ Items Within Factors Cries, whines or complains. Worries a lot. Indicates signs of emotional problems. Clings to adults or too dependent. Keeps up with schoolwork. Has difficulty remembering, sequencing. Has specific difficulty with mathematics. Has difficulty with tasks requiring reasoning. Has difficulty staying on task. Is outgoing, interacts with friends. Initiates activities with peers. Talks about his or her activities. Self-conscious or easily embarrassed.

ally; and (4) had social/behavioral difficulties during the current year. For this scale, higher scores indicate more positive social performance characteristics; internal consistency for the Social Abilities Domain was .71.

to 36 (significantly above average on all items). Alpha coefficients for the DSBQ factors ranged from .72 to .88. Therefore, the DSBQ appeared to have satisfactory validity for determining the construct validity of the SCAS.

Family Domain

Construct Validity of the SCAS

Seven SCAS items measured family risk and protective factors: before diagnosis home behavior problems, residence changes, serious illnesses in the last year, job loss in the last year, family problems, and caretaker changes. These items did not form a strong factor, and the internal consistency was .25. This low correlation suggested that although the items may measure important risk or protective factors, they do not appear to be conceptually congruent. Based on these findings, analyses to determine construct validity were limited to the Educational Characteristics and the Social Abilities Domains.

Educational Characteristics Domain

DSBQ Internal consistency of the total DSBQ instrument was .86 for the parent form, and .87 for the teacher form. Results of the factor analysis supported a five-factor structure for the parent and a six-factor structure for the teacher questionnaire. Conceptually, the majority of DSBQ items loaded on factors reflecting emotional, academic, or social characteristics of children with cancer. DSBQ items that loaded on the Emotional, Academic, and Social Factors are identified in Table 1. Factor scores were based on the number of items and scoring format (yes/no or 1 to 4). For example, scores on the Academic Factor ranged from 9 (significantly below average on all items)

Scores on the SCAS Educational Characteristics Domain were correlated with scores on the Parent and Teacher DSBQ Academic Factor to evaluate construct validity. The Educational Characteristics Domain was also correlated with the following Scales of the BASC: Learning Problems (higher score ⫽ more problems), Attention Problems (higher score ⫽ more problems), Attitude to School (higher score ⫽ more problems), and Study Skills (higher score ⫽ more positive characteristics), as well as the School Problems composite score. The SCAS Educational Characteristics Domain was negatively correlated with the Academic Factor scores from the Parent (r ⫽ ⫺.60; p ⱕ .01) and Teacher (r ⫽ ⫺.53; p ⱕ .01) DSBQ. The negative correlation between the SCAS and the DSBQ scales are in the predicted direction because higher scores on the DSBQ reflect fewer problems, whereas higher scores on the SCAS Educational Characteristics Domain indicate more problems. The SCAS Educational Characteristics Domain was positively correlated with BASC Learning Problems, Attention Problems, Attitude to School, and School Problems Composite (higher scores on all scales indicate more problems or risk factors); and negatively correlated with Study Skills (higher score indicates fewer problems or more protective factors). Results of correlation between the SCAS

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TABLE 2. Correlation Coefficents: SCAS Educational Characteristics with DSBQ and BASC DSBQ Factor Scores DSBQ Parent Academic Factor DSBQ Teacher Academic Factor BASC Scale or Composite Scores BASC Learning Problems Scale BASC Attention Problems Scale BASC Attitude to School Scale BASC Study Skills Scale BASC School Problems Composite

Child Domain and the specific DSBQ Factors and BASC Scales or Composite scores are found in Table 2. Social Abilities Domain Construct validity of the SCAS Social Abilities Domain (higher scores ⫽ more protective factors) was established by correlation with the DSBQ Social and Behavioral Factors (higher scores ⫽ more protective factors), BASC Aggression, Conduct Problems and Atypicality Scales (higher scores ⫽ more risk factors), BASC Externalizing Problems, Internalizing Problems and Behavioral Symptoms Index (higher scores ⫽ more risk factors), and BASC Adaptive Skills Composite (higher score ⫽ more adaptive skills). The Social Abilities Domain was positively correlated with the total DSBQ Parent and Teacher scores (r ⫽ .41 and .57, respectively; p ⱕ .01) as well as with scores

Pearson r

Significance

–.60 –.53

p ⱕ .1 p ⱕ .1

Pearson r .50 .42 .39 –.40 .41

Significance p ⱕ .1 p ⱕ .1 p ⱕ .1 p ⱕ .01 p ⱕ .1

on the DSBQ Social and Behavioral Factors (r ⫽ .35 to .51; p ⱕ .01). Correlation between the SCAS Social Abilities Domain and the BASC Scales and Composite scores were also in the predicted direction, and support construct validity of the SCAS Social Abilities Domain (Table 3).

Conclusions and Future Directions The SCAS was developed by a group of pediatric oncology nurses to measure the risk for school problems for children with cancer at the time of diagnosis. A theoretical framework based on medical, academic, social, and behavioral risk and protective factors guided the development of the SCAS. A multidisciplinary team of experts in pediatric oncology as well as parents and teachers of children with cancer reviewed the instrument and determined that it had good content validity.

TABLE 3. Correlation Coefficients: SCAS Social Abilities with DSBQ and BASC DSBQ Factor Scores DSBQ Teacher Behavioral Factor DSBQ Parent Behavioral Factor BASC Scale or Composite Scores BASC Aggression (Teacher Scale) BASC Conduct Problems (Teacher Scale) BASC Atypicality (Teacher Scale) BASC Externalizing Problems (Teacher Scale) BASC Internalizing Problems (Teacher Scale) BASC Behavioral Composite (Teacher Scale) BASC Adaptive Behavior (Teacher Scale) BASC Social Behavior (Teacher Scale) BASC Adaptive Behavior (Parent Scale) BASC Social Behavior (Parent Scale)

Pearson r

Significance

.51 .35

p ⱕ .01 p ⱕ .1

Pearson r –.38 –.39 –.39 –.33 –.34 –.38 .36 .31 .37 .36

Significance p ⱕ .1 p ⱕ .1 p ⱕ .1 p ⱕ .1 p ⱕ .1 p ⱕ .1 p ⱕ .5 p ⱕ .2 p ⱕ .1 p ⱕ .5

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The SCAS was tested for construct validity by comparison with specific scale and composite scores of the BASC parent, teacher, and child self-report forms and the DSBQ parent and teacher report forms. Construct validity was found to be adequate. After factor analysis, two domains, the Educational Characteristics Domain and the Social Abilities Domain of the SCAS, were determined to have good internal consistency. A third Domain, the Family Domain, was not found to have adequate reliability. However, descriptive findings from the Family Domain may suggest the importance of these items to the academic and behavioral adjustment of children with cancer. For example, many parents (64%) reported that their child had experienced body image alterations during cancer therapy but fewer parents (30%) reported that their child had experienced mental or emotional problems during therapy. Furthermore, children in this study missed an average of 33.9 school days during the previous school year and 21.8 days during the current school year. These descriptive findings suggest that missed school, body image changes and emotional problems are significant problems. Further analyses of Family Domain may indicate the need to include some of the items in the modified version of the SCAS for future testing. In conclusion, results from this study support the potential use of the SCAS Educational Characteristics and Social Abilities Domains for assessing protective and risk factors for future school competency among children receiving cancer therapy. The majority of children in this study were between 1 and 3 years from cancer

diagnosis and still receiving treatment. Future studies that determine if the SCAS Domains predict academic problems as well as social and behavioral problems of children recently diagnosed with cancer are needed. Specific items measuring family risk and protective factors did not demonstrate acceptable internal consistency suggesting they do not form a conceptually cohesive scale. However, individual items, such as mother or father education or other family problems may be useful in predicting school performance or social abilities, and warrant further examination. Because the SCAS may be used in future studies, additional evaluation of psychometric characteristics of the SCAS is important. Despite the growing body of literature on the academic and social/behavioral outcomes of cancer treatment in children, there is a paucity of information on intervention strategies to address this clinically significant problem. The availability of an instrument, such as the SCAS, to assess and ultimately predict risk for school problems is an important consideration in the development and testing of interventions. In summary, the SCAS is a time-efficient instrument that has the potential to identify children who are at high risk for school problems and may provide important information for developing individualized interventions.

Acknowledgment This project was funded in part by an Oncology Nursing Foundation/Sigma Theta Tau International Research Award. Additional support was provided by the Frank A. Campini Foundation and the Bay Echo Foundation.

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