Perceived Social Support, Psychological Adjustment, and Functional
Ability in Youths With Physical Disabilities
Sylia Wilson, Lindsay A. Washington, Joyce M. Engel, Marcia A. Ciol, and Mark P. Jensen University of Washington Objective: To examine the relationship between perceived social support and psychological adjustment and functional ability in youths with physical disabilities. Participants: Thirty-seven youths with neuromuscular disease and 33 with spina bida. Measures: Demographic and disability-related ques- tions, Child Health Questionnaire, Functional Disability Inventory, and Multidimensional Scale of Perceived Social Support. Results: Social support from family, but not from friends, was signicantly associated with better psychological adjustment. Signicant interactions emerged between family support and age, as well as between friend support and gross motor functioning, in the prediction of functional ability. Conclusions: Social support appears to play an important role in psychological adjustment and functional ability in this population, and the nature of this role may be moderated, to some extent, by age and gross motor functioning. Future research and clinical implications are discussed. Keywords: social support, physical disabilities, psychological adjustment, functional ability Youths living with physical disabilities face a variety of unique stressors, including restrictions in routine daily activities and par- ticipation, limited independence, and coping with differences be- tween themselves and their peers (Varni, Setoguchi, Rappaport, & Talbot, 1992). In addition to the demands associated with typical development, these youths must also cope with disability-specic stressors and, therefore, face increased psychological and physical demands associated with their diagnosis (Patterson & Geber, 1991; see also Appleton et al., 1997; Bennet, 1994; Holmbeck et al., 2003; Lavigne & Faier-Routman, 1992; Wallander & Thompson, 1995). A number of factors that may be associated with the psycho- logical adjustment of this population have been examined in pre- vious research, including perceived social support and functional ability. Both of these have emerged as signicant predictors of adjustment in youths with physical disabilities. Higher levels of social support and higher functional status are each positively associated with good psychological adjustment in youths with a number of physical disabilities. Varni, Setoguchi, Rappaport, and Talbot (1991), for example, found that low levels of social support from classmates increased the risk of depression and low self- esteem in youths with limb deciencies. Furthermore, Witt, Riley, and Coiro (2003) found, in a nationally representative sample, that lower youth functional status, independent of physical limitation, was associated with psychosocial maladjustment. Similar results have been found for a number of other diagnoses, including diabetes (La Greca et al., 1995), limb deciencies (Varni & Se- toguchi, 1991; Varni et al., 1992), juvenile rheumatoid arthritis (JRA; Varni, Wilcox, & Hanson, 1988; von Weiss et al., 2002), and spina bida (SB; Hommeyer, Holmbeck, Wills, & Coers, 1999). For more detailed reviews of the effects of social support and functional status on psychological adjustment in youths, see La Greca, Bearman, and Moore (2002), Lavigne and Faier-Rout- man (1993), and Wallander and Varni (1995). Although these studies focus on the role of social support in the lives of youths with physical disabilities, there is a lack of research investigating the relationship between social support and func- tional ability. Given past research indicating that social support is positively associated with psychological adjustment in youths with physical disabilities and that physical disability often impacts functional ability, the present study sought to specically examine the interaction between these factors. A search of the relevant literature revealed a paucity of research examining the relationship between social support and functional ability in youths with physical disabilities, though a link may well exist. Research with adults has examined the predictive effects of social support on functional ability in persons with physical dis- abilities and chronic illnesses. Evers, Kraaimaat, Geenen, Jacobs, and Bijlsma (2003) and Travis, Lyness, Shields, King, and Cox (2004) found that low levels of social support predicted poorer functional ability in adults with rheumatoid arthritis and depres- sion, respectively. This adult research suggests that it is likely that youths with physical disabilities may also benet from social support. For example, youths who have mild-to-moderate gross motor restrictions and who are able to participate in educational and extracurricular activities may have more opportunity for in- Sylia Wilson, Lindsay A. Washington, Joyce M. Engel, Marcia A. Ciol, and Mark P. Jensen, Department of Rehabilitation Medicine, University of Washington. This research was supported by Grant PO1 HD33988 from the National Institutes of Health and Child Health and Human Development, National Center for Rehabilitation Research. We gratefully acknowledge the con- tributions of Kristie Bjornson, Ciara Kim, Chiara LaRotonda, Kimberly McKearnan, Laura Nishimura, and Emily Phelps, Department of Rehabil- itation Medicine, University of Washington, in data collection and database management. Correspondence concerning this article should be addressed to Sylia Wil- son, Department of Rehabilitation Medicine, University of Washington, Box 356490, Seattle, WA 98195-6490. E-mail: sylia@u.washington.edu Rehabilitation Psychology 2006, Vol. 51, No. 4, 322330 Copyright 2006 by the American Psychological Association 0090-5550/06/$12.00 DOI: 10.1037/0090-5550.51.4.322 322 teraction and friendship with peers compared with those with more severe restrictions. This social interaction may, in turn, positively inuence these youths functional ability because it allows for increased participation, encouragement from peers, and exposure to extracurricular activities. A number of studies have examined social support on a global level (i.e., social support in general) and its association with functioning in youths. For example, Wallander and Varni (1989) found that children with a variety of chronic illnesses who reported high levels of support from both family and friends exhibited fewer behavior problems than did children who reported support from only one source. Research suggests, however, that the dif- ferent types of social support (i.e., that from family vs. that from friends or peers) experienced by youths may play differential roles in predicting psychological adjustment and functional status. Varni et al. (1988), for example, found that family, but not peer, support signicantly predicted both internalizing and externalizing behav- ior problems in youths with JRA. It is also possible that different types of social support may play different roles in adjustment as youths age (Kashani, Caneld, Borduin, Soltys, & Reid, 1994). In examining psychological ad- aptation in youths with diabetes, for example, Varni, Babani, Wallander, Roe, and Frasier (1989) found that perceived family support predicted adaptation in children whereas perceived friend support predicted adaptation in adolescents. This suggests the possibility that perceived social support from friends might in- crease in importance as children move into adolescence. To better understand the role that social support may play in persons with physical disabilities, the present study investigated the relationship between perceived social support and psycholog- ical adjustment and functional ability in youths with neuromuscu- lar disease (NMD) and SB. These two disability types were in- cluded both because of their commonality in the general population and because little is as yet known about them. The potentially moderating roles that age and gross motor functioning, an indicator of functional ability, may play in the association between social support and functioning are also examined. Given previous research in this area, our primary hypothesis was that higher perceived social support would be associated with better psychological adjustment in the sample, as indicated by higher scores on a mental health scale. On the basis of research with adults with physical disabilities and chronic illnesses, we further hypothesized that youths with higher perceived social support would report higher functional status. Finally, our third hypothesis was that age and gross motor functioning would moderate the association between perceived social support and both psycholog- ical adjustment and functional status of participants. Specically, we predicted that perceived friend support would be more impor- tant for psychological adjustment in older youths and that per- ceived family support would be more important for younger youths. Similarly, we predicted that perceived social support would show a stronger association with functioning among youths with higher gross motor functioning than among youths with lower levels of gross motor functioning. Method The data for this study came from a larger ongoing study of youths with physical disabilities on the nature and scope of pain in this population. The present article is the rst to examine data from this larger study. The present analyses focus on a subset of the measures obtained during youth interviews and from parent questionnaires that address issues related to youth-reported perceived social support, psychological adjustment, and functional ability, as well as parent/guardian-reported demographic infor- mation and disability level. Participants Participants were a convenience sample of youths with NMD (n 37) and SB (n 33), and their parents/guardians, from the greater Seattle, Washington, metropolitan area. Inclusion criteria included (a) a primary diagnosis of NMD or SB; (b) chronological age between 8 and 20 years; (c) capacity for expressive communication using augmentative communica- tion devices as needed, although, in fact, none of the participants in the present study used such devices during the interview; (d) no more than mild cognitive impairment as determined by a brief telephone screening with the parent/guardian and a minimum passing score of 17/25 on a modied Mini-Mental Status Examination (MMSE; Roccaforte, Burke, Bayer, & Wengel, 1992); and (e) use of English as the primary language. The MMSE has been successfully used in children as young as 4 years (Ouvrier, Goldsmith, Ouvrier, & Williams, 1993). The minimum passing score of 17/25 is the cutoff score suggested by Roccaforte et al. If the MMSE was conducted over the telephone, as opposed to in person, participants were not assessed on the motoric component of the examina- tion and, therefore, required a passing score of 15/22. See Table 1 for further demographic information. Materials Structured interviews for the youths and questionnaires for the parents/ guardians included questions and measures that assessed demographic information; disability level; psychological adjustment; impact of pain, illness, and disability on functioning; and perceived social support. Demographic data. Descriptive demographic data collected from the parent/guardian included the youths age and sex and the total family household income. Disability level. To assess gross motor functioning, we asked parents/ guardians to respond to a modied version of the Gross Motor Functioning Classication Scale (GMFCS; Palisano et al., 1997). The GMFCS was developed for use with the cerebral palsy population. The items were adapted slightly in the present study to accommodate for the multiple physical disabilities represented in our sample. The specic items used in the present study were the following: I walks without restrictions but has limitations in more advanced gross motor skills; II walks without an assistive device and has limitations walking outdoors and in the commu- nity; III walks with an assistive mobility device and has limitations walking outdoors and in the community; IV limited self-mobility with assistance or device (e.g., another person, walker, wheelchair) and uses power mobility outdoors and in community only; and V severely limited self-mobility even with the use of assistive technology (e.g., power mo- bility). Lower scores on the gross motor functioning scale indicate a higher level of functioning. Psychological adjustment. Youth participants answered questions from the Mental Health (MH) Scale from the child form of the Child Health Questionnaire (CHQCF87; Landgraf, Abetz, & Ware, 1996). The CHQCF87 is an 87-item self-report measure designed to assess youths physical and psychosocial well-being. The questionnaire is divided into 12 scales and includes a 16-item MH Scale, which measures the frequency of negative and positive states and is designed to capture anxiety, depression, and positive affect. Using this measure, participants rate how often they experienced different moods and feelings in the past 4 weeks on a 5-point Likert scale ranging from 1 (all of the time) to 5 (none of the time). A low score on the CHQCF87 MH Scale indicates that the child feels anxious 323 PERCEIVED SOCIAL SUPPORT IN YOUTHS and depressed all of the time, whereas a high score indicates that he or she feels peaceful, happy, and calm all of the time. The CHQCF87 is scored by rst computing a raw score, then transforming raw scores to standard- ized scores, using the method outlined by Landgraf et al. Standardized scores range from 0 to 100. The CHQCF87 MH Scale has demonstrated adequate internal consistency in samples of youths with psychological and physical diagnoses (e.g., attention decit hyperactivity disorder, asthma, JRA, and epilepsy; Cronbachs .82.86; Landgraf et al., 1996). The alpha for our sample was .88. The scale has also demonstrated substantial validity for measuring youths psychosocial well-being (Landgraf et al., 1996). Impact of illness, pain, or disability. Youth participants reported the impact of illness, pain, or disability on their physical and psychosocial functioning in everyday social roles by answering questions from the Functional Disability Inventory (FDI; Walker & Greene, 1991). The FDI is used to provide information on disruption of typical physical and social activities, including schoolwork, caused by illness, pain, or disability. Though this measure does not isolate pain as the primary contributor to functional impairment, it does provide insight into activity interference, an important aspect of this study. The FDI is comprised of 15 behaviors related to functioning in child-relevant settings, such as In the last few days, would you have had any physical trouble or difculty doing these activities (e.g., being at school all day)? Using the FDI, respondents rate the amount of difculty of each activity on a 5-point Likert scale ranging from 0 (no trouble) to 4 (impossible). The FDI is scored as a total sum of items. This score ranges from 0 to 60. We prorated FDI items left blank in the present study by calculating means based on answered items. The FDI is scored such that lower scores indicate a higher level of functional ability. The FDI has demonstrated good internal consistency in samples of youths with minor health complaints (e.g., dysmenorrhea, gastrointestinal upset, upper respiratory infections) and pediatric abdominal pain (Cronbachs .85.92; Walker & Greene, 1991). It has also been used in studies of recurrent headache, juvenile idiopathic arthritis, and sickle cell disease (Logan & Scharff, 2005; Peterson & Palermo, 2004). The alpha for our sample was .82. Evidence for the validity of the FDI as a measure of illness, pain, or disability comes from its signicant correlation with scores on other measures of physical and emotional health (Walker & Greene, 1991). Perceived social support from family and friends. Youth participants reported on perceived social support from family and friends by answering 8 items from the Multidimensional Scale of Perceived Social Support (MSPSS; Zimet, Dahlem, Zimet, & Farley, 1988). The original MSPSS is a 12-item self-report measure of perceived social support from family (4 items), friends (4 items), and a signicant other (4 items). For the present study, we used only those 8 items assessing perceived social support from family and friends, as we did not anticipate that the majority of participants in the present study would have a signicant other. For each item, participants rate their level of agreement on a 7-point Likert scale ranging from 1 (very strongly disagree) to 7 (very strongly agree). The MSPSS is scored as a total summed score for each of the subscores (family support and friend support). These subscores can range from 4 to 28. Higher scores on the MSPSS indicate a higher level of perceived social support. The MSPSS was shown to have good internal consistency in a typically developing adult sample (Cronbachs .88 for the global score; Zimet et al., 1988). Our sample had similarly high alphas (.86 for the global score, .80 for the family score, and .88 for the friend score). Validity of the original MSPSS scale comes from research that demonstrates its signicant negative association with depression and anxiety (Zimet et al., 1988). To our knowledge, the MSPSS has not yet been used to assess perceived social support in samples of youths. Procedure The study participants were recruited through mailings from clinics at the local regional childrens hospital, as well as through public postings, word of mouth, and, for some of the participants with NMD, a local summer camp for youths with muscular dystrophy. All of the participants and participating parents/guardians gave written informed assent/consent, and the study was approved by Childrens Hospital and Regional Medical Centers Institutional Review Board (Seattle, WA). Youth participants completed one-time, in-person interviews in the participants home, at the University of Washington Medical Center, at a local summer camp, or over the telephone. Youths were interviewed in a private setting whenever possible to minimize potential response interference from family members and to ensure privacy. Parents/guardians of participating youths also com- pleted brief questionnaires, either during the youth interview or by mail. Table 1 Demographic Characteristics Variable n % Sex Male 42 60 Female 28 40 Ethnicity a Caucasian 57 81 Asian 6 9 African American 3 4 Hispanic 3 4 American Indian 1 1 Family income b Under $10,000 3 6 $10,000$20,000 3 6 $20,000$30,000 5 10 $30,000$40,000 10 20 $40,000$50,000 5 10 $50,000$60,000 4 8 $60,000$70,000 3 6 Over $70,000 17 34 Neuromuscular disease diagnosis a Duchenne muscular dystrophy 11 30 Myotonic muscular dystrophy 6 16 Spinal muscular atrophy 6 16 CharcotMarieTooth 5 14 Becker muscular dystrophy 2 5 Congenital muscular dystrophy 2 5 Limb-girdle muscular dystrophy 2 5 Facioscapulohumeral muscular dystrophy 1 3 Other 2 5 Spina bida diagnosis Myelomeningocele 24 73 Meningocele 5 15 Other 4 12 Hydrocephalus 23 70 Gross motor functioning c I 21 30 II 18 26 III 3 4 IV 14 20 V 14 20 Note. N 70. Age: M 14.51, SD 3.06, range 920. a Percentages may not equal 100% because of rounding. b Total N may not equal 70 because of missing data. c I walks without restrictions but has limitations in more advanced gross motor skills; II walks without an assistive device and has limitations walking outdoors and in the commu- nity; III walks with an assistive mobility device and has limitations walking outdoors and in the community; IV limited self-mobility with assistance or device (e.g., another person, walker, wheelchair) and uses power mobility outdoors and in community only; V severely limited self-mobility even with the use of assistive technology (e.g., power mobility). 324 WILSON, WASHINGTON, ENGEL, CIOL, AND JENSEN Data Analysis Correlation coefcients were computed between continuous measures of demographic/descriptor variables (age and gross motor functioning), cri- terion variables (psychological adjustment and functional disability), and predictor variables (perceived family and friend support) to estimate the strength of the associations between the variables used in this study. We performed t tests to determine if sex or ethnicity (coded as Caucasian/non- Caucasian) were associated with the criterion and predictor variables. A series of chi-square and t-test analyses were conducted to determine whether participants with NMD and SB differed on demographic/descrip- tive (age, sex, ethnicity, and gross motor functioning), criterion (psycho- logical adjustment and functional disability), or predictor (perceived family and friend support) variables. Any signicant differences on these variables would suggest that the two groups were too dissimilar to collapse for primary regression analyses and should, therefore, be analyzed separately. Regression analyses were used to test the hypothesis that perceived social support was signicantly associated with psychological adjustment and functional ability. In these analyses, the CHQCF87 MH Scale and the FDI were the criterion measures, and the MSPSS Family and Friend subscales were the primary predictors. We followed West, Aiken, and Krulls (1996) suggestion that predictor variables be centered prior to computing interaction terms by rst subtracting the mean score from each participants MSPSS family and friend score. Any signicant univariate associations between demographic control variables (sex and ethnicity) would suggest the possibility that such variables might confound the association between perceived social support and psychological adjustment or functional ability, and, therefore, any such variable that showed a signicant univariate association with the criterion variables was entered as control variables in the rst step of the regression analyses. The primary predictors (perceived family and friend support) were then entered as a block in the next step. To determine the extent to which age or gross motor functioning might act as moderators of the association between perceived social support and psychological adjustment and functional ability, we entered age and the participants gross motor functioning scores next in separate regression analyses, and we entered, stepwise, a term representing the interaction between age and the gross motor functioning score and each primary predictor in a nal step (Cohen & Cohen, 1983). Results Participants with NMD and SB did not differ signicantly on demographic/descriptive (age, sex, ethnicity, and gross motor functioning), criterion (psychological adjustment and functional disability), or predictor variables (perceived family and friend support). The two groups were, therefore, collapsed for all further analyses. In addition, neither of the potential demographic control variables (sex and ethnicity) showed a signicant univariate asso- ciation with the criterion variables, so these variables were not included in the regression models. Table 2 provides descriptive statistics for each of the measures used in the present study. Correlation analyses between demo- graphic/descriptive (age and gross motor functioning), criterion (psychological adjustment and functional disability), and predictor variables (perceived family and friend support) revealed signi- cant associations between family support and psychological ad- justment, friend support and family support, friend support and functional disability, and gross motor functioning and functional disability (see Table 3). T tests examining the relationship between sex or ethnicity and the criterion and predictor variables, however, revealed no signicant effects. The regression analyses predicting psychological adjustment indicated a signicant effect for the perceived social support measures, with 19% of the variance in the CHQCF87 MH Scale accounted for by the MSPSS Family and Friend subscales. The beta weights in the nal equation of these models indicated that perceived family support made a signicant and positive indepen- dent contribution to the prediction of participant mental health (see Table 4), whereas friend support made a negative, but nonsignif- icant, contribution. Neither age nor gross motor functioning, nor interactions between family or friend support and these terms, contributed signicantly to the models. The regression analyses predicting functional ability indicated that both perceived family and friend support showed signicant direct associations with functional ability. Higher perceived family support predicted lower functional ability, as measured by higher scores on the FDI, whereas higher perceived friend support pre- dicted higher functional ability, as measured by lower scores on the FDI. Furthermore, after controlling for age in the rst model predicting functional ability, a signicant interaction between per- ceived family support and age emerged (see Table 4). After con- trolling for gross motor functioning in the second model predicting functional ability, and as might be expected, lower gross motor functioning scores were signicantly associated with lower func- tional ability, as measured by higher scores on the FDI. In addition, a signicant interaction between perceived friend support and gross motor functioning was found (see Table 4). To plot these interactions as continuous data, we reran regres- sion analyses predicting functional ability, including only family support, age, and the interaction of these two terms, and friend support, gross motor functioning, and the interaction of these two terms (see Table 5). As would be expected, on the basis of the omnibus analyses, the interactions were still signicant. The beta weights from these interactions were used to plot the effects of these interactions (see Figures 1 and 2), as recommended by Cohen and Cohen (1983). The three regression lines used in Figure 1 represent three levels of age and were created by substi- tuting the age score representing one standard deviation below the mean (11.45 years old), that representing the mean (14.51 years old), and that representing one standard deviation above the mean (17.57 years old) in the regression equation for the rst model predicting functional ability, and then solving for the criterion variable, functional ability. As is evident in Figure 1, the slopes of the regression lines for younger, mid-range, and older youths indicate that, among rela- tively older youths, higher levels of perceived family support were associated with higher functional ability, whereas, among younger Table 2 Descriptive Statistics for Each Measure Measure n M SD Range Mental health scale (CHQCF87) 70 76.54 14.44 32.81100.00 .88 FDI 70 11.38 8.95 032.00 .82 MSPSS family support 70 24.33 3.77 13.0028.00 .80 MSPSS friend support 70 22.74 5.56 3.0028.00 .88 Note. CHQCF87 Child Health Questionnaire, child version; FDI Functional Disability Inventory; MSPSS Multidimensional Scale of Perceived Social Support (family and friend subscores). 325 PERCEIVED SOCIAL SUPPORT IN YOUTHS youths, higher levels of perceived family support were actually weakly associated with lower functional ability. The three regres- sion lines used in Figure 2 represent three levels of gross motor functioning and were created in the same manner, but by substi- tuting the three gross motor functioning scores (mild restriction 1.18, moderate restriction 2.74, and severe restriction 4.30) in the regression equation for the second model predicting functional ability, before solving for the criterion variable. The slopes of the regression lines for the three gross motor functioning levels indi- cate that, for those youths with severe ambulatory restrictions, higher functional ability was strongly associated with higher per- ceived friend support. Discussion The present study investigated the relationship between per- ceived social support and psychological adjustment and functional ability in youths with NMD and SB, while also examining age and gross motor functioning as potential moderating factors in this relationship. The nding that higher perceived social support pre- Table 3 Correlation Matrix Illustrating Relationship Between Demographic/Descriptive and Criterion and Predictor Variables Variable Demographic variable Criterion variable Predictor variable Age GMF MH FDI MSPSS family support MSPSS friend support MSPSS friend support .05 .06 .12 .27* .51** MSPSS family support .12 .03 .42** .16 FDI .07 .40** .19 MH .19 .22 GMF .16 Age Note. GMF gross motor functioning; MH Mental Health Scale of the Child Health Questionnaire, child version; FDI Functional Disability Inventory; MSPSS Multidimensional Scale of Perceived Social Support (family and friend subscores). * p .05. ** p .01. Table 4 Multiple Regression Analyses Examining the Association of Perceived Social Support With Concurrent Age, Gross Motor Functioning, Mental Health, and Functional Ability Step and variable Total R 2 R 2 change F change Final unstandardized Mental Health Scale (CHQCF87) 1. Social support .19 .19 7.63** Family support 1.74** Friend support 0.27 2. Age .20 .02 1.38 0.62 Mental Health Scale (CHQCF87) 1. Social support .19 .19 7.63** Family support 1.78** Friend support 0.27 2. GMF .22 .04 3.17 1.80 Functional ability (FDI) with age as controlled variable 1. Social support .07 .07 2.64 Family support 3.51* Friend support 0.46* 2. Age .08 .01 0.45 0.52 3. Family Support Age .16 .08 6.57* 0.24* Functional ability (FDI) with GMF as controlled variable 1. Social support .07 .07 2.64 Family support 0.19 Friend support 0.53 2. GMF .22 .15 12.20** 2.44** 3. Friend Support GMF .27 .05 4.66* 0.29* Note. CHQCF87 Child Health Questionnaire, child version; GMF gross motor functioning; FDI Functional Disability Inventory. * p .05. ** p .01. 326 WILSON, WASHINGTON, ENGEL, CIOL, AND JENSEN dicted better psychological adjustment was consistent with our rst hypothesis. Specically, perceived social support contributed sig- nicantly to the prediction of participant mental health, explaining 19% of the variance in this criterion measure. This nding was explained primarily by the effect of perceived family support, which showed a positive and signicant association with psycho- logical adjustment, whereas friend support showed a negative, but nonsignicant, association with psychological adjustment. The lack of signicant association between perceived friend support and psychological adjustment is inconsistent with Varni et al.s (1989) nding that adaptation in adolescents with diabetes was predicted by perceived social support from friends. One ex- planation for this discrepancy may be the probable relative differ- ence in the amount of time that youths with physical disabilities spend with family members, in contrast to youths with chronic illnesses that do not involve physical limitations. For example, many youths who have physical disabilities may rely more on family for assistance with everyday tasks, such as getting out of bed, dressing, and transportation, including transportation to school or social activities with friends. In addition, older adoles- cents who use a wheelchair or have other mobility limitations might differ from peers in their capacity to participate indepen- dently in activities with friends. Many adolescents who are typi- cally developing experience greater independence when they turn 16 years old, as they often no longer need to rely on another person for transportation. It is possible that youths with physical disabil- ities, many of whom cannot drive themselves, either spend an increased amount of time at home, presumably with family mem- bers, or require a family members assistance to travel from place to place. The nding that higher perceived friend, but not family, support predicted higher functional ability was partially consistent with our second hypothesis. Findings were inconsistent with our specic L o w
H i g h Younger F u n c t i o n a l
A b i l i t y
( F D I ) Mid-Range Older Low Support High Support Family Support (MSPSS) Figure 1. Effect of age on the relationship between family support, as measured by the Multidimensional Scale of Perceived Social Support (MSPSS), and functional ability, as measured by the Functional Disability Inventory (FDI). The regression lines were created by substituting three levels of age in the regression equation and solving for functional ability. L o w
H i g h F u n c t i o n a l
A b i l i t y
( F D I )
Mild Restriction Moderate Restriction Severe Restriction Low Support High Support Friend Support (MSPSS) Figure 2. Effect of gross motor functioning on the relationship between friend support, as measured by the Multidimensional Scale of Perceived Social Support (MSPSS), and functional ability, as measured by the Func- tional Disability Inventory (FDI). The regression lines were created by substituting three levels of gross motor functioning in the regression equation and solving for functional ability. Table 5 Multiple Regression Analyses Examining the Association of Perceived Social Support With Concurrent Age, Gross Motor Functioning, and Functional Ability Step and variable Total R 2 R 2 change F change Final unstandardized Functional ability (FDI) with age as controlled variable 1. Family support .03 .03 1.75 2.99* 2. Age .03 .00 0.17 0.41 3. Family Support Age .10 .08 5.66* 0.23* Functional ability (FDI) with GMF as controlled variable 1. Friend support .07 .07 5.32* 0.45 2. GMF .22 .14 12.15** 2.41** 3. Friend Support GMF .27 .05 4.55* 0.28* Note. FDI Functional Disability Inventory; GMF gross motor functioning. * p .05. ** p .01. 327 PERCEIVED SOCIAL SUPPORT IN YOUTHS hypotheses about the nature of the moderating effects of age and gross motor functioning on the association between perceived social support and psychological adjustment and functional ability, although unanticipated moderating effects were found. In the rst model predicting functional ability, a signicant interaction be- tween perceived family support and age emerged, but follow-up analyses revealed that higher levels of perceived social support from the family were associated with higher functional ability among older youths, not younger youths, as predicted. Although conclusions about the reliability of these ndings must await further research and replication, the nding that, among younger youths, higher levels of perceived family support were actually weakly associated with lower functional ability was surprising. It is possible that family support may, in fact, be expressed through an excess of assistance, so that these younger youths are not given the opportunity or are not motivated to perform at a level at which they are actually capable. As these youths age, however, they may experience improvements in their functional ability as a result of the cumulative positive effect of family support while they were young. Future research should explore this possibility through longitudinal studies. In addition, if these results are replicated, these ndings suggest that family support may be particularly important in older youths with disabilities. Perhaps, again, because older youths with dis- abilities may be more dependent on their family than same-age peers who do not have a disability, family support may be even more important as children with disabilities age than when they are younger. Although as children move into adolescence the signif- icance of friendships increases and the presence of such relation- ships is important for social maturity development (Frey & Roth- lisberger, 1996), youths with physical disabilities may be limited in their ability to forge and maintain strong relationships with peers because of several factors. These may include physical restrictions, cognitive impairments, rehabilitation and medical ob- ligations like physical therapy and checkups, and social stigma toward people with disabilities (La Greca et al., 2002). As a result, older youths may continue to nd the social support they need for high functional status primarily from family members. In the second model predicting functional ability, a signicant interaction between perceived friend support and gross motor functioning emerged. Further follow-up analyses of this interaction indicated that the nature of the moderating effect of gross motor functioning on the association between perceived social support and functional ability was inconsistent with our prediction. We had anticipated that perceived social support would show a stronger association among participants with mild ambulatory restrictions. Instead, we found that, among youths with severe ambulatory restrictions, higher functional ability was associated with higher perceived social support from friends. As this is the rst time that such a moderating effect has been examined, its reliability cannot be assumed. If reliable, however, this moderating effect could be inuenced by the positive effects of perceived social support. For example, youths with severe ambulatory restrictions who nonethe- less have strong friend support and frequent involvement with peers might be invited or encouraged to do more physical activities with and by their peers. This, in turn, may increase the likelihood that these youths may both participate in these activities and develop skills useful for independent functioning. Certain limitations should be highlighted in the present study. First, it is important to note that our study populations included only youths with SB and NMD. Although youths with these disabilities experience a number of complications and physical restrictions that are common to other physical disabilities, it is possible that our results may not generalize to youths with all types of physical disabilities. Future research should, therefore, include youths with other diagnoses. A second limitation concerns the measures used in the present study, as well as the method used to administer the measures. The exclusive use of self-report data to assess the primary predictor and criterion variables has the potential to bias results with regard to the ability of participants to accurately evaluate social support and the capability of performing activities, as well as creating the possibility of a general source bias. Given that there are few previously published studies in this area, it is difcult to demon- strate the validity of these self-reported results by comparison with other research. Additional research on the impact of perceived social support on psychological adjustment and functional disabil- ity for youths is needed to determine the reliability of our ndings. Future research could potentially assess social support from other sources, such as through parent and teacher reports, to supplement ndings from primary sources. The use of the MSPSS to assess perceived social support is also a limitation of the measures used in the present study. Although the internal consistencies of the scores from this measure in our sample were high, the MSPSS has at present only been validated for use with adults. Furthermore, it measures perceived social support by using only eight items and does not assess other important aspects of social support, such as network size and density. It is possible, for example, that the ndings of the present study are in fact a reection of the fact that a signicant number of participants had few or no close friends, or had infrequent contact with peers. The limitations of the MSPSS may account for the unexpected nding that friend support was negatively, but not signicantly, associated with psychological adjustment. Future research would benet from the use of measures that assess addi- tional aspects of social support. The measures used were originally developed and validated as paper-and-pencil questionnaires but were interview-administered in the present study. As participants indicated answers to each question to an interviewer, instead of privately marking answers, responses may reect demand characteristics. This methodology was used nevertheless because of the potential for restrictions in ne motor functioning of the participants. Moreover, the strong internal consistencies found for each of the measures supports their reliability in the sample, even with this altered methodology. A nal limitation is the potential for selection bias in the study sample. Owing to the nature of our recruitment sites, participants in the present study had parents/guardians who were not only involved in their childrens medical care and recreation but who were also willing and able to contact researchers regarding enroll- ment. In addition, the study did not include youths with more than mild cognitive impairment. It is possible that the inclusion of youths with moderate-to-severe cognitive impairment might have affected the sample in terms of severity of physical disability, as well as the presence and strength of peer relationships. The scales used in this study, however, require the participants to reect accurately on recent emotions, as well as evaluate their physical capabilities, therefore necessitating that the youths possess a cer- 328 WILSON, WASHINGTON, ENGEL, CIOL, AND JENSEN tain level of cognitive functioning. The use of multiple informants in gathering future data may be a means of circumventing this issue, as this would allow for the inclusion of youths with mod- erate-to-severe cognitive impairment. Despite the limitations of the present study, however, the nd- ings offer several important new contributions. First, the results are consistent with previous research indicating that higher perceived social support predicts better psychological adjustment. Further- more, expanding on earlier studies, the present ndings suggest that perceived family and friend support play a particularly im- portant role for youths with physical disabilities. Moreover, we found that family and friend support interacted with age and gross motor functioning, respectively, to predict participant psycholog- ical adjustment and functional ability in the present sample. This suggests the possibility that perceived social support may be particularly important for functioning among older youths and among youths with more severe gross motor limitations. To our knowledge, this is the rst study to examine the role of perceived social support on functional ability of this population. Future social support research should take into consideration the moderating roles of age and gross motor functioning on the psychological adjustment and functional ability in youths with physical disabilities. If the ndings from the present study replicate in future studies, they would then argue for interventions to help families and friends of youths with physical disabilities to provide more effec- tive support to bolster psychological and physical functioning in this population. Interventions could include social support training programs and support groups for the parents/guardians and sib- lings of these youths. Moreover, the nding that higher perceived friend support is associated with higher functional ability in youths with severe ambulatory restrictions has implications for academic settings. Future research should examine the effects of supportive interactions between youths who are typically developing and youths with physical disabilities, particularly if the youths have severe physical restrictions and are, therefore, less likely to have opportunities for peer interactions. It is hoped that research of this nature, and the development of interventions based on the ndings of such research, will help to continue to improve the quality of life of youths with physical disabilities. References Appleton, P. L., Ellis, N. C., Minchom, P. E., Lawson, V., Boll, V., & Jones, P. (1997). Depressive symptoms and self-concept in young people with spina bida. Journal of Pediatric Psychology, 22, 707722. Bennet, D. S. (1994). Depression among children with chronic medical problems: A meta-analysis. Journal of Pediatric Psychology, 19, 149169. Cohen, J., & Cohen, P. (1983). Applied multiple regression/correlation analysis for the behavioral sciences (2nd ed.). Hillsdale, NJ: Erlbaum. Evers, A. W. M., Kraaimaat, F. W., Geenen, R., Jacobs, J. W. G., & Bijlsma, J. W. J. (2003). Pain coping and social support as predictors of long-term functional disability and pain in early rheumatoid arthritis. Behavior Research and Therapy, 41, 12951310. Frey, C. U., & Rothlisberger, C. (1996). Social support in healthy adoles- cents. Journal of Youth and Adolescence, 25, 1731. Holmbeck, G. N., Westhoven, V. C., Phillips, W. S., Bowers, R., Gruse, C., Nikolopoulos, T., et al. (2003). A multimethod, multi-informant, and multidimensional perspective on psychosocial adjustment in preadoles- cents with spina bida. Journal of Consulting and Clinical Psychology, 71, 782796. Hommeyer, J. S., Holmbeck, G. N., Wills, K. E., & Coers, S. (1999). Condition severity and psychosocial functioning in pre-adolescents with spina bida: Disentangling proximal functional status and distal adjust- ment outcomes. Journal of Pediatric Psychology, 24, 499509. Kashani, J. H., Caneld, L. A., Borduin, C. M., Soltys, S. M., & Reid, J. C. (1994). Perceived family and social support: Impact on children. Journal of the American Academy of Child and Adolescent Psychiatry, 33, 819823. La Greca, A. M., Auslander, W. F., Greco, P., Spetter, D., Fisher, E. B., & Santiago, J. V. (1995). I get by with a little help from my family and friends: Adolescents support for diabetes care. Journal of Pediatric Psychology, 20, 449476. La Greca, A. M., Bearman, K. J., & Moore, H. (2002). Peer relations of youth with pediatric conditions and health risks: Promoting social sup- port and healthy lifestyles. Developmental and Behavioral Pediatrics, 23, 271280. Landgraf, J. M., Abetz, L., & Ware, J. E. (1996). Child Health Question- naire (CHQ): A users manual. Boston: The Health Institute, New England Medical Center. Lavigne, J. V., & Faier-Routman, J. (1992). Psychological adjustment to pediatric physical disorders: A meta-analytic review. Journal of Pedi- atric Psychology, 17, 133157. Lavigne, J. V., & Faier-Routman, J. (1993). Correlates of psychological adjustment to pediatric physical disorders: A meta-analytic review and comparison with existing models. Developmental and Behavioral Pedi- atrics, 14, 117123. Logan, D. E., & Scharff, L. (2005). Relationships between family and parent characteristics and functional abilities in children with recurrent pain syndromes: An investigation of moderating effects on the pathway from pain to disability. Journal of Pediatric Psychology, 30, 698707. Ouvrier, R. A., Goldsmith, R. F., Ouvrier, S., & Williams, I. C. (1993). The value of the Mini-Mental State Examination in childhood: A preliminary study. Journal of Child Neurology, 8, 145148. Palisano, R., Rosenbaum, P., Walter, S., Rassell, D., Wood, E., & Galuppi, B. (1997). Development and reliability of a system to classify gross motor function in children with cerebral palsy. Developmental Medicine and Child Neurology, 39, 214223. Patterson, J. M., & Geber, G. (1991). Preventing mental health problems in children with chronic illness or disability. Childrens Health Care, 20, 150161. Peterson, C. C., & Palermo, T. M. (2004). Parental reinforcement of recurrent pain: The moderating impact of child depression and anxiety on functional disability. Journal of Pediatric Psychology, 29, 331341. Roccaforte, W. H., Burke, W. J., Bayer, B. L., & Wengel, S. P. (1992). Validation of a telephone version of the Mini-Mental State Examination. Journal of the American Geriatrics Society, 40, 697702. Travis, L. A., Lyness, J. M., Shields, C. G., King, D. A., & Cox, C. (2004). Social support, depression, and functional disability in older adult pri- mary-care patients. American Journal of Geriatric Psychiatry, 12, 265271. Varni, J. W., Babani, L., Wallander, J. L., Roe, T. F., & Frasier, S. D. (1989). Social support and self-esteem effects on psychological adjust- ment in children and adolescents with insulin-dependent diabetes mel- litus. Child and Family Behavior Therapy, 11, 117. Varni, J. W., & Setoguchi, Y. (1991). Correlates of perceived physical appearance in children with congenital/acquired limb deciencies. De- velopmental and Behavioral Pediatrics, 12, 171176. Varni, J. W., Setoguchi, Y., Rappaport, L. R., & Talbot, D. (1991). Effects of stress, social support, and self-esteem on depression in children with limb deciencies. Archives of Physical Medicine and Rehabilitation, 72, 10531058. Varni, J. W., Setoguchi, Y., Rappaport, L. R., & Talbot, D. (1992). 329 PERCEIVED SOCIAL SUPPORT IN YOUTHS Psychological adjustment and perceived social support in children with congenital/acquired limb deciencies. Journal of Behavioral Medicine, 15, 3144. Varni, J. W., Wilcox, K. T., & Hanson, V. (1988). Mediating effects of family social support on child psychological adjustment in juvenile rheumatoid arthritis. Health Psychology, 7, 421431. von Weiss, R. T., Rapoff, M. A., Varni, J. W., Lindsley, C. B., Olson, N. Y., Madson, K. L., & Bernstein, B. H. (2002). Daily hassles and social support as predictors of adjustment in children with pediatric rheumatic disease. Journal of Pediatric Psychology, 27, 155165. Walker, L. S., & Greene, J. W. (1991). The Functional Disability Inven- tory: Measuring a neglected dimension of child health status. Journal of Pediatric Psychology, 16, 3958. Wallander, J. L., & Thompson, R. J. (1995). Psychosocial adjustment of children with chronic physical conditions. In M. C. Roberts (Ed.), Handbook of pediatric psychology (2nd ed., pp. 124141). New York: Guilford Press. Wallander, J. L., & Varni, J. W. (1989). Social support and adjustment in chronically ill and handicapped children. American Journal of Commu- nity Psychology, 17, 185201. Wallander, J. L., & Varni, J. W. (1995). Appraisal, coping, and adjustment in adolescents with a physical disability. In J. L. Wallander & L. J. Siegel (Eds.), Adolescent health problems (pp. 209231). New York: Guilford Press. West, S. G., Aiken, L. S., & Krull, J. L. (1996). Experimental personality designs: Analyzing categorical by continuous variable interactions. Journal of Personality, 64, 148. Witt, W. P., Riley, A. W., & Coiro, M. J. (2003). Childhood functional status, family stressors, and psychosocial adjustment among school-aged children with disabilities in the United States. Archives of Pediatrics and Adolescent Medicine, 157, 687695. Zimet, G. D., Dahlem, N. W., Zimet, S. G., & Farley, G. K. (1988). The Multidimensional Scale of Perceived Social Support. Journal of Per- sonality Assessment, 52, 3041. Received August 4, 2005 Revision received December 1, 2005 Accepted February 7, 2006 330 WILSON, WASHINGTON, ENGEL, CIOL, AND JENSEN