Journal of Pediatric Psychology, 40(6), 2015, 602–608

doi: 10.1093/jpepsy/jsu160
Advance Access Publication Date: 21 January 2015
Original Research Article

Psychological Functioning in Youth With Spina

Bifida Living in Colombia, South America
Elizabeth G. Nicholls,1 MS, Juan C. Arango-Lasprilla,2 PHD,
Silvia L. Olivera Plaza,3 MS, Nadezda Mendez,3 BS, Lorena Quintero,3 BS,
Diego Mauricio Velasco Trujillo,3 and Brian P. Daly,1 PHD

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1
Drexel University, Philadelphia, Pennsylvania, 2University of Deusto, IKERBASQUE, Basque Foundation for
Science, Bilbao, Spain, and 3Universidad Surcolombiana, Neiva, Colombia
Correspondence concerning this article should be addressed to Juan Carlos Arango-Lasprilla, PHD, Department
of Psychology, University of Deusto, IKERBASQUE, Basque Foundation for Science, Bilbao, Spain. E-mail:
jcarango@deusto.es
Received May 27, 2014; revisions received December 10, 2014; accepted December 11, 2014

Abstract
Objective No studies have examined psychological functioning among youth with spina bifida
(SB) living in a developing country where access to mental health resources is often scarce. This
study compared self-reported psychological functioning between youth with SB living in
Colombia, South America, and a demographically matched comparison group of healthy
Colombian children. Methods 22 children with SB and 22 comparison children completed as-
sessments of depression and anxiety. Most (68.81%) participants were male, and the sample had a
mean age of 13.25 years (SD ¼ 2.65 years). Results Results revealed that children with SB re-
ported greater total symptoms of depression (p < .05), but fewer worry-related symptoms of anxi-
ety (p < .05). In addition, mean total scores for both depression and anxiety were in the nonclinical
range for youth with SB. Conclusions These findings highlight the need for targeted mental
health (i.e., depression) services for poor children with SB living in Colombia.

Key words: anxiety; depression; health-related quality of life; pediatrics; psychosocial functioning; spina bifida.

Spina bifida (SB) is diagnosed when a child’s spinal column does not
fuse successfully in utero, resulting in malformation of the spinal
cord and brain (Wallingford, Niswander, Shaw, & Finnell, 2013). It
is a heterogeneous condition that can involve a range of adverse
physical outcomes including paralysis, muscle weakness, and hydro-
cephalus, as well as a variety of secondary medical complications
that may require ongoing intervention (Deidrick, Grisson, &
Farmer, 2009; Fletcher et al., 2005; Fletcher & Brei, 2010;
Heffelfinger et al., 2008; Wallingford et al., 2013). Given the signifi-
cant and unique physical challenges associated with SB, researchers
have examined psychosocial functioning in this population, with
results from a recent meta-analysis revealing significantly more
symptoms of depression among children with SB as compared with
their typically developing peers (Pinquart & Shen, 2011a). On the
other hand, when examining symptoms of anxiety in youth with SB,
another recent meta-analysis (Pinquart & Shen, 2011b) revealed no
significant differences in levels of anxiety relative to healthy
same-aged peers. Some scholars have suggested the risk for mental
health problems may increase as children with SB age into adoles-
cence and adulthood (Bellin et al., 2010). For instance, high rates of
anxious and depressive symptoms have been identified in adults
with SB and, moreover, these factors are associated with poor over-
all quality of life (Kalfoss & Merkens, 2006).
Although results from studies that examined mental health func-
tioning in youth and adults with SB living in developed countries
such as the United States are informative, more studies are needed
that examine psychological functioning among medically involved
youth from diverse cultural, ethnic, and socioeconomic backgrounds
(Black, Eiser, & Krishnakumar, 2000). Children living in developing
countries are not only particularly susceptible to birth defects
(World Health Organization, 2003), but also encounter unique ill-
ness- and disability-related stressors. For instance, Pinquart and
Shen (2011a) identified more self-reported depressive symptoms
among children with chronic health conditions living in developing

C The Author 2015. Published by Oxford University Press on behalf of the Society of Pediatric Psychology.
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Colombian Youth With Spina Bifida 603

countries as compared with medically involved children living in the Table I. Child Demographic Characteristics (N ¼ 44)
industrialized world. However, notably absent from this meta-anal-
Characteristics SB (n ¼ 22) HC (n ¼ 22)
ysis was studies of children with SB living in developing countries
with high rates of poverty. Colombia, South America, has one of the Sex (% male) 15 (68.18) 15 (68.18)
highest income inequality ratios in the world, and over half of the Age (years) 13.27 (62.76) 13.25 (62.60)
poor are uninsured (Library of Congress, 2007; World Bank, 2007, Race/ethnicity
2012). Although Colombians with disabilities are legally guaranteed Hispanic/Latino 22 (100.0%) 22 (100.0%)
access to assistive devices (i.e., wheelchairs), many do not receive Socioeconomic status
Level 1 6 (27.23%) 6 (27.23%)
these resources, and it has been reported that only 20% of schools
Level 2 13 (59.09%) 13 (59.09%)
are handicap-accessible (International Disability Rights Monitor
Level 3 2 (9.09%) 2 (9.09%)
[IDRM], 2004). These disability-related challenges are especially
Level 4 1 (4.55%) 1 (4.55%)
concerning, given that SB already creates significant barriers to nor- Level 5 0 (0.0%) 0 (0.0%)
mative academic and social functioning, particularly among children Level 6 0 (0.0%) 0 (0.0%)

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with more severe physical limitations and greater levels of neurologi- Grade 7.09 (64.26) 7.22 (62.35)
cal involvement (Holmbeck et al., 2003, 2010). Primary caregiver
Children with SB in Colombia may be at increased risk for men- Mother 16 (72.73%) 19 (86.36%)
tal health problems, given their exposure to factors such as poverty, Father 1 (4.55%) 1 (4.55%)
lack of resources, and poor access to educational settings. Stepmother 0 (0.0%) 1 (4.55%)
Aunt 1 (4.55%) 0 (0.0%)
Moreover, because a considerable mental health treatment gap
Grandmother 4 (18.18%) 1 (4.55%)
exists in Latin America, children with SB who require such services
Educational setting
may also be unlikely to receive appropriate care (Kohn, Saxena,
Mainstreamed 16 (72.72%) 22 (100%)
Levav, & Saraceno, 2004; Machado, Lopera, Diaz-Rojas, Jaramillo, Home school 1 (4.55%) 0 (0%)
& Einarson, 2008). To our knowledge, no studies to date have Not attending 4 (18.18%) 0 (0%)
investigated psychological functioning in pediatric SB in any area of Other 1 (4.55%) 0 (0%)
Latin America. There is a compelling need to conduct pediatric psy-
chology research with international samples, given that differences Notes. SB ¼ spina bifida; HC ¼ healthy comparison.
in cultural factors (e.g., spiritual beliefs, illness attributions and con- No comparisons significant at p < .05.

notations) may compromise the generalizability of findings between

developed and developing countries (Black et al., 2000). In addition,
state-of-the-art information about issues related to child mental
health and development is often sparse in non-Western countries
with high rates of children living in conditions of poverty (Richter,
2003). Therefore, results from the current study may provide a cul-
ture-specific lens to better inform Colombian pediatric psychologists
and health-care providers about potential mental health challenges
experienced by children with SB. As such, the current investigation
is intended as a first step to understanding the psychosocial needs of
Colombian children with SB. The goal of our study was to deter-
mine whether self-reported symptoms of depression and anxiety dif-
fered between youth with SB and a group of healthy comparison
children living in Colombia, South America. Based on findings from
the recent meta-analyses conducted by Pinquart and Shen (2011a, b)
that included studies of youth with chronic medical conditions from
developing countries, it was hypothesized that children with SB
would report significantly higher levels of depressive, but not anx-
ious, symptomatology as compared with a demographically
matched comparison group.
limitations with completing questionnaires within the SB sample,
children in both groups were administered measures orally, consis-
tent with previous research (Carey et al., 1987; Lonigan, Carey, &
Finch, 1994; Varni, Seid, & Kurtin, 2001).
Each group consisted of 15 boys (68.18%) and 7 girls (31.82%),
with a mean age of 13.27 years (SD ¼ 2.76 years) for the SB group
and 13.25 years (SD ¼ 2.60 years) for the comparison group of
healthy children. Eighty-six percent (n ¼ 19) of participating chil-
dren reported socioeconomic status at Levels 1 and 2, which quali-
fies for the poorest status according to the Colombian Government
(International Federation for Housing and Planning, n.d.). All chil-
dren in the SB group were diagnosed with myelomingocele, with
77.27% (n ¼ 17) also having a history of hydrocephalus. Most chil-
dren in the SB group had a spinal lesion level at the lumbar or lum-
bosacral level (n ¼ 20, 90.90%). Two children (9.10%) had a lesion
at the thoracic level. Full demographic characteristics for the com-
bined sample are presented in Table I, and clinical characteristics for
the SB group are detailed in Table II.

Methods
Participants
Participants included 22 children with SB and 22 typically develop-
ing children matched on age, gender, and socioeconomic status.
Children were eligible to participate if they ranged in age from 8 to
17 years. Exclusion criteria included a previous diagnosis of a seri-
ous developmental disorder (i.e., autism spectrum disorder, intellec-
tual disability), serious psychological conditions (i.e., psychotic
disorders), or traumatic brain injury as documented in the medical
record or caregiver report. All children had a parent or legal guard-
ian provide consent before participating in the study. Because we
anticipated difficulties with executive functioning as well as physical
Measures
Children’s Depression Inventory
Symptoms of depression were assessed with the Spanish version
(Davanzo et al., 2004) of the Children’s Depression Inventory
([CDI]; Kovacs, 1980/1981, 2003), a 27-item self-report instrument
used with children who range in age from 7 to 17 years. On each
item, children endorse one of three symptom statements that best
describe how they have been feeling for the past 2 weeks. Total
scores range from 0 (no symptoms) to 54 (severe symptoms). T
scores of 70 are considered clinically significant. The CDI has been
used with children with chronic medical conditions (Pinquart &
Shen, 2011a), and the Spanish version (Davanzo et al., 2004) evi-
dences adequate validity and reliability (Cronbach’s a ¼ .72–.88).
Cronbach’s a for the CDI—Total Score in the current sample was
604 Nicholls et al.

Table II. Child Clinical Characteristics—Spina Bifida Sample follows: Worry subscale, a ¼ .59 for the comparison group and
(n ¼ 22) a ¼ .80 for the SB group; Social Anxiety subscale, a ¼ .60 for the
comparison group and a ¼ .68 for the SB group.
Characteristics SB sample (n ¼ 22) (%)

SB classification
Procedure
Myelomeningocele 22 (100.00)
Protocols for the current study were reviewed and approved by the
Spinal lesion level
Cervical 0 (0) institutional review boards at University of Neiva in Neiva,
Thoracic 2 (9.10) Colombia, and Drexel University in the United States. Research staff
Lumbar or lumbosacral 20 (90.90) reviewed records at the Hospital Universatario Hernando
Sacral 0 (0) Moncaleano Perdomo in Neiva, Colombia, to identify SB patients
History of hydrocephalus 17 (77.27) who met inclusion criteria. Potential participants and their parents
Complications in past year were called at home and given information about the study. All par-
Pressure ulcer 3 (13.64) ticipants with SB contacted by the team agreed to participate.

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Urinary complications 14 (63.64) Comparison group children and their caregivers were recruited
Other 4 (18.18)
through flyers posted at neighborhood churches, stores, and restau-
Method of elimination
rants, as well as by general word-of-mouth. When families (N ¼ 53)
Diapers 18 (81.81)
Catheterization 0 (0) called to inquire whether their child could serve as a participant in the
Eliminates independently 4 (18.18) healthy comparison group, the child’s age, gender, and socioeconomic
Health insurance status status were collected from the parent or legal guardian and they were
Private 13 (59.09) added to the healthy comparison list. As each child with SB was
Subsidized 9 (49.91) enrolled, the first matching healthy comparison child to contact the
Nonpsychiatric medications study team was contacted for enrollment. In total, 22 comparison
Services received children that matched a child with SB on all demographic variables
Mental health (in past) 4 (18.18) were included in the study. For families that agreed to participate, the
Mental health (current) 0 (0.00)
research team scheduled an appointment at their home. At this
Occupational therapy 18 (81.82)
appointment, a psychologist from the Universidad Surcolombiana
Physical therapy 22 (100.00)
Primary means of mobility collected sociodemographic information and history of medical or
Manual wheelchair 16 (72.73) psychological problems, and administered the questionnaires to the
Other 2 (4.50) child individually. Each participating child was given an anonymous
Walks with braces or walker 3 (13.64) number that was placed on all study measures and was kept locked in
Walks independently 1 (4.55) the office of a Universidad Surcolombiana psychologist. If children
scored above the clinical threshold on any outcome measure, the psy-
Notes. SB ¼ spina bifida. chologist offered to assist with a referral to an appropriate commun-
.70 for the comparison group and .77 for the SB group. Because ity mental health service.
Cronbach’s a levels for the subscales of the CDI were poor or unac-
ceptable in either or both of the SB or comparison groups, only the Data Analysis
total score was used in analyses. SPSS Statistics Version 20.0 was used to conduct all analyses.
Statistical assumptions were analyzed before conducting
Revised Children’s Manifest Anxiety Scale—Second Edition independent-samples t tests to detect differences in mean scores
Symptoms of anxiety were measured with a Spanish-translated ver- between groups. Because children with SB and healthy comparison
sion of the Revised Children’s Manifest Anxiety Scale—Second children were age- and gender-matched, raw scores were used in
Edition ([RCMAS-2]; Reynolds & Richmond, 2008). The RCMAS- analyses of CDI (transformed) and RCMAS-2 data. For interpretive
2 is a self-report instrument that consists of 49 yes/no items and is purposes, however, T scores were calculated on the CDI and
used with children and adolescents aged 6–19 years. Total scores on RCMAS-2 subscales for each participating child, and descriptive sta-
the RCMAS-2 range from 0 (no symptoms) to 49 (severe symp- tistics are reported in the Results section.
toms). T scores of 71 are considered extremely problematic, while
scores from 61 to 70 are considered to be clinically concerning. The
RCMAS-2 yields a Total Anxiety score and subscale scores for Results
Physiological Anxiety, Social Anxiety, and Worry. The RCMAS-2
Associations Between Outcome Measures
evidences strong psychometric properties with Cronbach’s a values
Results for the SB group revealed that RCMAS-2—Social Anxiety
ranging from .75 to .92 (Reynolds & Richmond, 2008). The
and RCMAS-2—Worry were significantly correlated, as were
RCMAS-2 is available in Spanish from the publisher, and has previ-
RCMAS-2—Social Anxiety and CDI—Total Score. For the compari-
ously been used to assess anxiety in children with chronic medical
son group, scores were not significantly correlated on any of these
conditions (Pinquart & Shen, 2011b). Because of the symptom over-
measures (Table III). Given the lack of significant correlations for
lap between psychosomatic symptoms assessed by the RCMAS-2
the comparison group, it was deemed inappropriate to combine out-
and organic physiological symptoms associated with SB (i.e., respi-
come measures into a single “adjustment” composite.
ratory dysfunction; Dahl et al., 1995), the Physiological Anxiety
subscale was excluded from analyses. In addition, because the
Physiological Anxiety subscale is a component of the RCMAS-2— Depression
Total Score, the Total Score was not included in analyses. Children with SB obtained a mean total raw score of 11.68
Cronbach’s a for the RCMAS-2 in the current sample was as (SD ¼ 6.29) on the CDI, corresponding to a mean T score of 51.68
Colombian Youth With Spina Bifida
Table III. Correlations Among Outcome Variables (N ¼ 44)
Spina bifida group Comparison group
CDI RCMAS-2 RCMAS-2
—Worry —Social Anxiety
CDI – 0.13 0.31
RCMAS-2—Worry 0.42 – 0.41
RCMAS-2—Social Anxiety 0.60** 0.57** –
Notes. PedsQL ¼ Pediatric Quality of Life Inventory, Version 4.0;
CDI ¼ Children’s Depression Inventory; RCMAS-2 ¼ Revised Children’s
Manifest Anxiety Scale, 2nd edition.
*p < .05; **p < .01; ***p < .001.
(SD ¼ 9.15). Children in the comparison group obtained a mean
total raw score of 7.82 (SD ¼ 4.49) and a mean T score of 46.22
(SD ¼ 5.38). Because the CDI—Total Score was positively skewed, a
square-root transformation was performed on this variable, which
resulted in normal distribution. Analysis of this transformed variable
revealed significantly greater depressive symptomatology among
children with SB as compared with healthy comparison children,
t(42) ¼ 2.38, p ¼ .02, d ¼ 0.71, 95% confidence interval
(CI) ¼ 1.13 to 0.09. The total score on the CDI for 13.64% of
children in the SB group corresponded to a qualitative description of
clinically significant symptomatology. In contrast, no children in the
comparison group had a score falling in the clinically significant
range, and the likelihood of having a score within this range did not
significantly differ by group [v2(1, N ¼ 44) ¼ 3.22, p ¼ .73,
V ¼ 0.27].
Anxiety
On the Worry subscale of the RCMAS-2, children with SB obtained
a mean T score of 52.09 (SD ¼ 9.96), compared with a mean T score
of 57.18 (SD ¼ 7.00) among healthy comparison children. Results of
an independent-samples t test revealed that children with SB
obtained significantly lower scores relative to healthy comparison
children, t(43) ¼ 2.80, p ¼ .04, d ¼ 0.63, 95% CI ¼ 0.06–4.12. In
terms of interpretive range classifications, 22.72% of children with
SB (n ¼ 5) and 31.82% of comparison children obtained T scores
within the clinically concerning or elevated range, but the likelihood
of doing so did not differ between groups [v2(1, N ¼ 44) ¼ 0.46,
p ¼ .74, V ¼ 0.10].
On the Social Anxiety subscale of the RCMAS-2, children with
SB obtained a mean T score of 52.14 (SD ¼ 8.49), compared with a
mean T score of 50.50 (SD ¼ 7.99) for comparison group children.
Scores did not differ significantly between groups, t(42) ¼ .59,
p ¼ .56, d ¼ 0.17, 95% CI ¼ 2.02 to 1.11. Among youth with SB,
18.18% of children (n ¼ 4) fell within the clinically concerning or
elevated range, compared with 4.54% in the comparison group
(n ¼ 1). However, the likelihood of obtaining T scores in the clini-
cally concerning or elevated range did not differ between groups
[v2(1, N ¼ 44) ¼ 2.03, p ¼ .35, V ¼ 0.215]. Results of these analyses
are presented in Table IV.
Discussion
In an era of increased globalization and international collaboration,
scholars have argued for a greater understanding of, and more
research efforts into, psychosocial concerns among medically
involved youth from diverse ethnic and cultural populations (Black
et al., 2000). To our knowledge, this is the first study to investigate
605
psychological functioning in children and adolescents with SB living
in Latin America. Key findings reveal greater overall symptoms of
depression among Colombian youth with SB relative to a matched
group of healthy comparison children from Colombia. However,
children with SB did not differ from comparison children on meas-
ures of social anxiety, and actually reported lower levels of worry as
compared with their typically developing peers.
The finding of between-group differences for symptoms of
depression is in accord with results of a recent meta-analysis
(Pinquart & Shen, 2011a), which reported higher rates of depressive
symptoms in children with SB as compared with typically develop-
ing youth. Similarly, Appleton et al. (1997) identified elevated rates
of depressive symptomatology among children with SB as compared
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with their healthy peers. Larger effect sizes were additionally identi-
fied in studies with a higher proportion of female participants, a
finding that was consistent with those of Appleton and colleagues
(1997). Interestingly, between-group differences in the current study
were found with a sample of Colombian youth with SB that was pri-
marily composed of boys, a finding that may reflect the impact of
culture-specific gender roles. In Latino men, higher levels of endorse-
ment of machismo, which refers to a cultural view of masculinity as
emphasizing physical strength, toughness, and ability to protect
others (Arciniega, Anderson, Tovar-Blank, & Tracey, 2008), and
gender role conflict are predictive of depression (Fragoso &
Kashubeck, 2000). In Latino adolescent boys, those who perceive
greater gender role conflicts also are at heightened risk for depres-
sive symptoms (Céspedes & Huey, 2008). Current findings of ele-
vated levels of depression in a majority-male group of Latino
children with SB may therefore suggest these youth struggle to rec-
oncile physical disabilities with cultural values of masculinity.
Although not specifically examined in our study, findings from
the Pinquart and Shen (2011a) meta-analysis revealed that children
living with chronic medical conditions in developing or threshold
countries reported greater levels of depressive symptomatology as
compared with their peers in more developed areas, and Holmbeck
et al. (2003) also reported that children with SB of low socioeco-
nomic status appeared at greater risk for psychosocial adjustment
difficulties. Pinquart and Shen (2011a) postulated that these differ-
ences were primarily owing to challenges accessing quality health
care in developing countries, which is likely associated with lack of
resources and high levels of poverty that are more prevalent in these
areas (Peters et al., 2008). In the current study, none of the children
with SB whose scores were in the clinically significant range for
anxiety and/or depressive symptoms were receiving psychological
care. Therefore, conditions of poverty or access to care problems
may have impacted study participant’s ability to receive indicated
mental health services. This finding highlights the need for improved
psychoeducation and mental health service delivery in areas of
Colombia with high levels of wealth inequality.
Although the specific mechanisms by which poverty might exac-
erbate depressive symptoms in children with chronic physical condi-
tions were not investigated by Pinquart and Shen (2011a), cognitive
and behavioral models of depression may shed light on this process.
American children with SB are more dependent on adults, socially
immature, socially restricted, physically inactive, and scholastically
challenged as compared with their peers without SB (Holmbeck
et al., 2003). From a behavioral perspective, each of these factors
could diminish the degree to which children obtain positive rein-
forcement from the environment, thus giving rise to depressive
symptoms (Lewinsohn, 1974). Moreover, in areas like Colombia
where children living in poverty have relatively minimal access to
medical care and assistive technologies, limitations posed by physical
606
Table IV. Comparison of Depressive and Anxious Symptoms Between Children With Spina Bifida and Healthy Comparisons (N ¼ 44)
Measure SB (n ¼ 22) HC (n ¼ 22)
CDI—Total Score 11.68 (66.29) 7.82 (64.49)
RCMAS-2—Worry 6.77 (63.79) 8.86 (62.80)
RCMAS-2—Social Anxiety 4.59 (62.68) 4.14 (62.46)
Note. SB ¼ spina bifida; HC ¼ healthy comparison; CDI ¼ Children’s Depression Inventory; RCMAS-2 ¼ Revised Children’s Manifest Anxiety Scale, 2nd
edition; CI ¼ confidence interval.*p < .05; **p < .01; ***p < .001.
disability may decrease children’s access to reinforcing activities in
the community. In most developed countries, differently abled chil-
dren are guaranteed access to appropriate education. In a developing
country like Colombia, lack of resources may create significant bar-
riers to school inclusion among differently abled children (IDRM,
2004). This challenge may further impact the degree to which chil-
dren with SB living in Colombia struggle to achieve normative aca-
demic and social functioning, as well as concomitant reinforcement
for successful social interactions in these areas. Cognitive factors also
may explain why children with SB in Latin America could be particu-
larly vulnerable to depression. For example, children living in poverty
with chronic medical conditions and little expectation of altering their
life circumstances could be especially likely to attribute negative
events to stable external causes, a tendency associated with risk for
depressive symptoms (Abela & Hankin, 2008).
Consistent with our hypothesis, greater anxious symptomatology
was not observed between children with SB and comparison chil-
dren, a finding that is consistent with the extant literature (Pinquart
& Shen, 2011b). In fact, children with SB reported significantly
fewer symptoms on the Worry subscale, which encompasses fear of
emotional isolation and apprehension about the future (Reynolds &
Richmond, 2008). The cultural context of the current sample may
explain this finding. More specifically, the primacy of family rela-
tionships and sense of familial cohesion may be especially pro-
nounced in children physically dependent on caregivers and
therefore serve as a protective factor against fears of isolation and
concerns about the future among Latino children with disabilities
(Appleton et al., 1997; Augutis et al., 2007).
One possible explanation for why children with SB reported
greater depressive, but not anxious, symptomatology as compared
with their typically developing peers may lie in affective distinctions
between these two constructs. Although mood and anxiety disorders
overlap considerably in clinical and community samples, symptoms
of these disorders may be distinguished by differential associations
with positive and negative affect. Negative affect refers to negative
mood states, such as fear, hostility, or anxiety, and high levels of neg-
ative affect are generally reflective of unpleasant emotional experien-
ces (Watson, Clark, & Carey, 1988). In contrast, positive affect refers
to an individuals’ engagement with the environment, enthusiasm, and
energy level, such that low levels of positive affect are characterized
by lethargy, fatigue, and anhedonia (Joiner, Catanzaro, & Laurent,
1996; Watson et al., 1988). Therefore, whereas high levels of negative
affect are associated with both depression and anxiety, low levels of
positive affect are more associated with depression (Joiner et al.,
1996; Watson et al., 1988). It is possible, then, that greater depressive
symptoms identified in children with SB in the current sample more
accurately reflect differences between groups in symptoms of anhedo-
nia than negative mood. Higher levels of anhedonia would be
expected in the context of children with SB experiencing compara-
tively limited opportunities for community engagement relative to
their typically developing peers.
Nicholls et al.
df t p d 95% CI
42 2.38 .02* 0.71 1.13 to 0.09
42 2.08 .04* 0.63 0.06 to 4.12
42 0.59 .56 0.17 2.02 to 1.11
Limitations
Findings from the present study represent an important first step to
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understanding psychological functioning in children with SB living
in emerging economies like Colombia; however, several limitations
should be noted. First, the lack of an established model of SB care in
Latin America and the fact that participants were drawn from a
mid-sized city in Colombia limits the generalizability of our find-
ings. Second, the present study was cross-sectional and therefore did
not permit analysis of changing needs and roles over time. Third,
only child report was assessed. Findings from the Pinquart and Shen
(2011a, b) meta-analyses indicated larger effect sizes for studies that
used parent or clinician ratings as compared with child ratings.
Therefore, it is possible that caregiver and/or clinician report of
child depressive and anxious symptomatology may have differed sig-
nificantly from current results. Fourth, in an attempt to reduce the
burden on participants and their caregivers, factors salient to Latino
culture that could impact children’s mental health and levels of resil-
ience (i.e., religious beliefs, family needs and resources, individual
coping skills) were not assessed. Similarly, potentially relevant fac-
tors such as parenting stress, caregiver burden, and other family var-
iables also were not assessed.
An additional important limitation is that the small sample size
may have prevented detection of group differences that could shed
additional light on psychological functioning among children with SB
in Colombia. For example, it is possible that the risk for depression
and anxiety may vary as a function of age, gender, family functioning,
parenting style, and other demographic factors. In addition, owing to
personnel constraints and a desire to avoid overburdening partici-
pants, it was not possible to perform neurocognitive screening. As
such, it is difficult to determine the degree to which neurocognitive
impairments may have impacted children’s responses on outcome
measures, as well as potential associations with symptoms of depres-
sion and anxiety. It is also notable that no children in the current sam-
ple had lesions at the sacral spine level, a finding that is divergent
from previously described samples in the English-language literature.
Because no epidemiological data regarding level of lesion exist for
Colombia, it is difficult to determine whether the current sample is
representative of Colombian youth with SB. However, Hispanics
have a relatively high frequency of genetic abnormalities associated
with upper-level lesions (Volcik et al., 2000). Finally, because norms
for the CDI and RCMAS-2 do not exist for Colombian youth, this
study relied on the published clinical cutoffs and normative data,
which are derived from youth living in the United States.
Implications
The documented shortage of practicing pediatric and child psychol-
ogists providing services to Latin American children living in pov-
erty remains an area of concern (Belfer & Rohde, 2005). One
recommendation is that pediatric psychologists living in developed
countries consider training mental health professionals in Latin
Colombian Youth With Spina Bifida
America in evidence-based interventions for children with depres-
sion. Such training should focus on empirically validated and tar-
geted treatment packages (e.g., brief cognitive-behavioral therapies,
behavioral activation), with an emphasis on mechanisms of change
underlying these interventions. Although in-person training may not
be feasible, pediatric psychologists, and particularly those who
speak Spanish, may consider developing relationships with
Colombian hospitals to provide training via Internet teleconferenc-
ing (e.g., Skype). This training should use a train-the-trainer model
to ensure that knowledge is then disseminated more broadly (Belfer
& Rohde, 2005; McHugh & Barlow, 2010).
Another important access-to-care issue relevant to our findings is
that even when psychological services are available to Colombian
children living in poverty with disabilities, they are likely to experi-
ence barriers to obtaining them. A lack of financial resources,
vehicles, and adequate roads for travel means that creative delivery
solutions are needed. Fortunately, Colombia has a relatively strong
Internet service infrastructure, and many children living in rural
areas are able to access the Web at schools and community centers.
As such, behavioral health services could be disseminated via tele-
phone or Internet conferencing, and such services could come
directly from Spanish-speaking pediatric psychologists living in the
United States. These services might be best supported by small serv-
ice grants aimed at providing evidence-based care to medically
involved children living in developing areas.
Another potential direction for providing low-cost mental health
services is found in the growing body of empirically supported, self-
directed Web-based treatment systems for ill and injured children.
For example, Web-based programs such as Coping Coach, devel-
oped to support children experiencing stress following acute illness
and injury, have shown promising preliminary results (Marsac et al.,
2013). In addition, Web-based cognitive-behavioral therapy for
depression has demonstrated efficacy in adult populations
(Christensen, Griffiths, & Jorm, 2004), and Web-based psychoedu-
cation programs for health conditions in children also have demon-
strated promise (Ritterband et al., 2003). Efforts to develop
Web-based and culturally appropriate programming for Colombian
children with SB modeled on these existing programs could enhance
children’s ability to obtain low-cost behavioral health services as
well as preventive interventions.
Results from the current study also have important implications
for future research efforts. Although the field of pediatric psychol-
ogy recognizes the need for international research (Black et al.,
2000), little of this work is being conducted in areas where many
children live in poverty. One factor preventing proliferation of this
work may be the dearth of culturally appropriate and validated
instruments. Operationalizing mental health concerns across cul-
tures presents numerous challenges, given that cultural norms can
significantly impact the ways in which individuals conceptualize
psychopathology, respond to questionnaires, and describe their
symptoms in interviews (Black et al., 2000). Therefore, targeted
efforts are needed to develop culturally sensitive and psychometri-
cally sound methods and instrumentation that provide psychologists
avenues to quantify the ways in which pediatric medical conditions
impact the emotional health of children living in developing areas.
Future research studies also should include larger samples to allow
for more fine-grained analysis of what specific resources (e.g.,
handicap-accessible public transportation, special educational pro-
grams) may impact psychological functioning among Colombian
children with physical disabilities. For example, it may be that chil-
dren who are more homebound experience greater levels of depres-
sion. Because such barriers to independence in adulthood may
607
confer risk for future mental health difficulties, the timing is right to
re-commit efforts to conducting pediatric psychology research in
international settings.
Conflicts of interest: None declared.
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