Journal of Pediatric Psychology, Vol. 29, No. 1, 2004, pp. 29-34
© 2004 Society of Pediatric Psychology; all rights reserved
Brief Report: Peer Rejection, Social Behavior, and Psychological Adjustment in Children with Juvenile Rheumatic Disease
1 Williams College and 2 Duke University Medical Center
All correspondence concerning this article should be addressed to Marlene J. Sandstrom, Department of Psychology, Williams College, Bronfman Science Center, Williamstown, Massachusetts 01267. E-mail: marlene.sandstrom{at}williams.edu.
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Objective To examine the associations among disease status, social competence, and depressive symptoms in children with juvenile rheumatic disease (JRD) and to test the hypothesis that individual differences in children's social competence account for a significant proportion of variance in depressive symptoms after controlling for disease status variables. Method Thirty-six children with JRD completed standardized instruments to assess pain, health status, and depressive symptoms. The rheumatologist completed a disease severity measure, and teachers provided ratings of peer rejection and social behavior. Results Pain, peer rejection, and problematic social behavior were all positively associated with depressive symptoms. Social variables remained significantly associated with depressive symptoms after controlling for level of pain. In addition, peer rejection moderated the association between pain and depressive symptoms, such that children with high levels of pain and high levels of peer rejection reported the highest frequency of depressive symptoms. Conclusions Health care providers should assess the social functioning of children with JRD in order to identify socially vulnerable children who may be at increased risk for internalizing problems.
Juvenile rheumatic disease (JRD) affects an estimated 250,000 children in the United States, constituting one of the five most common classes of chronic illness in childhood (Cassidy & Nelson, 1988
). JRDs are characterized by unpredictable phases of flare during which children may experience an abrupt exacerbation of symptoms, including joint swelling, pain, and limitation of function. Traditional treatment plans focus on reducing inflammation, maintaining function, and preventing deformities.
Interestingly, studies comparing the psychological profiles of children with JRD to healthy controls have produced somewhat mixed results (see LeBovidge et al., 2003, for review). While some studies indicate that children with JRD experience higher levels of psychological distress and poorer self-concept than healthy children (e.g., Daltroy et al., 1992; Wallander, Varni, Babani, Banis, & Wilcox, 1989), others demonstrate few significant differences between patient and control groups (e.g., Ungerer, Horgan, Chaitow, & Champion, 1988; Varni, Wilcox, & Hanson, 1988). Such equivocal findings have led to the search for key psychological and social factors that may moderate the complex relation between disease status and adaptation.
From a theoretical standpoint, there are a number of ways in which the symptoms of JRD may place children at increased risk for peer rejection. First, periodic flares of joint swelling, pain, and restricted mobility may lead children to miss school or social activities, resulting in limited contact with peers and a sense of alienation. In addition, JRD may be associated with joint deformities, growth disturbance, delayed puberty, or physical limitations that set ill children apart from their healthy classmates in highly visible ways. Finally, children with JRD may find it difficult to balance a developmentally normal desire for increased autonomy with the realistic need for continued parental assistance in the management of their disease.
A handful of researchers have begun to include peer-related variables in their assessment of children with JRD in order to document empirically potential social difficulties. Mirroring the equivocal results described earlier, some studies suggest that JRD is associated with increased social isolation and peer difficulties (e.g., Huygen, Kuis, & Sinnema, 2000; Timko, Stovel, Moos, & Miller, 1992), while others demonstrate that social patterns of children with JRD are very similar to those of children without chronic illness (Harris, Newcomb, & Gewanter, 1991; Noll et al., 2000). There is also some evidence to suggest that children with severe JRD may be at risk for increased social problems over time (Reiter-Purtill, Gerhardt, Vannatta, Passo, & Noll, 2003). While these conflicting findings may reflect differences in methodology across studies, they also suggest heterogeneity in the peer relations of children with JRD.
We speculated that individual differences in peer-related difficulties play a role in distinguishing between children who respond to JRD with internalizing problems such as depressive symptoms and those who do not. Specifically, we predicted that social difficulties would have an incremental effect on children's depressive symptoms after controlling for level of pain and that social difficulties would exacerbate the negative relation between pain and depressive symptoms.
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Participants
Children with JRD were recruited from the pediatric rheumatology clinic at a large southeastern medical center. Eligibility requirements dictated that children be between the ages of 7 and 16 years with a diagnosis of JRD for at least 3 months. (Pilot testing revealed that children under the age of 7 lacked the cognitive skills required to complete the self-report measures employed in this study.) Forty-one children met the requirements and were invited to participate in the study. Of these, a total of 36 children were successfully recruited; five families declined due to lack of time.
The sample consisted of 9 (25%) boys and 27 (75%) girls. The significantly larger percentage of girls in this sample is consistent with the prevalence of rheumatic disease in children. Children's ages ranged from 7 to 14 years (M = 10.22, SD = 2.33). Of the participants, 28 were white, 5 were African American, 2 were Native American, and 1 was Asian American. The majority of children (26, 72.2%) had a diagnosis of juvenile rheumatoid arthritis (JRA). Five children (13.9%) had spondyloarthropathy, 2 (5.6%) had scleroderma, 2 (5.6%) had mixed connective tissue disease, and 1 (2.7%) had multifocal osteomyolytis.
Procedure
Participants were recruited from the clinic during routine visits. Parents who agreed to have their children participate signed an informed consent form, and children provided verbal assent according to a protocol approved by the medical center's institutional review board. While in the clinic, children completed four standardized instruments designed to assess pain, health status, depressive symptoms, and self-esteem. The pediatric rheumatologist completed a disease severity measure. Finally, parents signed an additional consent form allowing teachers to complete a social behavior checklist. Return rate of teacher forms was 94%.
Disease Severity
The pediatric rheumatologist completed the Disease Activity Index (DAI), providing a global assessment of disease activity on a 5-point scale (5 = severe, 4 = moderate, 3 = mild, 2 = quiescent, and 1 = remission). The DAI has been positively correlated with pain intensity and disease activity in prior research (Varni, Thompson, & Hanson, 1987).
Pain
Children provided a pain rating using a 10-cm visual analogue scale (VAS). Previous research has provided support for the reliability and validity of the VAS in measuring musculoskeletal pain in children (Varni et al., 1987).
Disability
Children's disability status was assessed using the Childhood Health Assessment Questionnaire (Child HAQ; Singh, Athreya, Fries, & Goldsmith, 1994). The disability rating is based on items assessing difficulty in eight categories of daily function (dressing/grooming, getting up, eating, walking, washing, reaching, gripping, and activities) over the course of the past week. The Child HAQ has demonstrated good reliability and validity in children with all subtypes of JRA (Singh et al. 1994).
Peer Rejection and Social Behavior
Children's social-behavioral and global acceptance/rejection was assessed using the Teacher Checklist of Social Behavior (TCSB; Coie, Terry, Underwood, & Dodge, 1999). This is a 45-item measure assessing children's classroom behavior on six broad dimensions of social functioning. For the purposes of the current study, we used three of the six subscales: aggressive-dominant behavior (14 items, 
=.91); disruptive behavior (8 items, =.91), and prosocial behavior (5 items, =.74). Due to the strong intercorrelations among the aggressive-dominant, disruptive, and prosocial scales (all r's greater than.5), we summed these scores to form a composite measure of problematic social behavior. Teachers also provided single item ratings for social rejection and social popularity. Because these items demonstrated a strong negative correlation (r = -.69), we reverse-scored the popularity item and then averaged the two scores to create a total rejection score. Portions of the TCSB have shown adequate internal reliability and validity in previous studies (Coie & Dodge, 1988; Lochman, Coie, Underwood, & Terry, 1993). In addition, teacher ratings of rejection and popularity have demonstrated significant correlations with peer-based sociometric ratings (Cillessen, Terry, Coie, & Lochman, 2002).
Depressive Symptoms
Children completed the Children's Depression Inventory (CDI; Kovacs, 1992), a 27-item self-report scale designed to assess the severity of depressive symptoms. The CDI has shown adequate reliability and validity in previous research (Kovacs, 1992). Cronbach's indicated adequate internal reliability in the current sample ( =.92).
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Descriptive information for the measures is presented in Table I. Two children did not complete the CDI due to time constraints. Two additional children did not receive ratings on peer rejection or problematic behavior because their teachers failed to return this measure. Following the most conservative recommendation for handling missing data, we used the mean imputation method in which group means are substituted for missing scores (Tabachnick & Fidell, 2001
). Scores for our sample were similar to scores reported in previous studies on children with JRD (e.g., Noll et al., 2000; Schanberg et al., 2000). While the mean score for depressive symptoms was clearly below the level considered clinically significant, 9 children reported T scores greater than 50 and 4 children reported T scores greater than 60.
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Zero-order correlation analyses were conducted to examine the associations between depressive symptoms and disease as well as social variables. Results demonstrated significant associations between depressive symptoms and pain (r =.52, p =.001), rejection (r =.61, p =.000), and problematic behavior (r =.59, p =.000). Because we computed the correlation of depressive symptoms with five variables (disease severity, pain, disability, rejection, and problematic social behavior), we used the Bonferroni correction to control for the total number of correlations computed (
=.01). Two variables (disease severity and disability) were not significantly associated with depressive symptoms using this more stringent criteria. Next, a hierarchical regression was conducted in order to determine whether social variables had an incremental or moderating effect on depressive symptoms after controlling for medical variables. Only those variables that demonstrated significant associations with depressive symptoms were included in this analysis. Thus, pain was entered in the first step. Rejection and problematic social behavior (r =.66) were entered simultaneously in the second step. Finally, the interaction between pain and each of the social variables was entered in the third step.
Pain explained 27% of the variance in children's depressive symptoms, F(1,34) = 12.81, p =.001, ß =.52. Children with higher levels of pain reported more depressive symptoms. Although neither rejection (ß =.31) nor problematic social behavior (ß =.29) demonstrated a unique effect on depressive symptoms after controlling for pain, the combination of these social variables did have a significant incremental effect, F
(2,32) = 9.69, p =.001, explaining an additional 27% of the variance. Children who were rejected or who exhibited problematic social behavior reported more depressive symptoms than their better-accepted counterparts. Finally, the test of moderation revealed a significant effect, F(2, 30) = 5.65, p =.008, accounting for an additional 12% of the variance. Examination of the univariate effects revealed that rejection significantly moderated the association between pain and depressive symptoms (ß = 1.42, t = 2.62, p =.014).
In order to interpret this moderator effect, the relation between pain and depressive symptoms was determined for high, medium, and low levels of rejection (Aiken & West, 1991). As depicted in Figure 1, pain had the strongest association with depressive symptoms at high levels of rejection, a weaker association at intermediate levels of rejection, and no association at low levels of rejection. Thus, rejection exacerbated the positive impact of pain on depressive symptoms.
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Our results support the premise that childhood peer rejection and related interpersonal characteristics are associated with adjustment difficulties among children with JRD. Importantly, peer-related variables predicted a significant proportion of variance in children's depressive symptoms even after controlling for pain. In addition, peer rejection moderated the relation between pain and depressive symptoms, such that children who experienced high levels of pain and high levels of social rejection reported the greatest frequency of depressive symptoms. These findings are consistent with a growing body of literature documenting the importance of peer support in children's psychological adaptation to JRD (e.g., von Weiss et al., 2002
).
While the correlational design of our study precludes us from drawing any firm causal inferences from these results, we can envision several ways in which children's social relationships may be associated with disease management and adjustment. First, problematic social relationships may trigger the development of depressive symptoms in children with JRD. That is, a chronic lack of positive peer experiences and associated emotional support, in combination with high levels of pain, may lead rejected children to hold negative views about themselves, their relationships, and their future prospects. Alternatively, poor social relationships may be a consequence, rather than cause, of depressive symptoms. Children who feel poorly about themselves and who respond to peer overtures with negative mood, lethargy, or anhedonia may be viewed as undesirable or unresponsive play partners, ultimately leading to peer rejection. Or, there could be a reciprocal and mutually reinforcing relationship among pain, rejection, and depressive symptoms. Longitudinal research with healthy children has provided support for the premise that rejection is causally associated with depressive symptoms and other internalizing problems (e.g., Boivin, Hymel, & Bukowski, 1995); similar studies await replication in a JRD sample.
If such a causal pathway is supported by longitudinal research, it could have important implications for the comprehensive treatment of children with JRD. Specifically, we believe that physicians and medical care providers may have much to gain by assessing children's peer relations and behavioral characteristics as a routine part of the clinic visit, as they do medical status variables. The TCSB is a relatively brief, cost-effective, and reliable means of gathering such information and could help practitioners identify children who are actively disliked by peers, as well as those who engage in social behaviors that may place them on a rejection trajectory over time. Children who are flagged as socially at risk could then be referred to intervention programs designed to improve their interpersonal skills and boost classroom peer support. The addition of peer-support and social skills training programs to the traditional armamentarium of therapies designed to address pain, swelling, and disability may lead to a greater decrease in internalizing problems for those children at greatest risk. Reductions in internalizing problems may, in turn, be associated with greater medical compliance, less pain, and better overall adaptation to disease.
While the current study successfully highlights the important association between peer-relations variables and depressive symptoms in a JRD sample, several limitations are worth noting. First, the correlational nature of this study limits conclusions about directionality of effects. As previously mentioned, we need longitudinal and intervention studies in order to determine whether peer-related variables play a causal role in the psychosocial functioning of children with JRD. Second, we employed teacher ratings of children's overall acceptance, rejection, and social behavior in the classroom but did not access other important dimensions of peer support, including dyadic friendships or relationships with peers outside the classroom. In future studies, it will be important to examine the role of these potential sources of peer support. Finally, our study consisted of a very small, predominantly white sample in which most children scored in the low to middle range for pain and in the normative range for depressive symptoms. This restricted range of scores may have artificially weakened the observed relation between predictor and criterion variables. In future research, it will be important to collaborate with other pediatric rheumatology clinics in order to obtain a larger and more representative sample.
Received January 3, 2003; revision received March 25, 2003; accepted May 14, 2003
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