Journal of Pediatric Psychology, Vol. 26, No. 5, 2001, pp. 309-319
© 2001 Society of Pediatric Psychology
Social Information Processing and Magnetic Resonance Imaging in Children With Sickle Cell Disease
1 Emory University, 2 Medical University of South Carolina, 3 Emory University School of Medicine
All correspondence should be sent to Ronald T. Brown, Department of Pediatrics, Medical University of South Carolina, Hagood Avenue, P.O. Box 250822, Charleston, South Carolina 29425. E-mail: brownron{at}musc.edu .
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Abstract |
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Objective: To examine social information processing, social skills, and adjustment difficulties in children with sickle cell disease (SCD) as rated by caregivers, teachers, and the children themselves. Children were classified in two groups: cerebral vascular accidents (CVA) (n = 21) or without central nervous system (CNS) pathology (n = 20) on magnetic resonance imaging (MRI). Both groups had HbSS SCD. We compared these two groups and a third group of 11 children who had a milder type of SCD (HbSC).
Methods: Participants referred for evaluation of learning and behavior problems were administered MRIs to ascertain the presence of pathology and a series of measures designed to assess nonverbal emotional decoding abilities and ratings of social emotional functioning.
Results: Children with CVA displayed more errors on tasks of facial and vocal emotional decoding than did comparison controls without CVA.
Conclusions: Acquired neurological impairments in children with SCD seemed to be associated with difficulties in the decoding of emotions of other children and adults. We recommend that future research integrate neuropsychological and psychosocial research programs for pediatric chronic illness groups.
Key words: pediatric; sickle cell disease; cerebral vascular accident; social information processing.
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Introduction |
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Recent research has indicated that up to 20% of children with sickle cell disease (SCD) (HbSS type, the homozygous condition known as sickle cell anemia) sustain either overt or silent cerebral vascular accidents (CVA or stroke) (Armstrong et al., 1996
; Bonner, Gustafson,
Schumacher, & Thompson, 1999;
Brown et al., 2000). Brown et
al. found that children with overt CVA and silent infarcts differed from their
peers without central nervous system (CNS) pathology on measures of cognitive
functioning, including attention and executive functioning. Similarly,
Rodgers, Clark, and Kessler
(1984) provided evidence of
altered metabolism in the frontal lobe area, measured by position emission
tomography (PET). Taken together, the studies suggest deficits in cognitive
functioning in patients with SCD, with both overt and silent CVA
(Brown et al., 2000;
DeBaun et al., 1998;
Rodgers et al., 1984;
Schatz et al., in press).
SCD is a life-long chronic illness that poses major stressors on children
and places them at significant risk for problems with psychosocial adjustment
For example, the results of a meta-analysis indicated the prevalence of
depressive symptoms in youths with SCD
(Bennett, 1994). As rated by
parents and teachers, children with SCD exhibited more internalizing and
externalizing problems and were nominated less frequently for
social-desirability roles than their typically developing peers
(Noll et al., 1996;
Short, Vannatta, Kalinyak, & Noll,
1999), although not all investigators have corroborated these
findings (Lemanek, Horwitz, & Ohme-Frempong, 1994;
Noll, Ris, Davies, Bukowski, & Koontz,
1992). However, there is minimal research directed at
identification of factors that contribute to the psychosocial difficulties of
children with SCD.
Another line of inquiry suggests that the difficulties in emotional and
social adjustment characteristic of children with SCD may be related to
neurocognitive dysfunction from acquired damage to structures of the brain
associated with social and emotional processing skills. For example, as shown
in both adult psychopathology (Adolphs,
Demasio, Tranel, & Demasio, 1996) and clinical child
literature (Tramontana & Hooper,
1997), individuals who have sustained acquired brain injuries
frequently suffer from concomitant emotional and psychiatric disorders. Thus,
the difficulties in emotional and social adjustment experienced by children
with SCD may be associated with infarcts to structures of the brain related to
these functions (Noll et al.,
1996). In support of this notion, neurological deficits have been
demonstrated to play a significant role in the social and emotional processing
of children with various acquired brain injuries
(Tramontana & Hooper,
1997), as well as for children with certain types of learning
disabilities (Bryan & Bryan,
1990) and low incidence psychiatric disorders, such as autism and
schizophrenia (Tramontana & Hooper,
1997).
Perception of emotion by means of facial recognition and prosody (i.e., the
understanding of an individual's intended verbal communication by frequency,
pitch, intensity of loudness, duration, rhythm, and timing of speech) as it
relates to cerebral damage is receiving considerable research focus
(Adolphs et al., 1996;
Adolphs, Tranel, & Demasio,
1994; Adolphs, Tranel, Demasio,
& Demasio, 1995). In a study with pediatric populations,
Cohen, Branch, and Hynd (1994)
provided compelling evidence that the right hemisphere was dominant for
receptive prosody in children. Similarly, in an investigation of children who
had sustained early unilateral brain damage, only participants with right
hemisphere damage showed impairments on an affective comprehension task
(Trauner, Ballantyne, Friedland, &
Chase, 1996). Nonverbal learning disabilities also have been
associated with right hemisphere dysfunction in children, based on
neuropsychological profiles (Rourke &
Del Dotto, 1994), neurological examinations
(Denkla, 1983), and
neuroimaging studies (Grace & Malloy,
1992; Manoach, Sandson, &
Weintraub, 1995). Depressive symptoms in children with right
hemisphere dysfunction were also revealed.
We designed our investigation to extend the psychosocial and neuropsychological literatures related to SCD by examining the association of social information-processing deficits with acquired cerebral injuries in children with SCD. Few researchers in SCD have examined psychosocial and neurological functioning simultaneously. Our study included a group of children with HbSS SCD with documented (MRI) cerebral infarcts and two comparison control groups, including a group with HbSS SCD with no evidence (MRI) of cerebral vascular deficits and a group with HbSC disease, a milder variant of SCD, with no documented neurological insults. Our hypotheses proposed that participants with CNS pathology would demonstrate less accuracy in social information processing (as evidenced on a task of nonverbal emotional decoding abilities) and greater deficits in social skills than their peers without CNS pathology, as rated by both caregivers and teachers.
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Method |
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Participants
Participants were 52 children and adolescents with SCD receiving their treatment at a comprehensive National Institutes of Health sickle cell center. This center is located at a major university-affiliated teaching hospital that serves primarily individuals of lower socioeconomic status (SES). Thus, our sample was composed primarily of a fairly low SES group, and this is characteristic of other investigations of children and adolescents with sickle cell syndromes (Hurtig, Koepke, & Park, 1988
; Ievers, Brown,
Lambert, Hsu, & Eckman, 1998). Children were required to be at
least 6 years of age and not older than 17 years. Approximately 500 children
with sickle cell syndromes were followed at this center at the time that the
data were collected (from 1996 to 1998). Participants were referred to us by
pediatric hematologists to investigate their cognitive, academic, and
emotional functioning (Brown, Armstrong,
& Eckman, 1993; Brown et
al., 2000; Brown, Doepke,
& Kaslow, 1993; Devine,
Brown, Lambert, Donegan, & Eckman, 1999;
Ievers et al., 1998). Although
the children were referred to the investigators because of possible learning
problems and adjustment difficulties, only three of the children were
receiving special education services at the time of evaluation; none of the
participants was receiving psychotropic medication at the time of the
evaluation. All caregivers of children and adolescents who were approached to
participate in the study agreed to do so. Informed consent was obtained from the participants' caregivers, and assent was obtained from children and adolescents capable of understanding the nature of the study. Demographic information was collected with questionnaires, and medical information was obtained by chart reviews and the center's computer database. Caregivers were paid $25 for participation in the study. MRI examinations of the brain were conducted for clinical purposes within 3 months of the assessment. All of the children were right-handed. The length of the assessment was approximately 2 hours. Forty-one of the children had HbSS SCD, and 11 had HbSC SCD. The 41 children were divided into two groups, 21 with CNS pathology and 20 without.
Measures
Illness Variables
Disease severity was quantified in a manner similar to other investigations
of children with SCD (Brown et al.,
2000; Brown et al.,
1993; Devine et al.,
1999). The severity was measured by several variables that
included number of hospital contacts over the past 12 months, mean white blood
cell count over the past three clinic visits, and transfusion history.
Currently receiving transfusion therapy was coded as 3, a past history of
transfusions was coded as 2, and no recorded history was coded as 1. Because a
high hemoglobin level is associated with less disease severity for some
symptoms of SCD (e.g., stroke) (Charache,
Lubin, & Reed, 1989), reverse scoring was used for hemoglobin
levels averaged over the past three clinic visits.
Intellectual Functioning
To ensure equivalence of the groups for intellectual functioning, all
participants were administered an abbreviated form of the Wechsler
Intelligence Scale for Children-Revised (Information, Vocabulary, Block
Design, Object Assembly). These four subtests have been highly correlated with
the Full Scale intelligence score (FSIQ)
(Noll et al., 1996;
Wechsler, 1991). Scaled scores
were computed for each of the subtests and were subsequently converted into a
composite deviation quotient using Sattler's
(1992) formula.
Assessment of Nonverbal Emotional Decoding Abilities
The Diagnostic Analysis of Nonverbal Accuracy (DANVA)
(Nowicki & Duke, 1994) was
used to assess affective decoding abilities of all participants. This test is
similar to the one developed by Ekman and Friesen
(1976) that has been used in
an impressive body of research with adults
(Ekman, 1972). Two subtests
measuring nonverbal receptive abilities for child facial and prosodic
expressions of emotion (Child Faces and Child Voices), and three subtests
measuring nonverbal receptive abilities for adult facial and adult prosodic
expressions of emotion (African American Adult Faces, Adult Faces, and Adult
Voices) were used. Each of the subtests has 24 pictorial or audio scenes of
actors displaying four emotions (happy, sad, angry, fearful) at two levels of
intensities. Most of the actors displaying emotions were Caucasian and some
were African or Asian American. The African American Faces subtest consisted
of all African American actors. The Voices subtest had a neutral content
("I am going out of the room now"). For all subtests,
approximately half of the actors were female. Studies using the DANVA with
children have provided support for the construct validity of the test
(Baum & Nowicki, 1996;
Nowicki & Carton, 1993;
Nowicki & Duke, 1993,
1994;
Nowicki, Glanville, & Demertzis,
1998; Nowicki & Mitchell,
1998). All photographs and voices received at least 80% agreement
on type and intensity of emotion among elementary and high school students and
adults. The subtests have been found to have adequate internal reliability
(coefficient 
s =.64-.81) and test retest reliability (rs range
from.74 to.81) for children and adolescents 4 to 16 years.
For each of the DANVA subtests, responses were scored by a computerized
program that generated an error profile for each participant on each subtest.
The error analysis included total number of errors, number of errors for each
emotion at each intensity, type of error for each target emotion category
(e.g., number of instances in which a participant endorsed sad when the
stimulus was angry), and type of error for each target emotion category at
each intensity (e.g., number of instances in which a participant endorsed low
intensity sad when the designated stimulus was actually high intensity angry).
Intensity of emotion refers to the degree of complexity or ambiguity of the
various stimuli in communicating a particular emotion. For example, low
intensity emotional stimuli indicate a great deal of complexity or ambiguity;
high intensity emotional stimuli suggest little complexity or ambiguity in
communicating an emotion. Stimuli on the DANVA are graded for intensity of
emotional voice prosody and facial affect across adults, children, and African
American faces. An example of a high intensity facial affect is a large smile
on a face, depicting a happy adult; an example of a low intensity adult voice
is a command without affect requesting that a person cease talking.
Test-retest reliability for intensity of emotion has been found to range
from.70 to.81 (Nowicki & Carton,
1993).
Ratings of Social-Emotional Functioning
Social Skills Rating System (SSRS;
Gresham & Elliott,
1990). Caregiver and teacher ratings are obtained in the
areas of social skills competence, problem behaviors, and academic competence
(the latter is only in the teacher version). The SSRS was standardized
nationally with African American and Caucasian children, with these groups
slightly more overrepresented than other groups. Adequate to excellent
internal consistency and test-retest reliabilities have been demonstrated for
the SSRS. Criterion-related validity using other rating forms of
self-competence, problem behaviors, and self-concept also has been
demonstrated (Gresham & Elliott,
1990).
Children's Depression Inventory (CDI;
Kovacs, 1992). The CDI, a
frequently used self-report measure of depressive symptoms in children and
adolescents, was used to assess the extent to which symptoms of depression
might be associated with neurological impairment. Extensive data have been
reported supporting its reliability and validity, and several investigations
have supported its construct validity
(Kovacs, 1992) and its
cross-cultural sensitivity in studies of African American children
(Politano, Nelson, Evans, Sorenson, &
Zeman, 1986). We used standardized T-scores in our analyses.
Magnetic Resonance Imaging Studies
MRI studies of the brain without contrast were performed in accordance with
standard practices. Children who were younger and those who needed assistance
were sedated in accordance with the guidelines outlined by the American
Academy of Pediatrics (Committee on Drugs,
1992). Our procedures were similar to those of the Cooperative
Study of Sickle Cell Disease (Armstrong et
al., 1996) and other studies
(Brown et al., 2000;
DeBaun et al., 1998;
Schatz et al., in press). Each
child's MRI was reviewed independently by a pediatric neuroradiologist and a
pediatric radiologist. Any disagreements between the two radiologists were
resolved by consensus. MRI readings without CNS pathology were classified as
normal (no CNS pathology). Those with CNS pathology were classified as
cerebral infarction, atrophy, or cerebral infarction and atrophy. If no
pathology was found in the medical record or the MRI, the child was classified
as normal, without CNS pathology (n = 20). Children who had an MRI
indicating an infarct were classified in the positive CVA group (n =
21). A comparison control group consisted of children and adolescents with a
milder variant of SCD (HbSC), none of whom were found to have CVA according to
medical records (n = 11). Individuals with HbSC disease have much
lower risk for CVA than those with HbSS
(Ohene-Frempong et al., 1998).
Thus, our investigation compared three groups of children: (1) 21 children
with SCD (HbSS) with no evidence of CVA as documented by MRI (negative group),
(2) 20 with SCD (HbSS) with documented evidence of CVA as revealed by MRI, and
(3) 11 with a milder variant of SCD (HbSC) who served as comparison
controls.
Data Analyses
A series of one-way multivariate analyses of covariance (MANCOVA) was
performed for each domain of measures (DANVA total error scores, DANVA
intensity error scores, and social-emotional functioning ratings as provided
by caregivers, children, and teachers), and the classification of CNS
pathology (positive MRI, negative MRI, comparison controls) served as the
independent variable. No statistically significant differences between the
three groups were found, but significant associations were found for FSIQ and
the various DANVA subtests (rs ranged from -.04 to -.32, three of
five correlation coefficients were significant, p <.01),
indicating that children who scored lower on the FSIQ measure obtained higher
error scores on the DANVA subtests. For these reasons, FSIQ was used as a
covariate. Although no differences were found for the FSIQ, separate one-way
analyses of variance (ANOVAs) were performed for each of the WISC-III subtest
scores (Information, Vocabulary, Block Design, Object Assembly). Findings
revealed significant differences for the Block Design, F(2, 49) =
8.79, p <.05, and the Object Assembly, F(2, 49) = 4.83,
p <.05, subtests. The results of a Tukey post-hoc HSD test
revealed that the two groups with HbSS disease (CNS pathology, no CNS
pathology) differed significantly from the comparison controls (p
<.05). To determine whether performance on the various WISC-III subtest
scores was associated with performance on the DANVA scores, a series of
Pearson-product moment correlation coefficients was performed among the
measures. Correlations ranged from r =.04 to -.34. Six of the 20
correlation coefficients were significant (p <.05), again
indicating that children who scored lower on the various WISC-III subtests
obtained higher error scores on the DANVA. The pattern of associations for
both FSIQ and DANVA scores and the individual WISC-III subtests was similar,
and for this reason FSIQ was used as the covariate in each of the analyses.
Chronological age was not a covariate because no differences were found for
chronological age for the three groups. In addition, chronological age was not
found to be associated with any of the dependent variables (rs ranged
from.02 to -.16, all ns). Thus, three MANCOVAs were performed;
significant multivariate tests were followed by analyses of covariance
(ANCOVAs); and Tukey HSD post hoc analyses were performed on any dependent
measure for which there was a significant ANCOVA.
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Results |
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Of the 52 participants with SCD, 58% were male (n = 30) and 42% were female (n = 22), with a mean age of 11 years and 3 months (SD = 2 years, 10 months, range = 6 years, 4 months to 16 years). Grades in school ranged from first to tenth, with a mean of fifth grade (M = 5.33, SD = 2.76). Children were primarily in regular classrooms (94.2%; n = 49), although 3.8% (n = 2) were receiving special education resource services (part-time resource help in certain subjects) at the time of evaluation. One child (1.9%) was in a self-contained special education classroom at the time of assessment. Forty-one children (78.9%) had HbSS disease, and the 11 comparison control children (21.1%) had HbSC (the milder heterozygous condition for hemoglobin S and hemoglobin C).
Most caregivers in our sample were mothers (84.6%, n = 44). Other caregivers were fathers (9.6%, n = 5), grandmothers (1.9%, n = 1), and aunts (3.9%, n = 2). The marital status of caregivers was 28.9% (n = 15) currently married, 48% (n = 25) single, 21.2% (n = 11) separated or divorced, and 1.9% (n = 1) widowed. Although most caregivers had graduated from high school (n = 40, 76.9%), approximately a fourth (n = 12, 23.1%) had not completed high school and had not been granted an equivalent diploma through testing. The mean for years of education was 12.56 (SD = 1.61, range = 9-16 years). Most of the families had annual incomes of less than $10,000 (below poverty level) (n = 37, 67.3%). The remainder of the sample had incomes ranging from $10,000 to $19,000 (lower middle class, n = 13, 25%), $20,000 to $30,000 (middle class, n = 1, 1.9%), and above $31,000 (upper middle class, n = 1, 1.9%).
Table I presents the participants' chronological age and gender, children's FSIQ, and severity of disease (mean hemoglobin of the past three visits, white blood cell count, and number of hospital contacts over the past year) for each of the three groups. No significant differences were found for any of the demographic variables, although the two groups of children with HbSS (MRI positive and negative groups) had a higher frequency of receiving transfusion therapy (past and present), had lower hemoglobin levels, and higher white blood cell counts than their peers in the HbSC control group, thereby reflecting greater disease severity in the two HbSS groups.
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The first MANCOVA, conducted to determine whether there were any group differences when decoding facial and prosodic emotions, yielded a difference that only approached statistical significance. FSIQ scores were a covariate in each of the analyses. Given the exploratory nature of the investigation, coupled with the low power, we performed separate ANCOVAs on each of the dependent measures, and a statistically significant effect was revealed for the African American Faces total error score, F(2, 48) = 3.47, p <.04, and the Adult Voices total error score, F(2, 48) = 3.69, p <.03. To determine the source of statistical significance, we performed post hoc analyses on the African American Faces and the Adult Voices total error scores. The results of these Tukey HSD post hoc tests indicated that, for both measures, the group designated with CNS pathology made more errors than the HbSC comparison control group (p <.05; see Table II for these measures).
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A one-way MANCOVA with FSIQ as a covariate was performed on the high and low intensity DANVA scores and demonstrated a significant main effect, F(20, 78) = 1.89, p <.03. Subsequent ANCOVAs revealed significant effects for the African American Faces, F(2, 48) = 7.46, p <.002; Adult Voices, F(2, 48) = 4.81, p <.01; and Child Voices, F(2, 48) = 5.45, p <.007, low intensity error scores. Tukey HSD post hoc tests were performed for each of the measures to determine the source of significance. Participants in the positive MRI group made significantly more low intensity errors than did participants in either the negative MRI group or the HbSC comparison control group (p <.05; see Table II).
Finally, a third MANCOVA was used to determine whether there were any group differences for either caregiver (SSRS Social Skills, Problem Behaviors) or child ratings (CDI). No significant main effects were revealed, F(6, 88) =.89, ns, indicating that caregiver and child ratings did not differ as a function of MRI pathology. Because an insufficient number of teacher ratings were returned to include these scores in the MANCOVA, separate one-way ANCOVAs with FSIQs as covariates were performed for each of the teacher measures yielded on the SSRS, and none was significant (all Fs < 1.25; see Table II).
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Discussion |
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We examined the hypothesis that the social processing skills and social and emotional difficulties experienced by youths with SCD are associated with cerebral abnormalities, as identified on MRI. Findings revealed that children with HbSS SCD who had sustained cerebral injuries evidenced a greater frequency of errors on tasks associated with social information processing than did their peers with a milder variant of SCD (HbSC). We found errors in facial recognition for African American adults in children with CNS pathology, relative to their peers with HbSC disease. Children with documented cerebral abnormalities also evidenced a greater frequency of errors associated with tasks involving low intensity of adult and child facial and vocal recognition of emotions than their peers without CNS pathology and comparison controls with HbSC disease. Finally, participants with CNS pathology also demonstrated a greater frequency of errors for low intensity facial affect of African American adults in comparison to their peers with no CNS pathology and to comparison controls with HbSC disease.
The study supported our hypothesis that children with documented CNS pathology are less successful in correctly decoding emotions associated with voices or emotional prosody than are their peers without such documented pathology who suffer from a nearly identical chronic illness. Participants with CNS pathology were less accurate at decoding low intensity adult facial affect of African American individuals and low intensity prosodic expressions in adults and children compared to children without CNS pathology and those with HbSC disease. Children with CNS pathology made more errors as the intensity of the emotional prosody stimuli decreased and became more subtle. Children with CNS abnormalities showed difficulty in the identification of emotion in adult voices, low intensity child voices, and when decoding facial expressions of same-race adults, compared to their peers in the other two groups. These data are important because they suggest that children with SCD who suffer from documented CNS pathology may encounter difficulty decoding or interpreting certain social situations that are particularly complex or ambiguous. Because intelligence test scores were controlled statistically, our findings do not appear to be attributable to general cognitive functioning.
The finding that children with SCD who have acquired CNS abnormalities may
have difficulty reading subtle nonverbal and verbal social cues is in accord
with the learning disability literature, which suggests that children with
learning disabilities are at risk for social difficulties because they are
less proficient in processing subtle social messages
(Bryan & Bryan, 1990).
Taken together with our data, the results suggest that children with
neurocognitive impairments experience greater difficulty than their normally
developing peers in comprehending social situations in which the verbal and
nonverbal cues are ambiguous or less explicit, but they do not differ from
their peers in routine or well-known situations
(Pearl & Cosden, 1982).
These observations are in accord with those of Lemanek and colleagues
(1994), who found that
children with SCD and healthy comparison controls did not differ on global
teacher and parent ratings of social competence or on self-perceived social
competence. Several investigators
(Fletcher & Ewing-Cobbs,
1991; Perrott, Taylor, &
Montes, 1991) have suggested that behavior rating scales designed
for use in the general population have had mixed success in identifying the
more subtle sequelae of childhood brain disease.
For our sample, caregiver, teacher, and children's ratings reflected
adequate social and emotional functioning for all three groups of children
with SCD, including those with documented acquired brain injuries. However,
some studies of children and adolescents who have sustained acquired
neurological insults, as well as children with functional brain disturbances
such as learning disabilities (Shaffer et
al., 1985; Taylor & Alden,
1997; Tramontana & Hooper,
1997), clearly indicated increased vulnerability for adjustment
difficulties.
At first examination, our results may seem discrepant from other studies
suggesting psychological difficulties in youths with SCD
(Brown, Mulhern, & Simonian, in
press), but four factors may account for discrepancies. First, all
of the children in our sample were diagnosed with some type of SCD, thereby
mitigating differences among the groups. All of the children were receiving
some type of medical treatment (e.g., transfusion therapies) throughout the
course of the investigation. In addition, the mean age of participants in our
investigation was younger than that in previous studies where difficulties in
psychosocial adjustment have been reported. Most studies identifying
psychosocial problems in youths with SCD have focused either on adolescents
(Hurtig & Park, 1989) or
have provided compelling evidence that these difficulties emerge at
adolescence (Bennett, 1994;
Brown, Doepke, et al., 1993).
Most participants in our study were elementary school students. Thus, we
suggest that social processing difficulties may result in differential
developmental trajectories of social development that may not actually become
apparent to caregivers and teachers until well into adolescence. Therefore,
children with SCD must receive ongoing evaluation, particularly as they
transition to the stages of early and late adolescence. The task of social
processing, such as that used in this investigation, in addition to ratings of
global behavior as completed by teachers and caregivers, will be important in
the monitoring of these children during early and middle childhood, as well as
during adolescence. Finally, there has been considerable diversity across
studies in the assessment of psychosocial functioning. For example, many
investigators have differed in their choice of informants (e.g., child,
caregiver, or teacher) and in their assessment of psychopathology (e.g.,
internalizing, externalizing). As White and DeBaun
(1998) cogently observed,
results in the SCD literature have varied across studies as a function of the
methodology used.
The finding that children who have SCD with documented neurological impairments demonstrated deficits only on specific measures of social information processing (i.e., DANVA), and not on ratings of social skills and adjustment as reported by caregivers, teachers, and the children themselves, underscores the importance of multiple measurement sources in pediatric populations. Thus, although significant others in their environment are not always able to detect subtle difficulties in social cognition among children with SCD who have sustained neurological insults, our findings in part suggest that these deficits may be detected from psychometric assessment. The difficulties that these children experience in decoding of emotions may be detected in peer relationships and in relationships with adults in informal settings (e.g., with camp counselors). Future research will need to examine the association between peer sociometric ratings and SCD children's capacity for decoding emotions.
The contribution of our investigation must be considered within the
limitations of the study design, including the small sample size that may have
limited power. In addition, significant variability within the three groups
increased error variance and may have diminished significant effects. Further,
the children were part of a clinical sample, all of whom were initially
referred for a history of school difficulties. Both of the groups designated
as normal may have been more accurately designated as low functioning.
Additional research will need to include multisite collaborative clinical
samples and larger cohorts of children with SCD. Finally, volume of cerebral
injury was not assessed in our investigation, so future examination of both
volume and location of injury will be profitable
(Schatz et al., in press).
Some evidence suggests that premorbid functioning and rehabilitation
services provided immediately after injury may predict functioning shortly
after the injury (Kolb & Fantie,
1989; Taylor & Alden,
1997). Future research efforts with this population should
carefully examine premorbid functioning and rehabilitation services provided
to patients immediately after injury. Environmental factors such as family
functioning are robust predictors of children's functioning following brain
injury (Rivara et al., 1996;
Taylor et al., 1995;
Yeates et al., 1997), and
family functioning has been demonstrated to be an important mediator for
children's adjustment to SCD (Ievers et
al., 1998). Future research will need to demonstrate whether
family functioning interacts with these children's neurological status to
predict emotional adjustment.
Notwithstanding these limitations, ours is one of the first investigations
to examine neurological and psychosocial functioning simultaneously in a
pediatric chronic illness population. In part, our findings may explain the
etiology of these children's adjustment difficulties that have been noted in
other studies (Brown et al., in
press). Our data may show promise for the identification of the
functional impairments associated with CVA in children with SCD and may
eventually lead to rehabilitation efforts.
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Acknowledgments |
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This research was supported in full by a grant awarded from the National Institute of Mental Health, National Research Service Award, 5F31 MH 12071, and in part by a grant awarded from the National Institutes of Health, Heart, Lung, and Blood Branch, HLB P0-HL48-482. We thank David Freides, PhD, for his assistance with the design and conceptualization of this research.
Received June 29, 2000; revision received November 4, 2000; accepted January 3, 2001
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