Journal of Pediatric Psychology, Vol. 25, No. 3, 2000, pp. 147-149
© 2000 Society of Pediatric Psychology
Special Section: Peer Relationships |
Commentary: Children With Pediatric Conditions: Can Peers' Impressions Be Managed? And What About Their Friends?
University of Miami
All correspondence should be sent to Annette M. La Greca, Department of Psychology, P.O. Box 249229, University of Miami, Coral Gables, Florida 33124. E-mail: alagreca{at}miami.edu .
Having a chronic disease or life-threatening illness during childhood is a non-normative experience, and one that can substantially interfere with day-to-day functioning. Thus, it is no wonder that families, health professionals, and pediatric psychologists are concerned with normalizing children's social and emotional functioning, and enhancing children's adjustment when a chronic or life threatening disease is present.
One area of concern for children and adolescents with pediatric conditions
is how their peer relations may be affected. Peer relations—primarily
acceptance from one's peers and the support of close friends—are
critical to youngsters' social and emotional functioning. Peer acceptance
refers to the extent to which children are accepted by their peer group (i.e.,
classmates) and provides children with a sense of belonging or social
inclusion. On the other hand, close friendships provide children with a sense
of intimacy, companionship, and self-esteem
(Furman & Robbins, 1985
).
For example, close friends provide a significant source of emotional support
for adolescents who struggle with the management of a chronic disease, such as
diabetes (La Greca et al.,
1995). Given the importance of peers in development, it is
critical to understand the impact of pediatric conditions on children's peer
relations and to identify strategies for averting potential problems in
youngsters' social relations when a pediatric condition or disease is present.
These are the issues addressed by the special section.
The two articles included in this special section of JPP add to
our accumulating knowledge about the interplay of peer relations and pediatric
conditions. First, the study by Guite, Walker, Smith, and Garber has some good
news. Knowing that a child has somatic symptoms (recurrent abdominal pain),
and that these symptoms are medically based, apparently had little or no
impact on preadolescent children's liking for the hypothetical child. Nor did
the presence of a life-stressor (parental fighting) have an impact on the
hypothetical child's likeability. In fact, the main determinant of liking for
the hypothetical child was being of the same gender, a finding that is
consonant with a substantial literature on peer relations in middle childhood
(Hartup, 1983). For children of
this age, peer networks are primarily "all girl" or "all
boy," and cross-sex friendships are relatively rare. For this reason,
the additional finding of Guite and colleagues that disease status may be a
factor in girls' liking for boys has limited practical relevance. Overall,
then, the findings of Guite and colleagues are positive in suggesting that
children with recurrent abdominal pain (a relatively "invisible"
aliment) should not be at any particular disadvantage with peers just
because of their illness.
In contrast, the information provided here by Bell and Morgan paints a less
rosy picture. This study focused on children's reactions to hypothetical peers
who were obese. As these authors note, obesity is known to be a
stigmatizing condition among children. Given the "visibility" of
obesity, and the likelihood of overweight children being less able to
participate fully in recreational and play activities, one can easily see why
this condition might interfere with peer relations. Other pediatric conditions
that affect youngsters' physical appearance (e.g., burns, craniofacial
anomalies) or limit their physical activities (e.g., asthma, cystic fibrosis)
have been associated with peer relationship difficulties
(Schuman & La Greca,
1999). For example, several researchers have reported that
children with pediatric conditions that alter physical appearance (e.g.,
obesity, burns, acquired limb deficiency, etc.) have been found to experience
lower social acceptance than their peers (see
Schuman & La Greca, 1999)
and to be more reluctant to initiate and engage in peer relations
(Kapp-Simon & McGuire,
1997).
In this context, the interesting question that Bell and Morgan asked was "What can be done to lessen the negative impact of pediatric obesity?" This is a critical question, and one with much practical relevance. Many parents and teachers would be extremely interested to know what could be done to facilitate the social adjustment of children with stigmatizing medical conditions. Would telling peers about a child's medical condition help to lessen the potential negative impact of visible pediatric problems? Specifically, using videotaped methodology, Bell and Morgan evaluated whether providing children with a medical explanation for a child's obesity would positively influence children's attitudes or behavioral intentions to engage in activities with the target child. These authors found that the provision of information had a limited positive effect on children's attitudes but either had no effect or a negative effect on their behavioral intentions to interact with the target child, depending on the children's age. The older children in the sample (5th to 6th graders; average age = 11 years) were less willing to interact with the obese child who had a medical condition than the obese child who did not.
These findings suggest that, when a child has a visible or stigmatizing pediatric condition, giving the child's classmates advanced "warning" of the child's medical condition might not do much to enhance peers' receptivity to the child, and might even backfire. In some ways, given our understanding of peer reputations, these results are not surprising. Children often dislike those who are "different" in some way, and the presence of a nonnormative medical condition, in conjunction with apparent obesity, might simply give children further reason to avoid or exclude a child. The fact that providing children with medical information about another child had a more negative impact on older children does not bode well for the use of this strategy with adolescents.
At the same time, one wonders if children's receptivity would have been
enhanced if, instead, the children were told about the obese child's skills at
a particular sport, academic subject, or a task that children value? We
already know much about what children do and do not like in their peers
(Hartup, 1983). Why not provide
positive information to enhance children's receptivity, rather than give
children more ammunition to view an obese child as different in a nonnormative
way? This idea, of course, remains a question for further study. In fact,
further efforts to understand how to offset negative social consequences of
stigmatizing pediatric conditions would be very useful.
What other research directions in the "peer relations realm" should pediatric researchers pursue? Both the studies included in this special section focused on children's impressions of hypothetical peers. Do these findings hold up in "real world" settings, like the classroom or neighborhood?
We think a more intriguing avenue to explore, however, would be the impact
of these pediatric conditions on youngsters' close friendships. In
general, there is a paucity of research on the peer relations of youngsters
with pediatric conditions (see La Greca,
1990; Nassau & Drotar,
1997; Schuman & La Greca,
1999), and the small body of existing work has focused almost
exclusively on peer acceptance. What about children's close friendships?
Recurrent abdominal pain might not bother other peers or classmates, but what
if your best friend is someone who frequently complains of stomach aches and
cancels activities at the last minute? What are the friendships of obese
children like? Research on the close friendships of children and adolescents
with pediatric conditions is an important and understudied area. In this
regard, it would be particularly valuable to examine how children's close
friendships moderate the potential negative impact of pediatric conditions. If
children with pediatric conditions have positive and supportive close
friendships, does their overall peer likeability matter?
It is also important to understand the ways in which close friends provide
support for children and adolescents with pediatric illness. One thing we've
learned from adolescents with diabetes is that their close friends are
important sources of emotional support for their disease adjustment
(La Greca et al., 1995;
La Greca & Thompson, 1998).
In particular, adolescents' close friends help them to "feel
accepted" even though they have a chronic disease, and friends help them
with some of the day-to-day aspects of disease management. Friend support is
complementary to family support and represents a unique and important factor
in psychosocial adjustment. This point was well illustrated by Wallander and
Varni (1989), who found that
for children with chronic disease, those who had high levels of social support
from both family and peers showed significantly better adjustment than those
with social support from only one of those sources.
Of course, friends' influences may not always be positive, especially when
it comes to health-risk behaviors. For example, the best predictor of whether
an adolescent will smoke is whether he or she has friends who smoke (see
Harris, 1998). Similarly, we
recently found that adolescents' health-risk behaviors (such as smoking, drug
and alcohol use, and risky sexual behaviors) were strongly related to their
peer crowd affiliations; moreover, adolescents' closest friendships were
highly embedded within the same peer crowds
(La Greca, Prinstein, & Fetter,
1999). Findings such as these suggest strong influences from
friends for high-risk health behaviors and the need for further investigation
of the complex interplay between youngsters' peers/friends and various aspects
of health and disease.
In conclusion, we applaud the authors represented in this special section for examining peer issues in pediatric chronic disease and invite other pediatric psychology researchers to do the same. Health care professionals have long recognized the role of the family in youngsters' disease adaptation. It is time we also recognized that the peer system is integral to our understanding of how youngsters successfully adapt and cope with chronic pediatric conditions.
Received September 16, 1999; accepted September 17, 1999
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