A Measure of Adjustment in the Thalidomide Child*
JEANNE MANNERS, B.A., M.PHIL.
A well-investigated area in the field of physical disability is that of the effect such a disability has on the emotional adjustment of the individual (Goffman 3 , Wright11). Among the many studies, Colman 2 tested the "role-conflict hypothesis" that individuals with a less obvious disability become more emotionally disturbed because their roles are not clearly defined as either "normal" or "handicapped." He related the self-ideal concept discrepancy (judged to be a measure of adjustment) to the degree of physical disability. Finding that the discrepancy was greater for less disabled subjects, Colman confirmed the hypothesis.
Colman's study is mentioned mainly because of its methodology; in fact he studied a group of people quite different from the subjects of the present study. His subjects, in company with those of the majority of studies in this area, had acquired physical disabilities and he therefore was studying the psychological effects of physical changes in the body. The problem of the thalidomide child, however, may be quite different, since his deformities are congenital. Neff and Weiss5 emphasize this difference by suggesting that whereas congenital disabilities may affect the developmental process, traumatic ones may disrupt an already stable pattern of cognitions about the world. It therefore cannot be assumed that the body of work on acquired disability necessarily applies to the population of thalidomide children.
Kellmer Pringle and Fiddes 4 have studied the emotional adjustment of thalidomide children as part of a larger study. They found in general, as Wright11 had predicted, that there was no consistent difference between the disabled and the "normal" population. Wright said that the effects of physical handicap may be neither direct nor consistent. However, a slight difference seemed to appear on close inspection of the data. In the thalidomide group the balance of the sexes in the maladjusted group is almost equal, whereas in the "normal" group, as in most surveys, the number of maladjusted boys outweighs the number of girls by about 2:1. The reason for this unusual finding may be that girls are more preoccupied with their physical appearance, and that when this is marred, symptoms of maladjustment manifest themselves.
The present study set out to measure adjustment at a critical age in the children's lives, the beginning of adolescence. This was seen as a period during which preoccuption with physical appearance would be at its height, and perhaps when signs of maladjustment would become evident. Stephenson's 8 Q-sort technique appeared to be an appropriate measure of adjustment. This technique requires the subject to sort a set of self-referent statements into groups according to the degree to which they describe his own and his ideal personality. In the present study each subject also sorted statements according to how they applied to "my best friend" in order to give a comparison of how he saw himself as compared with others. The discrepancy between the real self and the ideal self is a measure of adjustment: a large self-ideal discrepancy indicates poor adjustment. This aspect of the Q-sort technique has been investigated by Turner and Vanderlippe 9 .
In the present small study a group of 15 children (seven boys and eight girls), all damaged by the drug thalidomide, were compared with a group of ten "normal" children (five boys and five girls). The former group had a mean age of 139.5 months (SD = 11.5), the latter a mean age of 132.6 months (SD = 5.7). These children thus were matched on age and also were found to be comparable on verbal intelligence, as measured by the Short Form of the Wechsler Intelligence Scale for Children (WISC10), and on reading age as measured by the Schonell Graded Word Reading Test 7 . The children were seen individually, and all tasks were administered during one session. Questionnaire data also were obtained for each child to provide a measure of independence for the thalidomide group and a measure of psychiatric maladjustment (Rutter, et al . 6 ) for both groups. Questionnaires were completed by the parents or full-time caretakers in the thalidomide group and by the teachers in the normal group.
No differences were found between the groups on the measure of adjustment, and the prediction of more maladjustment in the thalidomide girls due to their growing preoccupation with their marred physical appearance was unconfirmed. Several factors were considered in relation to this finding. First is the possibility of error in the implicit assumption that at about 11 years, as the disabled subjects approached or entered adolescence, they would become more aware of their problems, giving rise to symptoms of maladjustment. This assumption may not be valid early in adolescence and yet it still may be true for older adolescents. Indeed, Blakeslee 1 points out that awareness of the difference between self and others does become acute during the adolescent period. Secondly, the Q-sort may not have been a truly valid measure of adjustment, although it certainly measures something of the child's feelings about himself. The correlation between the Q-sort scores and scores on the questionnaires was certainly nonsignificant, but this may reveal simply the difference between a self-reflective and a behavioural measure of adjustment. The questionnaire data may not be reliable with such severely disabled subjects, but this assumption would require further investigation. In general, it seemed that the thalidomide children were unable to use the Q-sort technique in the way the normal children could. The different sorts that these children made were intercorrelated (correlations significant at the five per cent level), indicating that their concepts of "myself," "my ideal self," and "my best friend" were all equivalent. This could be the result of denial of difficulties on the part of the thalidomide children, or it could be that these children all have lived in environments which have been protected in various ways, and that they do not yet appreciate the differences between themselves and others. Finally, in the matter of sample size, a larger sample may have given a more realistic impression of the facts.
Some further interesting findings were made. Predictably, the thalidomide group obtained lower performance scores on the WISC, with the difference between the two groups significant at the one per cent level. This difference must have been the result of the physical handicaps of the thalidomide children, since the performance section of the test depends on physical dexterity and speed to a large extent. Measures of handicap showed that severity of handicap correlated negatively with age (significant at five per cent level) and positively with high verbal Factor on the WISC (significant at one per cent level). This suggests that the handicap (as opposed to the disability) decreases as the child gets older, probably as he learns to cope in a more efficient fashion. The fact that good verbal ability is associated with a high degree of handicap is a most interesting finding and probably is a fact that many people have supposed to be true of physically handicapped individuals. Such a finding probably is attributable to the fact that the most physically handicapped individuals must rely on their verbal abilities, since they otherwise may have little to contribute. If such a finding were confirmed elsewhere it could make a contribution to the difficult task of vocational guidance for this group of severely disabled subjects.
The present study has produced some tentative conclusions about the development of the thalidomide child, conclusions which could lead to further research into both the emotional adjustment and the intellectual development of these children. Such information could have important implications for the future training both of this group of children and others with congenital handicaps.
Descriptors: Rehabilitation; psychological factors; congenital deficiencies, multiple; adolescents; sex factors.
St. Lawrence's Hospital, Caterham, Surrey, England
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