Variables Influencing Self-Esteem in Children with Congenital or Acquired Limb Deficiencies
LORI ANN RUBENFELD, MA., JAMES W. VARNI, PHD,DARLENE TALBOT, MSW AND YOSHIO SETOGUCHI, MD
Over the past two decades, numerous advances have been made in the fabrication of prostheses for children, particularly where appearance is concerned.1 Unfortunately, little has been accomplished toward an empirical understanding of the psychological and social needs of children with congenital or acquired limb deficiencies. The literature which does exist has been based upon clinical observations of children and adolescents who have an amputation as a result of bone sarcomas; patients experience difficulty developing a positive body image, and manifest depression, anxiety, and loss of self-esteem.2-8 Self-esteem is an important outcome measure for children with visible physical differences such as a limb deficiency. A growing number of studies have linked self-esteem with depressive symptornatology in children.9-10 Theoretically, the self-esteem construct reflects a child's cognitive appraisal of competence in areas that are deemed important (e.g., scholastic achievement, physical appearance, as well as the support which the child receives from significant others in the environment." From this perspective, children form their sense of self-esteem based largely on social interactions with their parents, teachers, and peers, and their perceived competence in areas which are generally important to them such as school, athletics, and social acceptance. Additionally, the family has been hypothesized as a critical determinant of the child's earliest and continuing concepts of self.12 The present study was designed to identify specific variables which influence self-esteem in children with limb deficiencies, with the expectation that such variables would provide target areas for clinical intervention.
Subjects and Procedures
The subjects for the present study were participants in a large ongoing evaluation project (Child and Adolescent Needs Project) being conducted at the University of California at Los Angeles Child Amputee Prosthetics Project. The project was designed to assess comprehensively the psychological and social adjustment of both children and adolescents with congenital and acquired limb deficiencies and their families. Forty-one children (26 boys and 15 girls) participated in the study. Their mean age was 10.5 years, with a range of 8 to 13 years (SD = 1.6). Thirty-four children had a congenital limb deficiency. The mean socioeconomic status based on education, occupation, gender and marital status was 42 (SD = 13.6).13
The construct of self-esteem was measured by the Self-Perception Profile for Children which yields a score of general self-esteem in addition to scores in perceived physical appearance, scholastic competence, behavioral conduct, social acceptance, and athletic competence.14
The construct of social support was measured by the Social Support Scale for Children which assesses the degree to which the child perceives support and regard from parents, teachers, close friends and classmates15 Family functioning was measured by the Family Environment Scale which was completed by each child's mother. 16
Results and Discussion
Demographic variables, specifically age, sex, socioeconomic scale, and degree of limb loss, were not significantly correlated with general self-esteem. All four of the social support domains (parent, teacher, close friend, and classmate) were significant predictors of general self-esteem, indicating that higher levels of perceived social support and positive regard from significant others in the child's life are associated with higher levels of general self-esteem. Of the four domains, classmate support was the most highly predictive (r = .55, p less than .001). The strong association between classmate support and self-esteem may reflect the negative values physically healthy children hold about cosmetic physical handicaps which may influence their behavior and attitudes toward children with limb deficiencies .17
Of the ten areas of family functioning assessed, two, namely conflict (r = -.39, p less than .005) and organization (r = .44, p less than .005), were found to be significantly related to general self-esteem. Higher family conflict (defined as the amount of openly expressed anger, aggression and conflict among family members) was associated with lower self-esteem. Similarly, higher organization in the family was associated with higher self-esteem. These findings are consistent with previous studies which indicate that the family is an important mediating factor in the child's adaptation to chronically ill and handicapping conditions18
It was not surprising that among the self-perception domains, perceived physical appearance was so strongly predictive of general self-esteem (r = .65, p less than .001). From this perspective, considerable value may exist in investigating the potential benefits of cosmetic prosthetic devices in enhancing general selfesteem in some children, particularly given the relationship between self-esteem and depressive symptomatology. Athletic competence was also significantly related to self-esteem, as were social acceptance, scholastic competence and behavioral conduct.
These results have implications for primary and secondary prevention efforts. Clinical interventions can be developed to modify the several predictor variables found to influence self-esteem. For example, social skills training may increase the child's ability to access social support from significant others in their environment. Adaptive physical education equipment may enable children with physical handicaps to participate actively in sports, increasing their athletic competence in addition to their acceptance by peers. Family therapy may facilitate a reduction in family conflict. Lastly, given the strong relationship between scholastic competence and general self-esteem, efforts toward improving academic performance (e.g., tutors, special programs) might contribute to greater overall self-esteem.
This research was supported by grants from the Shriners Hospital Research Fund and the Milo B. Brooks Foundation.
Child and Adolescent Needs Project, University of California Rehabilitation Center, 1000 Veteran Avenue, Room 25.26, Los Angeles, CA 90024
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