A Controlled Longitudinal Study of the Social Functioning of Children With Juvenile Rheumatoid Arthritis

[Guest guest]

A Controlled Longitudinal Study of the Social Functioning of Children With

Juvenile Rheumatoid Arthritis * Reiter-Purtill, MA, A.

Gerhardt, PhD, Vannatta, PhD, Murray H. Passo, MD and B.

Noll, PhD *

Children's Hospital Medical Center and the University of Cincinnati

All correspondence should be sent to B. Noll, Division of

Hematology/Oncology, Children's Hospital Medical Center, 3333 Burnet Ave.,

Cincinnati, Ohio 45229-3039. E-mail: nollr0@... .

Abstract Top

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Abstract

Introduction

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Method

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Results

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8e7cc6f57485956e64c64e182#SEC2>

Discussion

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8e7cc6f57485956e64c64e182#SEC3>

References

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8e7cc6f57485956e64c64e182#BIBL>

*Objective* To complete an assessment of social functioning of children with

juvenile rheumatoid arthritis (JRA) and nonchronically ill controls who had

been evaluated 2 years earlier (Noll et al., 2000[image:

Go]<http://jpepsy.oxfordjournals.org/cgi/content/full/28/1/17?ijkey=9412a8955f96\

4fe8e7cc6f57485956e64c64e182#REF27>)

and to examine the impact of disease severity or disease activity over time

on the social functioning of children with JRA. *Methods* Peer-, teacher-,

and self-reports of social functioning were obtained from 57 children with

JRA and 63 controls. Social reputation and social acceptance were examined

cross-sectionally and longitudinally. *Results* Cross-sectional analyses

indicated no significant differences between children with JRA and controls

on measures of social functioning. For children with more severe disease,

like ratings declined over the 2-year period relative to children with mild

disease. Children with active disease were chosen fewer times over the

2-year period as a best friend than children in remission.

*Conclusions* Because

children with severe or active JRA may be at risk for difficulties with

social acceptance over time, they are appropriate targets for interventions

that ameliorate or prevent these difficulties.

*Key words:* juvenile rheumatoid arthritis; children and adolescents; social

functioning; peer relationships; disease severity.

Introduction Top

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Abstract

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8e7cc6f57485956e64c64e182#ABS>

Introduction

Method

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8e7cc6f57485956e64c64e182#SEC1>

Results

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8e7cc6f57485956e64c64e182#SEC2>

Discussion

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8e7cc6f57485956e64c64e182#SEC3>

References

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8e7cc6f57485956e64c64e182#BIBL>

Juvenile rheumatoid arthritis (JRA) is a heterogeneous group of conditions

primarily distinguished by inflammation of the connective tissues (e.g., the

joints), JRA affects approximately 30,000-50,000 children each year in the

United States (Lawrence et al., 1998[image:

Go]<http://jpepsy.oxfordjournals.org/cgi/content/full/28/1/17?ijkey=9412a8955f96\

4fe8e7cc6f57485956e64c64e182#REF16>).

Children with JRA can experience chronic pain, stiffness in joints,

limitations in mobility, delayed puberty, and growth disturbances that can

lead to permanent disability and deformity. Approximately 10% of children

with JRA will experience severe functional disabilities as adults (Cassidy &

Petty, 1995[image:

Go]<http://jpepsy.oxfordjournals.org/cgi/content/full/28/1/17?ijkey=9412a8955f96\

4fe8e7cc6f57485956e64c64e182#REF6>).

Additional complications can involve the cardiac, pulmonary, ocular,

endocrine, and auto-immune systems. Long-term treatment of JRA, palliative

rather than curative, is multifaceted, often including medication, physical

and occupational therapy, orthopedic surgery, and nutritional support. Onset

of JRA appears to peak at ages 1-3 years and 8-12 years. It is more common

in girls than in boys and generally follows infection or physical trauma

(Cassidy & Petty, 1995[image:

Go]<http://jpepsy.oxfordjournals.org/cgi/content/full/28/1/17?ijkey=9412a8955f96\

4fe8e7cc6f57485956e64c64e182#REF6>;

Vandvik & Hoyeraal, 1993[image:

Go]<http://jpepsy.oxfordjournals.org/cgi/content/full/28/1/17?ijkey=9412a8955f96\

4fe8e7cc6f57485956e64c64e182#REF36>

).

With few exceptions (, Newcomb, & Gewanter, 1991[image:

Go]<http://jpepsy.oxfordjournals.org/cgi/content/full/28/1/17?ijkey=9412a8955f96\

4fe8e7cc6f57485956e64c64e182#REF12>

), studies of children with JRA suggest that they are at risk for

experiencing social difficulties, often attributed to the physical effects

of the disease and its treatment, as well as the many disruptions to daily

living that children with JRA experience. For instance, alterations in

appearance (e.g., swollen or deformed joints) may cause peers to react

negatively, and many forms of play and sports that stress affected joints are

restricted. Side effects from treatment (e.g., nausea and vomiting produced

by anti-inflammatory drugs), as well as medical procedures and frequent

visits to the doctor, may lead to repeated school absences and limited time

with peers (Lovell et al., 1990[image:

Go]<http://jpepsy.oxfordjournals.org/cgi/content/full/28/1/17?ijkey=9412a8955f96\

4fe8e7cc6f57485956e64c64e182#REF17>

).

These events have the potential to negatively affect the social functioning

of children with JRA. Several studies have reported that children with JRA

participate in fewer activities than nonchronically ill controls or siblings

(Billings, Moos, , & Gottlieb, 1987[image:

Go]<http://jpepsy.oxfordjournals.org/cgi/content/full/28/1/17?ijkey=9412a8955f96\

4fe8e7cc6f57485956e64c64e182#REF2>;

Timko, Stovel, Moos, & , 1992[image:

Go]<http://jpepsy.oxfordjournals.org/cgi/content/full/28/1/17?ijkey=9412a8955f96\

4fe8e7cc6f57485956e64c64e182#REF34>

). Children with JRA also have been described as socially isolated (Wilkinson,

1981[image:

Go]<http://jpepsy.oxfordjournals.org/cgi/content/full/28/1/17?ijkey=9412a8955f96\

4fe8e7cc6f57485956e64c64e182#REF40>),

as considering themselves less popular and attractive than healthy siblings

(Timko et al., 1992[image:

Go]<http://jpepsy.oxfordjournals.org/cgi/content/full/28/1/17?ijkey=9412a8955f96\

4fe8e7cc6f57485956e64c64e182#REF34>),

and as exhibiting lower social competence than population norms (Daltroy et

al., 1992[image:

Go]<http://jpepsy.oxfordjournals.org/cgi/content/full/28/1/17?ijkey=9412a8955f96\

4fe8e7cc6f57485956e64c64e182#REF7>).

Two studies have reported that adolescents with JRA are especially at risk

for poor social functioning (Billings et al., 1987[image:

Go]<http://jpepsy.oxfordjournals.org/cgi/content/full/28/1/17?ijkey=9412a8955f96\

4fe8e7cc6f57485956e64c64e182#REF2>;

Daltroy et al., 1992[image:

Go]<http://jpepsy.oxfordjournals.org/cgi/content/full/28/1/17?ijkey=9412a8955f96\

4fe8e7cc6f57485956e64c64e182#REF7>),

suggesting that deterioration in social functioning may accompany

adolescence. Finally, multiple studies have suggested that children with severe

forms of JRA experience more social difficulties than patients with mild or

inactive forms (Billings et al., 1987[image:

Go]<http://jpepsy.oxfordjournals.org/cgi/content/full/28/1/17?ijkey=9412a8955f96\

4fe8e7cc6f57485956e64c64e182#REF2>

; Timko et al., 1992[image:

Go]<http://jpepsy.oxfordjournals.org/cgi/content/full/28/1/17?ijkey=9412a8955f96\

4fe8e7cc6f57485956e64c64e182#REF34>;

Ungerer, Horgan, Chaitow, & Champion, 1988[image:

Go]<http://jpepsy.oxfordjournals.org/cgi/content/full/28/1/17?ijkey=9412a8955f96\

4fe8e7cc6f57485956e64c64e182#REF35>

).

Despite the evidence that children with JRA experience problems in social

functioning, a number of methodological problems have made findings

difficult to interpret. Such problems have included a failure to report

recruitment rates and the use of inappropriate comparison groups. Moreover,

most information about the social relationships and adjustment of children

with JRA has been provided by parents, teachers, or the child, but few

studies have reported data directly from the chronically ill child's peer

group.

The first purpose of this longitudinal investigation was to extend an

earlier study of the peer relationships of children with JRA and

nonchronically ill controls (Noll et al., 2000[image:

Go]<http://jpepsy.oxfordjournals.org/cgi/content/full/28/1/17?ijkey=9412a8955f96\

4fe8e7cc6f57485956e64c64e182#REF27>

) by repeating an assessment of social functioning 2 years later. In both

the initial study and this 2-year follow-up, methodological limitations of

previous work were addressed. In particular, a control group was recruited

during the initial assessment by pairing each child with JRA with a

classmate who was the same race, gender, and age. In addition, data were

obtained from multiple sources (e.g., teacher-, peer-, and self-reports) using

standardized measures. At the first assessment, Noll et al.

(2000[image:

Go]<http://jpepsy.oxfordjournals.org/cgi/content/full/28/1/17?ijkey=9412a8955f96\

4fe8e7cc6f57485956e64c64e182#REF27>)

reported no differences between the two groups on measures of social

reputation (What is the child like?) or social acceptance (Is the child

liked?).

Although no differences in social functioning were observed initially,

living with the physical effects and complications of JRA and its treatment,

as well as enduring continued daily hassles and disruptions, might result in

the emergence of social difficulties over time. In addition, 51% of the

children with JRA had made the transition from grade school to junior high or

high school while participating in this study. This transition is often

difficult for healthy children, but may be especially challenging for

children coping with a chronic illness. In this investigation, we

hypothesized that at the 2-year follow-up children with JRA would be

identified by peer-, teacher-, and self-reports as being more socially

withdrawn and isolated, as having fewer friends, and as being less popular

than their controls. The effects of gender and grade level in school

were examined

for possible interactions with group (JRA vs. control) across all measures.

Children with JRA were also compared to controls on a number of nonsocial

attributes related to chronic illness. Specifically, we hypothesized that

children with JRA would be perceived by peers as less attractive and

athletic than controls, as well as more tired, more physically ill, and more

often absent from school. Finally, the effects of disease severity (mild or

moderate/severe), activity (active or full/partial remission), and duration

on social functioning were examined. We expected that more severe disease

and a longer duration of disease would be associated with greater

difficulties in social functioning.

The second purpose of this investigation was to examine whether the role of

group (JRA vs. control), disease severity, and disease activity affected the

subsequent social functioning of children with JRA. We hypothesized that

children with JRA, especially those with more severe or active disease,

would experience increased social difficulties over time. These social

difficulties

included more socially withdrawn and isolated behavior, less popularity, and

fewer friends.

Method Top

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Abstract

<http://jpepsy.oxfordjournals.org/cgi/content/full/28/1/17?ijkey=9412a8955f964fe\

8e7cc6f57485956e64c64e182#ABS>

Introduction

<http://jpepsy.oxfordjournals.org/cgi/content/full/28/1/17?ijkey=9412a8955f964fe\

8e7cc6f57485956e64c64e182#BDY>

Method

Results

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Discussion

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References

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This follow-up study was part of a larger, longitudinal project examining

the psychosocial impact of pediatric chronic illness on children and their

families. The initial phase involved an assessment of the social functioning

of children with JRA and controls in the school (Noll et al., 2000[image:

Go]<http://jpepsy.oxfordjournals.org/cgi/content/full/28/1/17?ijkey=9412a8955f96\

4fe8e7cc6f57485956e64c64e182#REF27>)

followed by an assessment of family functioning in the home. Children with JRA

and their controls were followed prospectively 2 years later with a repeated

school-based assessment of social functioning.

*Participants*

Participants with JRA were recruited from patient rosters at a large,

pediatric tertiary care facility in the Midwest. This center is the only

treatment facility with board-certified pediatric rheumatologists within a

50-mile radius, and a hospital tax levy ensures treatment for disadvantaged

youths. Thus, nearly every child with JRA in the area receives

treatment at this

institution. Initial selection criteria for this study required that

children be 8-15 years of age, attending school without full-time special

education, and living within 50 miles of the medical center. All children

with JRA who participated in the initial study (*N* = 74) were potential

participants for this 2-year follow-up. Children with JRA were diagnosed

according to the classification standards of the American College of

Rheumatology

(Cassidy et al., 1986[image:

Go]<http://jpepsy.oxfordjournals.org/cgi/content/full/28/1/17?ijkey=9412a8955f96\

4fe8e7cc6f57485956e64c64e182#REF5>)

and were 10-17 years of age (*M* = 12.98 years, *SD* = 1.53) at the time of

second data collection. Mean time since diagnosis was approximately 8 years

(*M* = 98 months, *SD* = 37, range = 34-173 months). Of the 74 children

participating at time 1, 5 children with JRA no longer met inclusion

criteria (2 were living more than 50 miles from the medical center, 2 were

no longer in school, 1 was receiving full-time special education). Six

children could not be located, and 2 families and 4 schools declined to

participate, leaving 57 children with JRA (19 boys and 38 girls). For this

follow-up sample, type of disease at onset was classified as the following: (a)

pauciarticular (e.g., affecting four or fewer joints; *n* = 22); (

polyarticular (e.g., affecting five or more joints; *n* = 27); or ©

systemic (e.g., affecting other organ systems; *n* = 8). Disease course was

classified as (a) pauciarticular (*n* = 26), ( polyarticular (*n* = 25),

or © systemic (*n* = 6).

Controls were identified from a pool of children who participated in the

initial classroom study. This was accomplished by selecting a classmate who

was the same gender and race and who had the closest date of birth to the

child with JRA (see Noll et al., 2000[image:

Go]<http://jpepsy.oxfordjournals.org/cgi/content/full/28/1/17?ijkey=9412a8955f96\

4fe8e7cc6f57485956e64c64e182#REF27>).

This procedure was used so that illness status was not confounded with

multiple social, economic, or cultural risk factors (Masten,

1989[image:

Go]<http://jpepsy.oxfordjournals.org/cgi/content/full/28/1/17?ijkey=9412a8955f96\

4fe8e7cc6f57485956e64c64e182#REF20>).

Control families were screened to ensure that they did not have a child with

chronic illness. If a potential control's family declined participation,

then the next classmate whose birth date was closest to that of the target

child was contacted, until a family agreed to participate. Of the 74

controls who participated in the initial study, 4 children were living more

than 50 miles from the medical center, 4 children could not be located, and

3 schools declined to participate, leaving 63 controls (21 boys, 42 girls).

*Measures*

*Revised Class Play* (*Masten, Morison, & Pellegrini, 1985[image:

Go]<http://jpepsy.oxfordjournals.org/cgi/content/full/28/1/17?ijkey=9412a8955f96\

4fe8e7cc6f57485956e64c64e182#REF22>

*). The Revised Class Play (RCP) is a descriptive matching instrument that

requires students or teachers in a classroom to imagine that they are the

director of a play and to cast members of their class into roles of this

hypothetical play. Earlier factor analyses of peer nominations on the RCP

with younger children (grades 3-7) indicated that these roles are designed

to measure social reputation along three dimensions:

sociability—leadership, aggressive—disruptive,

and sensitive—isolated. Children are assigned scores for each item according

to the number of times they were nominated for each role, and these item

scores are summed for each source to create dimension scores (e.g.,

aggressive—disruptive). *Z*-score transformations of the dimension scores

are completed within each classroom to adjust for unequal class size prior

to conducting analyses (Masten et al., 1985[image:

Go]<http://jpepsy.oxfordjournals.org/cgi/content/full/28/1/17?ijkey=9412a8955f96\

4fe8e7cc6f57485956e64c64e182#REF22>).

These dimension scores have adequate psychometric properties and predict

later functioning (Hymel, Rubin, Rowden, & LeMare, 1990[image:

Go]<http://jpepsy.oxfordjournals.org/cgi/content/full/28/1/17?ijkey=9412a8955f96\

4fe8e7cc6f57485956e64c64e182#REF14>;

Masten et al., 1985[image:

Go]<http://jpepsy.oxfordjournals.org/cgi/content/full/28/1/17?ijkey=9412a8955f96\

4fe8e7cc6f57485956e64c64e182#REF22>;

Morison & Masten, 1991[image:

Go]<http://jpepsy.oxfordjournals.org/cgi/content/full/28/1/17?ijkey=9412a8955f96\

4fe8e7cc6f57485956e64c64e182#REF23>;

Noll, Bukowski, Rogosch, LeRoy, & Kulkarni, 1990[image:

Go]<http://jpepsy.oxfordjournals.org/cgi/content/full/28/1/17?ijkey=9412a8955f96\

4fe8e7cc6f57485956e64c64e182#REF25>;

Noll, LeRoy, Bukowski, Rogosch, & Kulkarni, 1991[image:

Go]<http://jpepsy.oxfordjournals.org/cgi/content/full/28/1/17?ijkey=9412a8955f96\

4fe8e7cc6f57485956e64c64e182#REF28>;

Rubin, 1993[image:

Go]<http://jpepsy.oxfordjournals.org/cgi/content/full/28/1/17?ijkey=9412a8955f96\

4fe8e7cc6f57485956e64c64e182#REF31>

).

Recently, it has been suggested that a four-factor structure for the RCP is

a more meaningful, alternative scoring system for a broader age range of

children (Zeller, Vannatta, Schafer, & Noll, 1999[image:

Go]<http://jpepsy.oxfordjournals.org/cgi/content/full/28/1/17?ijkey=9412a8955f96\

4fe8e7cc6f57485956e64c64e182#REF41>).

The four-factor structure continues to have dimensions related to

aggressive—disruptive and sensitive—isolated behaviors consistent with those

described by Masten et al. (1985[image:

Go]<http://jpepsy.oxfordjournals.org/cgi/content/full/28/1/17?ijkey=9412a8955f96\

4fe8e7cc6f57485956e64c64e182#REF22>)

for younger children, but the original sociability—leadership factor was

split into a popular—leadership and a prosocial factor. The

popular—leadership dimension consists of items that reflect popularity with

peers (e.g., someone everybody likes to be with) and leadership skills (e.g.,

someone who is a good leader). The prosocial factor consists of items

that pertain

to social etiquette with peers (e.g., someone who is polite, someone who

helps others). Internal consistencies for each factor were computed based on

this study's sample, and in general, the majority of factors demonstrated

adequate and comparable reliability (Cronbach's [image: {alpha}]s range from

..77 to .90 for peers, .46 to .73 for teachers, and .65 to .78 for

self-data). In addition, evidence for validity has been provided previously in

the pattern of associations with measures of peer acceptance (Zeller et al.,

1999[image:

Go]<http://jpepsy.oxfordjournals.org/cgi/content/full/28/1/17?ijkey=9412a8955f96\

4fe8e7cc6f57485956e64c64e182#REF41>

).

For this study, three roles were added that were relevant to chronic illness

(e.g., " someone who is sick a lot, " " someone who misses a lot of school, "

and " a person who is tired a lot " ), along with two roles related to physical

appearance and two roles related to athletic competence (Noll et al.,

1999[image:

Go]<http://jpepsy.oxfordjournals.org/cgi/content/full/28/1/17?ijkey=9412a8955f96\

4fe8e7cc6f57485956e64c64e182#REF26>

). The ratings for each role were standardized within gender for each

classroom. A single score for both physical appearance and for athletic

competence was created by combining the two items assessing each domain,

with higher scores indicating greater attractiveness and athletic ability

(Vannatta, Zeller, Noll, & Koontz, 1998[image:

Go]<http://jpepsy.oxfordjournals.org/cgi/content/full/28/1/17?ijkey=9412a8955f96\

4fe8e7cc6f57485956e64c64e182#REF38>).

These roles have been used in previous research, have discriminated between

children with a chronic illness and healthy children, and have been

associated concurrently with multiple domains of social reputation and

acceptance (Graetz & Shute, 1995[image:

Go]<http://jpepsy.oxfordjournals.org/cgi/content/full/28/1/17?ijkey=9412a8955f96\

4fe8e7cc6f57485956e64c64e182#REF11>;

Vannatta, Gartstein, Short, & Noll, 1998[image:

Go]<http://jpepsy.oxfordjournals.org/cgi/content/full/28/1/17?ijkey=9412a8955f96\

4fe8e7cc6f57485956e64c64e182#REF37>;

Vannatta, Zeller, et al., 1998[image:

Go]<http://jpepsy.oxfordjournals.org/cgi/content/full/28/1/17?ijkey=9412a8955f96\

4fe8e7cc6f57485956e64c64e182#REF38>

).

*Three Best Friends.* Children were asked to choose the three peers in their

class whom they thought of as their best friends. From these data, each

child was given a social preference score based on the number of times he or

she was chosen as a friend by peers and a mutual friendship score indicating

how many of his or her friendship selections were reciprocated.

*Z*-score transformations

of total and reciprocated best friend scores were completed separately for

boys and girls within each classroom to adjust for unequal class size. This

measure has been demonstrated to provide a stable and valid index of peer

acceptance (Bukowski & Hoza, 1989[image:

Go]<http://jpepsy.oxfordjournals.org/cgi/content/full/28/1/17?ijkey=9412a8955f96\

4fe8e7cc6f57485956e64c64e182#REF3>;

Gottman, Gonso, & Rasmussen, 1975[image:

Go]<http://jpepsy.oxfordjournals.org/cgi/content/full/28/1/17?ijkey=9412a8955f96\

4fe8e7cc6f57485956e64c64e182#REF10>

).

*Like Rating Scale* (*Asher, Singleton, Tinsley, & Hymel, 1979[image:

Go]<http://jpepsy.oxfordjournals.org/cgi/content/full/28/1/17?ijkey=9412a8955f96\

4fe8e7cc6f57485956e64c64e182#REF1>

*). This instrument assesses social preference by providing a measure of the

degree to which each child in the class is liked or disliked by peers. The

children are asked to rate each of their classmates and themselves on a

5-point Likert scale ranging from 1 (i.e., " someone you do not like " ) to 5 (

i.e., " someone you like a lot " ) (Asher et al., 1979[image:

Go]<http://jpepsy.oxfordjournals.org/cgi/content/full/28/1/17?ijkey=9412a8955f96\

4fe8e7cc6f57485956e64c64e182#REF1>).

For each child, an average social preference score was computed and then

converted to *Z*-scores for boys and girls within each classroom. This

measure has been shown to be a reliable index of a child's relative social

acceptance, with test-retest correlations of .81 to .86 over a 4-week

interval (Asher et al., 1979[image:

Go]<http://jpepsy.oxfordjournals.org/cgi/content/full/28/1/17?ijkey=9412a8955f96\

4fe8e7cc6f57485956e64c64e182#REF1>;

Ladd, 1981[image:

Go]<http://jpepsy.oxfordjournals.org/cgi/content/full/28/1/17?ijkey=9412a8955f96\

4fe8e7cc6f57485956e64c64e182#REF15>

).

*Severity Ratings.* At time 1 and time 2, disease severity was rated by a

pediatric rheumatologist as mild or moderate/severe based on disease onset

and course, the presence of vision problems, radiographic evaluation,

pharmacotherapy, the number of active joints, and the presence of functional

disability. At time 1, 49% of the children (*n* = 36) were classified as

having mild disease and 51% (*n* = 38) as having moderate/severe disease (Noll

et al., 2000[image:

Go]<http://jpepsy.oxfordjournals.org/cgi/content/full/28/1/17?ijkey=9412a8955f96\

4fe8e7cc6f57485956e64c64e182#REF27>).

At the 2-year follow-up, 27 of the children initially classified with mild

disease and 30 of the children with moderate/severe disease continued to

participate. Disease severity was unrelated to whether or not a child

continued to participate at time 2 ([image: {chi}]2 [1, *N* = 74] = .16, *ns

*). Disease severity ratings completed at time 2 were available for 53 of

the 57 children who participated at follow-up, as some of these children had

transitioned to other clinic or care facilities. Of these children,

40% (*n*= 21) continued to be classified as having

mild disease at time 2, while 53% (*n* = 28) were classified again as having

severe disease. For 8% of the children, the severity of disease changed over

time, from mild to moderate/severe (*n* = 2) or from moderate/severe to mild

(*n* = 2). In addition, each child's disease status was rated at times 1 and

2 as active or in full/partial remission. Active disease status was defined as

the presence of synovitis (swelling or painful loss of motion), while

partial remission was described as a lack of synovitis but continued use of

medication. At time 1, 55% (*n* = 41) of the children's disease status was

evaluated as active, and 45% (*n* = 33) had disease in full/partial

remission (Noll et al., 2000[image:

Go]<http://jpepsy.oxfordjournals.org/cgi/content/full/28/1/17?ijkey=9412a8955f96\

4fe8e7cc6f57485956e64c64e182#REF27>).

At time 1, 34 of the children who had active disease and 23 who were in

full/partial remission continued to participate at the 2-year follow-up.

Disease activity was unrelated to whether or not a child continued to

participate at time 2 ([image: {chi}]2 [1, *N* = 74] = 1.81, *ns*). Disease

activity ratings made at time 2 were available for 51 of the 57 children who

participated at follow-up. Of these children, disease status remained active

in 43% (*n* = 22) of the children and in full/partial remission in 29%

(*n*= 15) of the children. Twenty-seven percent of the children's

disease changed in status from active to in remission (*n* = 9) or from in

remission to active (*n* = 5). Because so few children experienced changes

in disease severity or activity, analyses were not completed to examine

change over time.

*Procedures*

The initial study of peer relationships and this 2-year follow-up required

informed consent/assent and were approved by the local institutional review

board. The procedures detailed here were used in both studies.

Data collection at time 2 occurred in 110 different classrooms and involved

meeting children as a group in their class at school, usually the English

class. English was chosen because it is a required class to which students

are usually assigned based on ability and level of interest. Thus, there is

an increased probability that each child's friends would be in that

class (Ollendick,

Greene, Weist, & Oswald, 1990[image:

Go]<http://jpepsy.oxfordjournals.org/cgi/content/full/28/1/17?ijkey=9412a8955f96\

4fe8e7cc6f57485956e64c64e182#REF29>).

Each child's teacher, along with available classmates who returned a

consent form

(90%; *N* = 2,250 of 2,489), completed the RCP. During administration of the

RCP, children in the class were given a roster listing all of their

classmates of the same gender as the target child to eliminate sex-role

stereotyped nominations and increase the probability of choosing the target

child. Children were asked to nominate one peer from the roster other than

himself or herself for each role and were told that they could use a name as

many times as they wanted if they thought a classmate could play more than

one role. The RCP was administered again, at which time the children were

asked to mark the roles that they thought they would be best at playing. For

the Three Best Friends measure, the children were given another list with the

names of every child in the class from which they could nominate their

first, second, and third best friend. Finally, the children were asked to

complete the Like Rating Scale. Although peer nomination methods of social

reputation and social acceptance such as these were initially developed for

school-age children, this methodology has been used successfully to assess the

social functioning of older children in junior high and high school

(Casiglia, Lo Coco, & Zappulla, 1998[image:

Go]<http://jpepsy.oxfordjournals.org/cgi/content/full/28/1/17?ijkey=9412a8955f96\

4fe8e7cc6f57485956e64c64e182#REF4>;

Luthar, 1995[image:

Go]<http://jpepsy.oxfordjournals.org/cgi/content/full/28/1/17?ijkey=9412a8955f96\

4fe8e7cc6f57485956e64c64e182#REF18>;

Luthar & McMahon, 1996[image:

Go]<http://jpepsy.oxfordjournals.org/cgi/content/full/28/1/17?ijkey=9412a8955f96\

4fe8e7cc6f57485956e64c64e182#REF19>

).

*Analyses*

Two-tailed independent *t* tests were conducted to compare families of

children with JRA and controls on demographic variables. In addition,

two-tailed, independent *t* tests were also used to compare groups of

children on measures of social reputation and social acceptance at time 2.

Correlational analyses were completed to examine the associations between

disease duration and all measures of social functioning, as well as the

degree of individual stability in RCP scores and measures of social acceptance

over 2 years. Finally, the effects of several disease variables on changes

in social functioning (i.e., RCP scores and measures of social acceptance)

over time were examined with a series of analyses of variance (ANOVA) with

repeated measures using time as a within-subjects variable and either type

of participant (JRA vs. control), disease severity (mild vs.

moderate/severe), or disease activity (full/partial remission vs. active) as

a between-subjects variable. Holm's procedure for multiple corrections was

applied to all comparisons not hypothesized a priori to control for Type I

error (Holland & Copenhauer, 1988[image:

Go]<http://jpepsy.oxfordjournals.org/cgi/content/full/28/1/17?ijkey=9412a8955f96\

4fe8e7cc6f57485956e64c64e182#REF13>

).1<http://jpepsy.oxfordjournals.org/cgi/content/full/28/1/17?ijkey=9412a8955f96\

4fe8e7cc6f57485956e64c64e182#FN1>Only

those significant results adjusted for

multiple comparisons are discussed.

Using GPOWER for power calculations (Faul & Erdfelder, 1992[image:

Go]<http://jpepsy.oxfordjournals.org/cgi/content/full/28/1/17?ijkey=9412a8955f96\

4fe8e7cc6f57485956e64c64e182#REF9>),

the sample of 120 children produced sufficient power (.77-.96) to detect

medium effects for *t* tests (*d* = .5) and for correlational analyses

(*d*= .3). For the repeated measures analyses

using type of participant as the between-subjects variable, the sample of

120 children produced adequate power to detect medium effects for the

between-subjects variable (.87), the within-subjects variable (.99), and the

within-between interaction term (.99). Finally, for the repeated measures

analyses using disease severity or disease activity as the

between-subjects variable,

the sample of 57 children permitted a medium effect size to be detected with

..57 power for the between-subjects variable, .96 power for the

within-subjects variable, and .96 for the within-between interaction term.

Results Top

<http://jpepsy.oxfordjournals.org/cgi/content/full/28/1/17?ijkey=9412a8955f964fe\

8e7cc6f57485956e64c64e182#top>

Abstract

<http://jpepsy.oxfordjournals.org/cgi/content/full/28/1/17?ijkey=9412a8955f964fe\

8e7cc6f57485956e64c64e182#ABS>

Introduction

<http://jpepsy.oxfordjournals.org/cgi/content/full/28/1/17?ijkey=9412a8955f964fe\

8e7cc6f57485956e64c64e182#BDY>

Method

<http://jpepsy.oxfordjournals.org/cgi/content/full/28/1/17?ijkey=9412a8955f964fe\

8e7cc6f57485956e64c64e182#SEC1>

Results

Discussion

<http://jpepsy.oxfordjournals.org/cgi/content/full/28/1/17?ijkey=9412a8955f964fe\

8e7cc6f57485956e64c64e182#SEC3>

References

<http://jpepsy.oxfordjournals.org/cgi/content/full/28/1/17?ijkey=9412a8955f964fe\

8e7cc6f57485956e64c64e182#BIBL>

*Attrition Analyses*

Mann-Whitney non-parametric tests were conducted to compare the subsample of

children who did not continue to participate at time 2 (*N* = 28) with those

children who did (*N* = 120). No significant differences were identified

between families of longitudinal and nonlongitudinal participants on

demographic variables (i.e., family socioeconomic status [sES] and

income, family

size, and parental age and education). Only one significant difference was

observed on the measures of social functioning. Nonlongitudinal participants

selected themselves significantly more often than longitudinal participants

for aggressive—disruptive roles on the RCP-self (*M*non = .16, *SD* = .95; *

M*long = -.22, *SD* = .81; *U* = 1161.50, *p* < .05). However, these

nonlongitudinal participants were not perceived as different from

longitudinal participants on this dimension of the RCP from the perspectives of

teachers or peers.

*Demographic and Background Factors*

Demographic information collected at time 1 was reanalyzed for those

families of children with JRA and control families who continued to

participate at the 2-year follow-up. Similar to results at time 1 (see Noll

et al., 2000[image:

Go]<http://jpepsy.oxfordjournals.org/cgi/content/full/28/1/17?ijkey=9412a8955f96\

4fe8e7cc6f57485956e64c64e182#REF27>),

the mean age for children with JRA (*M*JRA = 12.98 years, *SD* = 1.53) and

controls (*M*CC = 13.12 years, *SD* = 1.55) was similar, as were estimated IQ

scores (based on Vocabulary and Block Design subtests of WISC-R; *M*JRA =

108.2, *SD* = 16.2; *M*CC = 103.9, *SD* = 14.0). No significant differences

were observed for SES and income, family size, and parental age and

education. Duncan scores of SES (TSEI2; Nakao & Treas, 1992[image:

Go]<http://jpepsy.oxfordjournals.org/cgi/content/full/28/1/17?ijkey=9412a8955f96\

4fe8e7cc6f57485956e64c64e182#REF24>)

indicated that, on average, the heads of households for both groups held

positions in sales or management (*M*JRA = 49.4, *SD* = 20.3; *M*CC = 48.8,

*SD* = 19.2).

*Cross-Sectional Analyses of Social Functioning*

The first set of analyses was designed to examine the social reputation and

social acceptance of children with JRA and controls at the 2-year follow-up.

In addition, the effects of concurrent ratings of disease severity,

activity, and duration on social functioning were examined.

*Social Reputation*

We hypothesized that children with JRA would have difficulties with social

functioning relative to controls. Independent *t* tests were completed for

each dimension of the RCP for teacher-, peer-, and self-report. No

significant differences were observed (Table

I<http://jpepsy.oxfordjournals.org/cgi/content/full/28/1/17?ijkey=9412a8955f964f\

e8e7cc6f57485956e64c64e182#TBL1>

).

*View this table:*

[in this window]<http://jpepsy.oxfordjournals.org/cgi/content/full/28/1/17/TBL1>

[in a new

window]<http://jpepsy.oxfordjournals.org/cgi/content-nw/full/28/1/17/TBL1>

*Table I.* Peer Relationships of Children with JRA (*n* = 54-57) and

Controls (*n* = 60-63): Teacher, Peer, and Self-Nominations

To test for interactions between type of participant (JRA vs. control) with

gender or with grade level (based on a median split at 7th grade), ANOVAs

for all RCP dimensions were performed (2 x 2 design). All two-way

interactions with type of participant were nonsignificant.

Roles related to chronic illness (i.e., " sick a lot, " " misses a lot of

school, " and " tired a lot " ), physical appearance, and athletic competence

were also examined using independent *t* tests. No significant differences

were observed between children with JRA and controls according to peer

report. In ANOVAs, two-way interactions between type of participant and

gender or grade level were also nonsignificant for these roles.

*Social Acceptance*

Independent *t* tests were conducted on all measures of social acceptance.

No significant differences were identified between children with JRA and

controls on the number of times they were selected by peers as a best friend

or received reciprocated friendship nominations. In addition, analyses of

like ratings showed no significant differences between the two groups (Table

I<http://jpepsy.oxfordjournals.org/cgi/content/full/28/1/17?ijkey=9412a8955f964f\

e8e7cc6f57485956e64c64e182#TBL1>

). ANOVAs indicated that these results did not vary by gender or grade level

of the child.

*Disease Severity, Activity, and Duration*

Differences in social functioning were examined as a function of concurrent

ratings of disease severity and disease activity. No significant differences

were identified on any of the measures of social functioning (i.e., RCP

dimensions, Three Best Friends, and Like Rating Scale) for children with

moderate/severe disease relative to children with mild disease, nor for

children with disease in remission relative to children with active disease.

Analyses were also conducted to investigate the role of disease duration.

Correlations between the measures of social functioning and the number of

months since the child with JRA was diagnosed were completed. No significant

associations were identified.

*Stability of RCP Dimensions and Measures of Friendship Across Time*

Stability of individual differences in RCP scores and measures of friendship

and social acceptance from time 1 to time 2 were examined using

correlational analyses. This was done for the subsamples of children with

JRA and controls, as well as for the sample as a whole. Although

considerable stability was observed across time for most peer- and

self-report measures, less stability was apparent for teacher nominations on

the RCP (Table

II<http://jpepsy.oxfordjournals.org/cgi/content/full/28/1/17?ijkey=9412a8955f964\

fe8e7cc6f57485956e64c64e182#TBL2>).

This might be expected, given that these indices reflected the views of a

single rater and that the children had different teachers at time 2, and in

some cases, were at different schools (i.e., they had started junior high

school or high school). To examine if the magnitude of the correlations for

each measure differed between children with JRA and controls, Fisher's *r*to

*Z* transformations were performed. No significant differences in stability

were observed, indicating that individuals in both subsamples tended to

retain their relative position across measurement occasions.

*View this table:*

[in this window]<http://jpepsy.oxfordjournals.org/cgi/content/full/28/1/17/TBL2>

[in a new

window]<http://jpepsy.oxfordjournals.org/cgi/content-nw/full/28/1/17/TBL2>

*Table II.* Stability (*r*) of RCP Dimensions, Measures of Friendship, and

Like Ratings for Children With JRA (*n*JRA = 54-57), Controls (*n*c =

57-63), and the Entire Sample (*N* = 115-120)

*Change in Social Functioning From Time 1 to Time 2*

The effects of several disease variables on changes in social functioning

over time were examined. A series of ANOVAs with repeated measures was

completed with time as a within-subjects variable and either type of

participant (JRA vs. control), disease severity (mild vs. moderate/severe),

or disease activity (full/partial remission vs. active) as a

between-subjects variable. Time 1 ratings of disease severity and activity

were used for all longitudinal analyses, because these variables were

considered fairly stable over time, with few children experiencing change in

either disease classification. These analyses were conducted on all RCP

scores and on the measures of friendship and social acceptance.

*Type of Participant*

Mixed factorial ANOVA with time (within-subject) and type of participant

(between-subjects) revealed one significant main effect for type of

participant. On average, over the 2-year period, children with JRA were

selected by teachers more often for prosocial roles on the RCP than controls

(collapsing across time, marginal means: *M*JRA = .43; *M*CC = .03), *F*(1,

116) = 6.34, *p* <

..05.2<http://jpepsy.oxfordjournals.org/cgi/content/full/28/1/17?ijkey=9412a8955f\

964fe8e7cc6f57485956e64c64e182#FN2>

One interaction between type of participant and time was observed for peer

report on the sensitive—isolated dimension of the RCP, *F* (1, 117) = 5.28,

*p* < .05. While the overall interaction was significant, post hoc analyses

indicated that this interaction reflected trends rather than significant

effects of time for children with JRA (*M*1 = .05, *SD*1 = .93; *M*2 = .33,

*SD*2 = 1.22), *F*(1, 55) = 3.99, *p* < .10, and controls (*M*1 = .22, *SD*1=

1.11; *M*2 = .09, *SD*2 = 1.02), *F*(1, 62) = 1.37, *ns*. No main effects

for time were identified.

*Disease Severity*

For children with JRA, mixed factorial ANOVA with time 1 ratings of disease

severity as the between-subjects variable revealed no significant main

effects for group (mild vs. moderate/severe) or for time. However, several

interactions between group and time were observed. One significant

interaction was identified for the aggressive—disruptive dimension of the

RCP, *F*(1, 54) = 6.37, *p* < .05. Self-reported aggressive—disruptive scores

on the RCP increased significantly for children with mild disease (*M*1 =

-.43, *SD*1 = .52; *M*2 = .12, *SD*2 = 1.01), *F*(1, 26) = 7.21, *p* < .05,

while remaining relatively constant over time for children with

moderate/severe disease (*M*1 = -.21, *SD*1 = .90; *M*2 = -.28, *SD*2 =

..69), *F*(1, 28) = .07, *ns*.

Two additional interactions between disease severity group and time were

observed for the number of reciprocated best friends, *F*(1, 52) =

5.02, *p*< .05, and like ratings,

*F*(1, 54) = 7.51, *p* < .01. While the overall interaction was significant,

post hoc analyses revealed that the number of reciprocated best friends did

not change significantly over time for children with mild disease (*M*1 =

-.19, *SD*1 = .92; *M*2 = .25, *SD*2 = .87), *F*(1, 25) = 4.24, *p* < .10,

nor for children with moderate/severe disease (*M*1 = .07, *SD*1 =

..92; *M*2= -.18,

*SD*2 = .91), *F*(1, 27) = 1.33,

*ns*.3<http://jpepsy.oxfordjournals.org/cgi/content/full/28/1/17?ijkey=9412a8955\

f964fe8e7cc6f57485956e64c64e182#FN3>However,

like ratings deteriorated significantly for

children with moderate/severe disease (*M*1 = .14, *SD*1 = .82; *M*2 = -.22,

SD2 = .98), *F*(1, 28) = 5.67, *p* < .05, but did not significantly change

for children with mild disease (*M*1 = .10, *SD*1 = .97; *M*2 = .31, *SD*2 =

..74), *F*(1, 26) = 2.24, *ns*.

*Disease Activity*

For children with JRA, mixed factorial ANOVAs with time 1 ratings of disease

activity as the between-subjects variable were completed next. One

significant main effect for group (active vs. full/partial remission) was

observed. Children with active disease and children with disease in

remission differed on the number of times they were selected by peers as a

best friend, and these differences remained stable over time. On average,

over the 2-year time period, children with active disease were chosen fewer

times as a best friend than were children with their disease in

remission (collapsing

across time, marginal means: *M*act = -.22; *M*rem = .15), *F*(1, 55) = 4.47,

*p* <

..05.4<http://jpepsy.oxfordjournals.org/cgi/content/full/28/1/17?ijkey=9412a8955f\

964fe8e7cc6f57485956e64c64e182#FN4>

One significant main effect for time was observed for sensitive—isolated scores

on the RCP. All children with JRA, irrespective of disease activity,

experienced increasing sensitive—isolated scores on the RCP over time

according to peer report, (collapsing across groups, marginal means: *M*

time1 = .03; *M*time2 = .32), *F*(1, 54) = 4.60, *p* <

..05.5<http://jpepsy.oxfordjournals.org/cgi/content/full/28/1/17?ijkey=9412a8955f\

964fe8e7cc6f57485956e64c64e182#FN5>

No significant interactions between disease activity group and time were

found.

Discussion Top

<http://jpepsy.oxfordjournals.org/cgi/content/full/28/1/17?ijkey=9412a8955f964fe\

8e7cc6f57485956e64c64e182#top>

Abstract

<http://jpepsy.oxfordjournals.org/cgi/content/full/28/1/17?ijkey=9412a8955f964fe\

8e7cc6f57485956e64c64e182#ABS>

Introduction

<http://jpepsy.oxfordjournals.org/cgi/content/full/28/1/17?ijkey=9412a8955f964fe\

8e7cc6f57485956e64c64e182#BDY>

Method

<http://jpepsy.oxfordjournals.org/cgi/content/full/28/1/17?ijkey=9412a8955f964fe\

8e7cc6f57485956e64c64e182#SEC1>

Results

<http://jpepsy.oxfordjournals.org/cgi/content/full/28/1/17?ijkey=9412a8955f964fe\

8e7cc6f57485956e64c64e182#SEC2>

Discussion

References

<http://jpepsy.oxfordjournals.org/cgi/content/full/28/1/17?ijkey=9412a8955f964fe\

8e7cc6f57485956e64c64e182#BIBL>

This study evaluated the social functioning of children with JRA 2 years

after an initial study of their peer relationships and emotional well-being

(Noll et al., 2000[image:

Go]<http://jpepsy.oxfordjournals.org/cgi/content/full/28/1/17?ijkey=9412a8955f96\

4fe8e7cc6f57485956e64c64e182#REF27>).

We expected that social difficulties might emerge as children grew

older. Methodological

problems apparent in earlier work were addressed in both the initial study

and this 2-year follow-up by having an appropriate comparison group, data

from multiple sources, and reasonable recruitment and retention rates.

At the 2-year follow-up, cross-sectional analyses revealed that children

with JRA as a group were not different from controls on any of the measures

of social reputation or social acceptance. In addition, children with JRA

were not different from controls in terms of a number of nonsocial

attributes related to chronic illness, physical appearance, and athletic

competence, suggesting that peers did not perceive these children as

chronically ill. These findings did not vary by gender or by grade of the

child, even though the median split for grade level was near the

transition from

grade school to junior high or high school. Finally, concurrent measures of

disease characteristics such as severity, activity, and duration did not

affect social functioning at time 2. These findings of minimal social

difficulties for children with JRA are similar to our initial findings (Noll

et al., 2000[image:

Go]<http://jpepsy.oxfordjournals.org/cgi/content/full/28/1/17?ijkey=9412a8955f96\

4fe8e7cc6f57485956e64c64e182#REF27>

).

In contrast, longitudinal analyses provided evidence that social functioning

deteriorated slightly over time for some children with JRA. For instance, a

significant interaction between type of participant (JRA vs. control) and

time was identified for peer-reported withdrawn behavior. While post hoc

analyses revealed no significant change in these behaviors for either group

of children, there was a trend for peers to perceive children with JRA as

exhibiting increasing withdrawn behaviors over time (*p* = .051). In fact,

the increase in withdrawn behavior over time was significant in a separate

analysis involving disease activity. These results need to be replicated,

particularly with longer-term longitudinal research, as these trends

may continue

and strengthen over time. Additionally, children with more severe disease at

time 1 had declines in like ratings over time, whereas these scores did not

change significantly for children with mild disease. With respect to disease

activity at time 1, children with active disease were chosen fewer times as

a best friend at both assessment points than were children with disease in

remission.

These findings are consistent with a number of studies in which children

with JRA, particularly adolescents and children with more severe disease,

were found to be at risk for experiencing social difficulties. For instance,

studies have reported that older children with severe disease participated

in fewer activities with friends than controls, according to self-report

(Billings et al., 1987[image:

Go]<http://jpepsy.oxfordjournals.org/cgi/content/full/28/1/17?ijkey=9412a8955f96\

4fe8e7cc6f57485956e64c64e182#REF2>),

and exhibited lower social competence according to the Child Behavior

Checklist (CBCL; Daltroy et al., 1992[image:

Go]<http://jpepsy.oxfordjournals.org/cgi/content/full/28/1/17?ijkey=9412a8955f96\

4fe8e7cc6f57485956e64c64e182#REF7>).

In addition, Wilkinson (1981[image:

Go]<http://jpepsy.oxfordjournals.org/cgi/content/full/28/1/17?ijkey=9412a8955f96\

4fe8e7cc6f57485956e64c64e182#REF40>)

observed that adolescents ages 12 to 19 with severe JRA suffered from social

isolation as measured by the number of peer contacts they had during a

1-month period. While these studies used cross-sectional designs, Timko et

al. (1992[image:

Go]<http://jpepsy.oxfordjournals.org/cgi/content/full/28/1/17?ijkey=9412a8955f96\

4fe8e7cc6f57485956e64c64e182#REF34>)

assessed a group of children with JRA and their healthy siblings two times

over 1 year. At both assessments, children with JRA participated in fewer

activities with friends than healthy siblings, and those with severe disease

had fewer very good friends than children with mild disease or siblings.

Despite the comparable findings of some social difficulties for children

with JRA, this study was able to extend previous work in several ways.

First, many researchers have described social difficulties primarily in

terms of a decrease in the frequency of contacts with friends, as well as

the number of activities in which the child with JRA participated.

However, such

a decrease may be the result of functional limitations and life disruptions

(e.g., repeated visits to the doctor) that inhibit participation in

activities rather than poor social functioning (Daltroy et al., 1992[image:

Go]<http://jpepsy.oxfordjournals.org/cgi/content/full/28/1/17?ijkey=9412a8955f96\

4fe8e7cc6f57485956e64c64e182#REF7>;

Drotar, Stein, & Perrin, 1995[image:

Go]<http://jpepsy.oxfordjournals.org/cgi/content/full/28/1/17?ijkey=9412a8955f96\

4fe8e7cc6f57485956e64c64e182#REF8>).

This study suggested greater risk for difficulties in peer relationships for

some children with JRA, specifically in social withdrawal and social

acceptance. Peer relationships are considered central to healthy emotional

and social development ( & Asher, 1987[image:

Go]<http://jpepsy.oxfordjournals.org/cgi/content/full/28/1/17?ijkey=9412a8955f96\

4fe8e7cc6f57485956e64c64e182#REF30>),

and there is evidence that an early pattern of isolated and withdrawn

behavior is a risk factor for future difficulties with social acceptance by

peers, negative self-perceptions, excessive anxiety, and depression (Hymel et

al., 1990[image:

Go]<http://jpepsy.oxfordjournals.org/cgi/content/full/28/1/17?ijkey=9412a8955f96\

4fe8e7cc6f57485956e64c64e182#REF14>;

Rubin & Mills, 1988[image:

Go]<http://jpepsy.oxfordjournals.org/cgi/content/full/28/1/17?ijkey=9412a8955f96\

4fe8e7cc6f57485956e64c64e182#REF32>).

Over time, participation in fewer activities and diminished peer contact may

lead to having fewer friends (Daltroy et al., 1992[image:

Go]<http://jpepsy.oxfordjournals.org/cgi/content/full/28/1/17?ijkey=9412a8955f96\

4fe8e7cc6f57485956e64c64e182#REF7>

).

Using multiple sources of information about social difficulties was another

means by which this study extended previous findings. Most studies have

reported social difficulties for children with JRA from only one

perspective, usually the parent. In this study, social difficulties were

assessed from multiple sources. Reliance on parent report when assessing

social functioning may be particularly problematic, because parents

primarily observe their children at home rather than during direct

interactions with peers. For instance, the activities and social subscales of

the CBCL social competence measure have demonstrated poor concordance with

children's self-ratings and with peer nominations (Schneider & Byrne,

1989[image:

Go]<http://jpepsy.oxfordjournals.org/cgi/content/full/28/1/17?ijkey=9412a8955f96\

4fe8e7cc6f57485956e64c64e182#REF33>).

In this study, most of the findings indicating social difficulties were

based on peer report. Peers may be the best judges of a child's social

functioning, as they have the most daily interactions with the child. In

addition, peer report in this study consisted of multiple raters (i.e., the

child's classmates) of each child, thereby providing a more stable measure

of social functioning than single rater sources (e.g., teacher).

Several findings in this investigation that were not hypothesized are

noteworthy. First, teachers perceived children with JRA as being more

prosocial than controls over time. While this seems to be an indication of

better functioning for children with JRA, peers did not perceive them in

this manner. It is conceivable that the withdrawn, and therefore

nondisruptive, behavior of children with JRA is interpreted as

prosocial by teachers.

Second, self-report indicated that children with mild disease perceived

themselves as becoming more similar over time to their classmates with

respect to aggressive and disruptive behaviors, whereas children with severe

disease perceived themselves as remaining the same over time, specifically

that they engaged in less aggressive and disruptive activity than peers.

These findings suggest that children with mild disease may view themselves

as being less passive and as adjusting over time to the physical limitations

of the disease. In contrast, children with more severe disease may continue

to perceive themselves as being hindered by their physical limitations (e.g

.., chronically fatigued). Finally, a significant interaction between disease

severity (remission vs. active) and time was identified for the number of

reciprocated best friends. While post hoc analyses revealed no significant

change over time in these behaviors for either group of children, there was

a trend for children with mild disease to exhibit increasing reciprocated best

friends over time (*p* = .050). Improvement in social acceptance for

children with mild disease may be a result of the less disruptive nature of

their disease.

There are several limitations to this investigation. First, this study

obtained data from children at one treatment center. Replication at

different centers using a multisite approach is necessary. Second, a large

number of statistical tests were completed on this sample. Thus, spurious

effects must be considered when interpreting these results, and significant

findings need to be replicated. Finally, the cross-sectional results

of this study

appeared to indicate that children with JRA exhibited considerable

psychological hardiness. These results support the theory that the social

development of children is highly protected, with maladjustment occurring

only with exposure to severe adversity (e.g., family disruption or central

nervous system damage; Masten, Best, & Garmezy, 1990[image:

Go]<http://jpepsy.oxfordjournals.org/cgi/content/full/28/1/17?ijkey=9412a8955f96\

4fe8e7cc6f57485956e64c64e182#REF21>).

For example, children with central nervous system tumors demonstrate

considerable social deficits (Vannatta, Gartstein, et al., 1998[image:

Go]<http://jpepsy.oxfordjournals.org/cgi/content/full/28/1/17?ijkey=9412a8955f96\

4fe8e7cc6f57485956e64c64e182#REF37>),

while children with other forms of pediatric cancer do not (Noll et al.,

1999[image:

Go]<http://jpepsy.oxfordjournals.org/cgi/content/full/28/1/17?ijkey=9412a8955f96\

4fe8e7cc6f57485956e64c64e182#REF26>).

However, longitudinal analyses revealed subtle decrements in social

functioning over time for children with more severe or active disease. These

findings support disability/stress models that suggest that chronic illness

creates ongoing strain, requiring continuous adjustment, with the potential

for disrupting a child's psychosocial development (Wallander, Varni,

Babani, Banis,

& Wilcox, 1989[image:

Go]<http://jpepsy.oxfordjournals.org/cgi/content/full/28/1/17?ijkey=9412a8955f96\

4fe8e7cc6f57485956e64c64e182#REF39>).

Moreover, these results appear to fit a dose response model of disease

effects in which children with more severe or active disease have increasing

difficulties over time compared with children with milder disease.

This investigation is one of the few studies to examine social functioning

of children with chronic illness longitudinally. Future work might focus on

extending longitudinal studies, particularly into young adulthood. It is

also important to understand whether the slight deterioration in social

functioning observed in this study is associated with more clinically

significant social problems over time or with the development of

difficulties in emotional well-being, particularly internalizing

symptoms. Thus,

further research is needed to examine the social functioning and emotional

well-being of these children later in life.

In summary, our findings suggest that children with more severe or active

JRA are at risk for a slight increase in social difficulties over time. From

a clinical perspective, effect sizes in this study were small and,

therefore, may not be sufficient to warrant intervention for most children

with JRA. However, there may be subgroups of children with JRA who

experience increasing difficulties over time and would be appropriate

targets for interventions to ameliorate or prevent such difficulties in the

future. Thus, future research should focus on identifying the mechanisms

that result in increasing social difficulties over time for some children

with JRA. Such work is imperative for the evaluation and development of

interventions to improve the quality of social functioning among these

children.

Acknowledgments

This study was funded in part by a grant from the National Arthritis

Foundation.

The authors wish to acknowledge the special contribution of the families and

schools participating in this project. Portions of this article have been

presented at the annual meeting of the American Psychological Association,

Washington, DC, August 2000.

Notes

*This paper was reviewed and accepted during the term of the previous

editor, Anne E. Kazak, PhD, ABPP.*

1 In an attempt to avoid spurious findings (i.e., control familywise Type I

error), corrections for multiple comparisons were applied for exploratory

tests. In conducting tests of hypothesized effects, a less conservative

approach was taken to avoid inflation of Type II error. For these tests,

nondirectional, rather than directional, tests were used to limit Type I

error, but corrections were not applied for the number of analyses

performed. This more liberal approach was taken to increase power, given

that this investigation is one of the few studies to examine social functioning

of children with a chronic illness longitudinally. [image:

Back]<http://jpepsy.oxfordjournals.org/cgi/content/full/28/1/17?ijkey=9412a8955f\

964fe8e7cc6f57485956e64c64e182#RFN1>

2 Cell means for children with JRA: at time 1 (*M*1 = 0.34, *SD*1 = 1.16)

and at time 2 (*M*2 = 0.54, *SD*2 = 1.16). Cell means for controls: at time

1 (*M*1 = -.07, *SD*1 = .89) and at time 2 (*M*2 = 0.13, *SD*2 = 1.00). [image:

Back]<http://jpepsy.oxfordjournals.org/cgi/content/full/28/1/17?ijkey=9412a8955f\

964fe8e7cc6f57485956e64c64e182#RFN2>

3 To aid in the interpretation of the Reciprocated Best Friends scores,

descriptive statistics are provided using the raw data. Cell means for

children with mild disease: at time 1 (*M*1 = 1.30, *SD*1 = .99) and at time

2 (*M*2 = 1.81, *SD*2 = .98). For children with severe disease: at time 1 (*

M*1 = 1.53, *SD*1 = 1.04) and at time 2 (*M*2 = 1.45, *SD*2 = .83). Scores

ranged from 0 to 3 for both groups of children. [image:

Back]<http://jpepsy.oxfordjournals.org/cgi/content/full/28/1/17?ijkey=9412a8955f\

964fe8e7cc6f57485956e64c64e182#RFN3>

4 Cell means for children with active disease: at time 1 (*M*1 = -.31,

*SD*1= .76) and at time 2 (

*M*2 = -.13, *SD*2 = .77). For children with their disease in remission: at

time 1 (*M*1 = .18, *SD*1 = .93) and at time 2 (*M*2 = .12, *SD*2 = .95). To

aid in the interpretation of the Best Friends scores, descriptive

statistics are

also provided using the raw data. For children with active disease: at time

1 (*M*1 = 2.06, *SD*1 = 1.48) and at time 2 (*M*2 = 2.41, *SD*2 = 1.37).

Scores ranged from 0 to 6 nominations at time 1 and 0 to 5 at time 2. For

children with disease in remission: at time 1 (*M*1 = 2.83, *SD*1 = 1.80)

and at time 2 (*M*2 = 2.74, *SD*2 = 1.42). Scores ranged from 0 to 8

nominations at time 1 and 0 to 5 at time 2. [image:

Back]<http://jpepsy.oxfordjournals.org/cgi/content/full/28/1/17?ijkey=9412a8955f\

964fe8e7cc6f57485956e64c64e182#RFN4>

5 For children with active disease: at time 1 (*M*1 = .20, *SD*1 = .93) and

at time 2 (*M*2 = .39, *SD*2 = 1.24). For children with their disease in

remission: at time 1 (*M*1 = -.18, *SD*1 = .91) and at time 2 (*M*2 = .24, *

SD*2 = 1.21). [image:

Back]<http://jpepsy.oxfordjournals.org/cgi/content/full/28/1/17?ijkey=9412a8955f\

964fe8e7cc6f57485956e64c64e182#RFN5>

*Received May 21, 2001;* *revision received October 16, 2001;* *accepted

December 3, 2001*

References Top

<http://jpepsy.oxfordjournals.org/cgi/content/full/28/1/17?ijkey=9412a8955f964fe\

8e7cc6f57485956e64c64e182#top>

Abstract

<http://jpepsy.oxfordjournals.org/cgi/content/full/28/1/17?ijkey=9412a8955f964fe\

8e7cc6f57485956e64c64e182#ABS>

Introduction

<http://jpepsy.oxfordjournals.org/cgi/content/full/28/1/17?ijkey=9412a8955f964fe\

8e7cc6f57485956e64c64e182#BDY>

Method

<http://jpepsy.oxfordjournals.org/cgi/content/full/28/1/17?ijkey=9412a8955f964fe\

8e7cc6f57485956e64c64e182#SEC1>

Results

<http://jpepsy.oxfordjournals.org/cgi/content/full/28/1/17?ijkey=9412a8955f964fe\

8e7cc6f57485956e64c64e182#SEC2>

Discussion

<http://jpepsy.oxfordjournals.org/cgi/content/full/28/1/17?ijkey=9412a8955f964fe\

8e7cc6f57485956e64c64e182#SEC3>

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--

" So, now I shall talk every night. To myself. To the moon. I shall walk, as

I did tonight, jealous of my loneliness, in the blue-silver of the cold

moon, shining brilliantly on the drifts of fresh-fallen snow, with the

myraid sparkles. I talk to myself and look at the dark trees, blessedly

neutral. So much easier than facing people, than having to look happy,

invulnerable, clever. With masks down, I walk, talking to the moon, to the

neutral impersonal force that does not hear, but merely accepts my being.

And does not smite me. "

- Sylvia Plath