Journal of Pediatric Psychology, Vol. 13, No. 2, 1988, pp.

197-212

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Children With Chronic Physical Disorders:
Maternal Reports of Their Psychological Adjustment1
Jan L. Wallander2
Sparks Center, University of Alabama at Birmingham
James W. Varni
Orthopaedic Hospital and University of Southern California

Lina Babani, Heather Tweddle Banis, and Karen Thompson Wilcox

University of Southern California

Received March 16, 1987; accepted May 9, 1987

Advances in biomedical science have resulted in dramatic improvements in

the medical care of chronically ill and handicapped children. Past measure-
ment problems have resulted in a lack of clarity regarding the psychological
adjustment of these children. The mothers of 270 chronically ill and han-
dicapped children were administered the Child Behavior Checklist in an at-
tempt to identify patterns of behavioral functioning across six pediatric
chronic disorders: juvenile diabetes, spinabifida, hemophilia, chronic obesity,
juvenile rheumatoid arthritis, and cerebral palsy. In general, it was found
that children in all chronic disorder groups were perceived by their mothers
as evidencing on the average more behavioral and social competence problems
than expected based on norms for children in general. However, their be-
havioral and social adjustment was reported as better than that of a norma-
tive sample of children referred to mental health clinics. There were essentially
no differences between children with different chronic disorders in terms of
behavior problems and social competence. The results were taken to sup-
port the view that these children were as a group at risk for adjustment

'This research was supported in part by grants from The Crippled Children's Guild through
the Behavioral Pediatrics Program at Orthopaedic Hospital; University of Southern Califor-
nia Faculty Research and Innovation Fund; and the Biomedical Research Support Grant
program.
2
A1I correspondence should be sent to Jan L. Wallander, Sparks Center, University of Alaba-
ma at Birmingham, 1720 Seventh Avenue South, Birmingham, Alabama 35233.
197
0146-8693/88/0600-0197M6.00/0 © 1988 Plenum Publishing Corporation
198 Wallander, Vami, Babani, Banis, and Wilcox

problems. They were also discussed in terms of the noncategorical approach,

which suggests that similar psychosocial challenges are faced across pedi-
atric chronic physical disorders.
KEY WORDS: chronically ill and handicapped children; diabetes; hemophilia; spina bifida;
arthritis; obesity; cerebral palsy; psychological adjustment.

Advances in biomedical science and technology during the past 20 years has

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resulted in dramatic improvements in the medical care of chronically ill and
handicapped children. Many children who either died early in life or were
institutionalized are now living well into adulthood and functioning in the
community. With this improvement in life status, psychological issues have
become more salient. Simply surviving a chronic physical disorder is no longer
sufficient; the psychological functioning of these children must receive at-
tention (cf. Varni, 1983).
The early literature on the psychological adjustment of chronically ill
and handicapped children reported that a chronic physical disorder predis-
posed children to psychological maladjustment or even psychopathology (e.g.,
Knowles, 1971; Lawler, Nakielny, & Wright, 1966; McCullum & Gibson,
1970; Tropauer, Franz, & Dilgard, 1970). These findings were tempered some-
what by large and carefully designed epidemiological surveys conducted in
the late 1960s. Pless and Roghman (1971) reviewed the results of three such
studies. They found quite consistently that the proportion of chronically ill
and handicapped children who were deemed maladapted was about twice
that of physically healthy children. The incidence rate varied, however, be-
tween 13 and 26% for parent report and 16 and 39% for teacher report. These
findings suggested that chronically ill and handicapped children as a group
are at higher risk for psychological adjustment problems than healthy chil-
dren. Only a minority, however, evidence maladjustment. In contrast, more
recent studies have found less of a difference, if any at all, between children
with several different specific chronic physical disorders and controls (e.g.,
Drotar et al., 1981; Gayton, Friedman, Tavormina, & Tucker, 1977; Tavor-
mina, Kastner, Slater, & Watt, 1976). These contrasting findings regarding
the psychological concomitants of chronic physical disorders led Pless and
Zvagulis (1981) to conclude that "the picture is not nearly as clear as it was
once thought to be" (p. 191). The earlier belief that a chronic physical dis-
order in children is associated with adjustment problems has today been
replaced by uncertainty.
There are several reasons for these equivocal findings. First, determin-
ing adjustment in children is an inexact science. The earliest studies in par-
ticular relied on clinical impressions rather than psychometric and statistical
procedures. One possible reason for the reliance on weaker procedures is that,
until recently, no adequate procedures existed for measuring psychological
Adjustment of Chronically Dl Children 199

adjustment in children. Today however, several instruments are available

(e.g., Achenbach & Edelbrock, 1983; Wirt, Lachar, Klinedinst, & Seat, 1977)
with demonstrated reliability and validity for this purpose. They also have
well-developed norms, allowing for statistical statements as to the adjust-
ment of a given child or group of children.
A second reason for the inconclusive findings is that different perspec-
tives have been utilized in measuring chronically ill and handicapped chil-

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dren's adjustment. For example, as Pless and Roghman (1977) have noted,
parent and teacher reports yield different incidence rates of maladjustment.
Semistructured child interview procedures and clinicians' diagnostic evalua-
tions add further variability. Though for some purposes it may be prefera-
ble to use several sources for measuring child adjustment, parents are
generally the most knowledgeable observers of their children's behavior across
time and settings (Achenbach & Edelbrock, 1983). Admittedly, parental report
may sometimes be influenced by factors unrelated to the child's behavior (Bro-
dy & Forehand, 1986). It remains nonetheless that mental health clinic-
referrals for children are most often made by parents and in all other cases
their consent must be sought. Consequently, parental report appears to be
a very reasonable single choice for assessing children's adjustment.
A third reason for the discrepant results between studies is that those
having found no differences in adjustment for chronically ill and handicapped
children used much smaller samples. This makes it harder to obtain reliable
population estimates. Larger absolute mean adjustment score differences
would therefore be required before groups would be found statistically sig-
nificantly different. The same actual score difference, in other words, can
lead to differing statistical outcomes and conclusions when different sample
sizes are used. It is possible, thus, that the observed discrepancy in previous
research is more apparent than real.
A final reason to be noted for the disparate findings is that children
with different chronic physical disorders have been investigated in different
studies. Those studies that have found no difference between chronically ill
and healthy children (e.g., Drotar et al., 1981; Tavormina et al., 1976) have
tended to focus on a single disorder (e.g., only cystic fibrosis or only dia-
betes). Those that have found differences more often have included represen-
tatives from a broad range of chronic physical disorders (cf. Pless &
Roughman, 1971). This becomes important when there are findings suggest-
ing that certain features present in some chronic disorders but not in others
are related to the children's adjustment. The most noteworthy example is
the poorer adjustment found in children with disorders that involve brain
damage compared to those that do not (Breslau, 1985; Rutter, Graham, &
Yule, 1970). It may be that those single-disorder studies that found no ad-
justment differences for chronically ill or handicapped children may have
200 Wallander, Varni, Babani, Banis, and Wilcox

studied a particular disorder that indeed is not associated with a negative

psychosocial outcome. This issue needs to be clarified by comparing several
disorders in one study using the same assessment procedure.
Consequently there remain many questions regarding the psychologi-
cal status of children with different chronic physical disorders. It was the
general aim of the present study therefore to measure the psychological ad-
justment of children with chronic physical disorder using the same psy-
chometrically reliable and valid instrument across several disorders. The

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following specific questions were addressed in this investigation: (a) What
is the average psychological adjustment of chronically ill and handicapped
children, as reported by their mothers; (b) is there a difference in the inci-
dence of maladjustment for these children; (c) does their adjustment differ
from that of children in general or children referred to outpatient mental
health clinics; (d) does the adjustment differ among groups of children with
different chronic physical disorders; (e) does the adjustment of these chil-
dren relate to their sex, age, or family socioeconomic status (SES); and (f)
do they evidence any specific pattern of adjustment problems?

METHOD

Subjects

Chronically ill and handicapped children were recruited from the am-
bulatory care clinics of three hospitals affiliated with the University of
Southern California (Orthopaedic Hospital, Childrens Hospital of Los An-
geles, and the Pediatric Pavilion at the Los Angeles County-University of
Southern California Medical Center). These clinics specialized in the mul-
tidisciplinary care of children with either juvenile diabetes, spina bifida,
hemophilia, juvenile rheumatoid arthritis, or cerebral palsy. In addition, chil-
dren with chronic obesity were recruited from a general pediatrics clinic.
Chronic obesity was defined as 25% over median population weight for the
child's age, sex, and height for a minimum duration of 2 years. Chronic obesi-
ty was included given that it is a persistent health problem similar to a chronic
physical illness in many respects. Clinic master lists were reviewed first to
identify potential subjects. Mothers with children in the age range of 4 to
16 were then contacted either through the mail, by telephone, or when she
appeared with her child for a regularly scheduled clinic appointment. The
project was explained to her. If she volunteered to participate, she signed
an informed consent form.
This resulted in a sample of 270 children, ages 4 to 16, with 147 (54%)
boys and 123 (46%) girls. The distribution of these children across age inter-
vals and the six chronic disorders are presented in Table I, as are the distri-
Adjustment of Chronically 111 Children 201

butions of the mothers' educational level and family income. The procedure
of the current study was imbedded in different data collections, each focused
on one of the chronic physical disorders, but of varying scope and content
aside from the commonality presented herein. This explains the uneven dis-
tribution of this sample across chronic disorders. The average child in this
sample was 10.3 years old. His/her mother had completed slightly less than
12 years of education and the family had an income of $22,000 the previous
year. The average family in this sample, consequently, had a slightly lower

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SES than the average family in the United States population in 1985, when
these data were collected.

Procedure and Instrument

The mother of each child completed the procedure for this study in per-
son. An assistant explained each step and answered any questions. Foliow-

Table I. Subject Characteristics

Variable n° % of sample
Chronic disorder groups
Juvenile diabetes 80 30
Spina bifida 77 29
Hemophilia 40 15
Chronic obesity 30 11
Juvenile rheumatoid arthritis 24 9
Cerebral palsy 19 7
Child's age
4-5 19 7
6-7 49 18
8-9 51 19
10-11 51 19
12-13 41 15
14-15 43 16
16 16 6
Mother's education
Junior high school or less 76 28
Some high school 30 11
High school diploma 56 20
Community college 65 24
College degree 32 12
Graduate education 11 4
Family income
State aid only 24 9
<$10,000 39 14
$10-20,000 76 28
$20-30,000 47 17
$30-40,000 27 10
>$40,000 57 21
°N = 270.
202 Wallander, Varni, Babani, Banis, and Wilcox

ing the signing of the informed consent form, the mother completed a series
of instruments. Of relevance to the current study is only the Child Behavior
Checklist (CBCL; Achenbach & Edelbrock, 1983). The research assistant sub-
sequently checked that it was filled out appropriately or discrepancies were
resolved.
The CBCL is a 138-item checklist completed by a parent. Normative
data, stratified for three age groups (4-5, 6-11, 12-16) and sex, are availa-
ble for 1,300 community nonclinic-referred and 2,300 mental health clinic-

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referred children between the ages of 4 and 16. Extensive analyses have yielded
principal component solutions for the 118 behavior problem items that are
different for the two sexes and three age groups. However, the two second-
order principal components of Internalizing Behavior Problems and Exter-
nalizing Behavior Problems exist for all sexes and age groups and can serve
as summary scales of behavior problems. The same holds for the summary
scale of Social Competence, which is constituted by 20 items measuring the
child's activities, peer relations, and school performance. Whereas most of
the analyses are based on the three summary scales, some were conducted
on the first-order scales. Following standard procedures and using available
norms (Achenbach & Edelbrock, 1983), scores on all scales were computed
as normalized T scores.

RESULTS

Psychological Adjustment

The mean T scores for the sample as a whole were 57 (SD = 10) on
the Internalizing Behavior Problems, 55 (SD = 10) on the Externalizing Be-
havior Problems, and 42 (SD = 13) on the Social Competence scales. The
distribution for each scale around its mean was essentially normal and not
markedly influenced by extreme scores; both kurtosis (range = -0.34 to
+ 0.44) and skewness (range = -0.19 to +0.14) were minimal and the me-
dian for each scale was identical to the mean. The average chronically ill
or handicapped child consequently was reported to display more internaliz-
ing behavior problems than 75% and more externalizing behavior problems
than 69% of those in the normative sample of community children. Also,
the social competence of the average chronically ill or handicapped child was
worse than that of 78% of the community norm sample.
Adjustment of Chronically 111 Children 203

Incidence of Maladjustment

The determination of what portion of the sample is reported to be

maladjusted depends in part on what definition is used. The developers of
the CBCL (Achenbach & Edelbrock, 1983) recommend that those who ob-
tain a T score 2 standard deviations away, in the deviant direction, from
the mean of the community norm sample (T score > 70 for the behavior
problems scales and T < 30 for the Social Competence scale) be considered

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clinically maladjusted. Thus, 12% of the chronically ill and handicapped chil-
dren were considered maladjusted based on their reported internalizing be-
havior problems and 9% similarly based on reported externalizing behavior
problems; 20% evidenced social competence difficulties in the defined malad-
justed range. A more liberal definition of 1 standard deviation away from
the normative means for community children obviously places more chil-
dren in this category. If a T score more deviant than 84% of the norm sam-
ple defines maladjustment 44, 34, and 46% of the chronically ill and
handicapped children met this criterion based on their scores on the Inter-
nalizing Behavior Problems, Externalizing Behavior Problems, and Social
Competence scales, respectively.

Comparisons With Normative Samples

Z tests comparing mean scores indicated that the chronically ill and han-
dicapped children were significantly different from the normative sample of
community children on the Internalizing Behavior Problems, Externalizing
Behavior Problems, and Social Competence summary scales (Z = 10.60,7.86,
and —14.95, respectively; allp < .001). Their mean scores indicate they were
reported to display significantly more behavior problems and a lower level
of social competence on the average than community children.
Z tests comparing the mean scores of the chronically ill and handicapped
children to those of the normative sample of mental health clinic-referred
children similarly indicated them to be significantly different on all three
CBCL summary scales (Internalizing Behavior Problems Z = -14.89, Ex-
ternalizing Behavior Problems Z = -18.07, Social Competence Z = 6.68;
allp < .001). The mean scores of these two samples indicated that the chron-
ically ill and handicapped children were reported to display significantly fewer
behavior problems and a higher level of social competence on the average
than children referred for mental health services.
204 Wallander, Varni, Babani, Banis, and WDcox

Comparison Among Different Chronic Disorders

The means and standard deviations on the three CBCL summary scales
for children with different chronic physical disorders are presented in Table
II. One-way ANOVAs, with chronic physical disorder as the between-subjects
factor, were completed on the Tscores from each summary scale. While the
Internalizing Behavior Problems scale yielded nonsignificant results, F(5, 264)
= 1.00, p = ns, significant differences among disorders were obtained for

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both the Externalizing Behavior Problems, F(5, 264) = 2.98, p < .05, and
Social Competence, F(5, 264) = 6.59, p < .001, scales. Post hoc analysis,
using the Newman-Keuls procedure, indicated that only the Externalizing
Behavior Problems scale score for the Juvenile Rheumatoid Arthritis condi-
tion was significantly lower than the scores of all the other chronic physical
disorders. These other disorders did not differ significantly from one another.
Similarly, only the Social Competence score for the Cerebral Palsy condi-
tion was significantly lower than the scores of all the other chronic physical
disorders, which did not differ from another another.

Relationship to Age, Sex, and SES

Pearson product-moment correlation coefficients were computed be-

tween scores on each of the three CBCL summary scales and age, but none
were significant, all |r|(268) < .04, all/? = ns. The whole sample was also
stratified into two groups, representing older (age > 12) and younger (age
< 12) children, respectively. Comparing CBCL summary scale scores be-
tween these two age groups using / tests similarly yielded no significant differ-
ences, all /(268) < 1.08, all p - ns.
Comparisons between the scores of boys and girls on the three CBCL
summary scales using t tests yielded a significant difference for the Exter-

Table II. Means and Standard Deviations for Chronic Disorders on the CBCL Sum-
mary Scales
Internalizing Externalizing Social competence
Chronic disorder M SD M SD M SD
Juvenile diabetes 57 10 54 11 45 12
Spina bifida 57 9 55 9 43 12
Hemophilia 57 11 57 11 42 16
Chronic obesity 60 11 57 12 39 11
Juvenile rheumatoid arthritis 54 7 49° 7 41 10
Cerebral palsy 57 11 59 11 27" 8
"Group mean significantly (p < .05) different from the means of all other chronic
disorders on this scale.
Adjustment of Chronically III Children 205

nalizing Behavior Problems scale only, /(268) = 2.03, p < .05. Boys were
on the average reported to display significantly more externalizing behavior
problems than girls, but the difference was very slight in absolute terms (mean
T score for boys = 56 and girls = 54). However, the noted difference be-
tween the overall sample of chronically ill and handicapped children and the
normative sample of community children could not be attributed to the higher
externalizing scores obtained by the boys in the former sample. Both boys
and girls in this sample were reported to display significantly more exter-

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nalizing behavior problems when compared only to same sex peers in the
community norm sample (Z = 6.26 and 3.91, respectively; all/? < .001).
Pearson product-moment correlations were also computed between each
CBCL summary scale and two indices of SES. Internalizing and externaliz-
ing behavior problems were significantly negatively related, r(268) = — .19
and —.17, respectively, p < .05, and social competence was significantly
positively related, r(268) = .35, p < .001, to mothers'educational level. Fa-
mily income was significantly positively related with social competence, r(268)
= .40, p < .001, but not with internalizing or externalizing behavior
problems, r(268) = —.12 and —.10, respectively;/? = ns.
These significant relationships between adjustment and some SES in-
dices raise the possibility that the significant differences noted between the
chronically ill and handicapped children and the normative sample of com-
munity children were mainly due to chronically ill and handicapped children
from lower SES families. Indeed, this sample was slightly overrepresented
by lower SES families. To evaluate this possibility, children obtaining scores
in the lower one-third on the distribution on each measure of SES were re-
moved and comparisons repeated on the subsample made up only of those
in the upper two-thirds in terms of SES. These remaining chronically ill and
handicapped children still obtained mean T scores significantly higher on
the two behavior problems scales (all Z > 4.92, all p < .001) and lower on
the Social Competence scale (Z = - 9.04, p < .001) than the normative sam-
ple of community children. The mean T scores of this subsample were in
fact essentially indistinguishable from those of the overall sample of chroni-
cally ill and handicapped children.

Specific Adjustment Problems

All analyses of maternal reports of adjustment presented thus far were

based on the three CBCL summary scales. The CBCL also provides infor-
mation on adjustment in specific areas based on scores on the first-order
subscales. However, since these subscales were derived from principle com-
ponent analysis conducted separately for three age groups and sex, the num-
ber and content of these subscales vary for different ages and sex. The mean
206 Wallander, Varni, Babani, Banis, and Wilcox

T scores for the appropriate behavior problems and social competence sub-
scale are presented in Table III for four subsamples. These were obtained
by stratifying by sex and two age groups (6-11, 12-16). Results are not
presented for the youngest age group (4-5) because of its inadequate size
in the study sample (n = 19).
The subscale means were all between a T score of 58 and 63, with 89%
actually being between 59 and 62. Repeated measures ANOVA were com-
puted separately for the four age group and sex subsamples using the CBCL

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behavior problem subscales as the within-subjects factor. In spite of small
differences in subscale means, this analysis revealed several to be different
from one another. As can be noted from the F values reported in Table III,
there were significant differences among behavior problem subscale means
for boys age 6-11, girls age 6-11, and girls age 12-16, but not for boys age
12-16. Post hoc comparisons among subscales were made using the Newman-
Keuls procedure and a conservative/? level set at .01. The results of these
tests indicated that boys age 6-11 obtained scores for Somatic Complaints
which were significantly higher than their scores on all other behavior problem
subscales, except Hyperactive and Delinquent, and for Hyperactive which
were significantly higher only than their scores on Obsessive-Compulsive.
All other behavior problem subscale comparisons yielded nonsignificant
differences for this subsample. Girls age 6-11 obtained scores on Somatic
Complaints which were significantly higher only than their scores on
Depressed, but no other behavior problem subscale comparisons were sig-
nificant. Girls age 12-16, finally, obtained scores on Somatic Complaints
which were higher than their scores on all other behavior problem subscales,
which in turn did not differ significantly from one another.
Inspection of the mean scores reported in Table III and results of these
analyses indicated, not surprisingly, that these children were reported con-
sistently as high on the Somatic Complaints subscale. This subscale is part
of the Internalizing Behavior Problems summary scale. These findings raise
the possibility that the noted differences between chronically ill and han-
dicapped children and the normative sample of community children on the
Internalizing Behavior Problems scale was due mainly to the elevated scores
on the Somatic Complaints subscale. To evaluate this possibility, a modi-
fied Internalizing Behavior Problems score was calculated by disregarding
items constituting the Somatic Complaints subscale and prorating to still ob-
tain a comparable T score. The chronically ill and handicapped children ob-
tained a mean T score on this modified Internalizing Behavior Problems
summary scale of 55. This is still significantly higher than the comparable
score reported for the normative sample of community children (Z = 7.14,
p < .001).
Adjustment of Chronically III Children 207

Table III. Mean T Scores for CBCL Problem Area Scales

Age 6-11 Age 12-16
Boys Girls Boys Girls
Problem area scales (n = 78) (n = 76) (n = 56) (n = 40)
Behavior problems scales
Depressed 60 59
Depressed withdrawal 59
Uncommunicative 60 60
Schizoid 62 59

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Schizoid or anxious 60
Schizoid-obsessive 61
Anxious obsessive 58
Obsessive-compulsive 59 60
Somatic complaints 63 62 62 63
Social withdrawal 60 60
Hostile withdrawal 61
Immature 62
Immature-hyperactive 60
Hyperactive 62 61 61
Aggressive 60 60 60 58
Delinquent 61 60 59 59
Cruel 60 60
Sex problems 60
F° 2.96' 2.50* 1.31 5.03c
df (8,600) (8, 424) (8, 568) (7, 252)
Social competence scales
Activities 39 40 40 43
Social 47 45 48 48
School 41 39 44 42
F° 15.06" 10.42'' 6.58C 5.62'
df (2, 142) (2, 106) (2, 144) (2, 68)
"Repeated measures ANOVA conducted on scale scores separately within sex
and age groups.
"p < .05.
c
p < .01.
*p < .001.

The same four ANOVAs as for the behavior problems subscales were
also completed using the three social competence subscales as the within-
subjects factor. Significant effects were obtained for this factor for all four
subsamples, as can be noted from the F values presented in Table III. Post-
hoc Newman-Keuls comparisons with a conservative p level set at .01 showed
that both boys and girls at age 6-11 scored significantly lower on Activities
and School than they did on Social. Boys age 12-16 scored lower on Activi-
ties in comparison to Social, while girls age 12-16 scored lower on School
in comparison to Social. Other social competence subscale comparisons were
not significant.
208
Wallander, Varni, Babani, Banis, and Wilcox

DISCUSSION

This study was designed to measure the psychological adjustment of

children with different chronic physical disorders using a well-developed psy-
chometric instrument. The results generally suggest that these children con-
stitute a population at risk for adjustment problems. That is, their mothers
reported them as displaying significantly more internalizing and externaliz-
ing behavior problems and a lower level of social competence than expected

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compared to nonclinic-referred community children. This was the case even
when their reported somatic complaints were disregarded. About 10% met
statistical criteria for being clinically maladjusted in terms of the amount
of behavior problems they displayed, whereas 20% did so in terms of their
social competence. Equally important, however, the majority of these chron-
ically ill and handicapped children were found not to evidence adjustment
problems. Moreover, these children were better adjusted on the average, ac-
cording to their mothers, than children referred to mental health clinics.
Comparisons among children with different chronic physical disorders
indicated they were reported by their mothers to show very few differences
in adjustment. Children with juvenile diabetes, spina bifida, hemophilia, and
chronic obesity were indistinguishable from one another in terms of psycho-
logical adjustment measured herein. Only children with juvenile rheumatoid
arthritis displayed fewer externalizing behavior problems and children with
cerebral palsy a poorer social competence than children with other chronic
physical disorders. Chronically ill and handicapped children's adjustment
showed no association with their age. Boys in this sample were reported to
display significantly more externalizing behavior problems than girls even
though corrections for differing base rates are built into the score transfor-
mations made for the scale used in this study. These children's overall social
competence, which was defined herein as being involved in activities, having
friends, and doing well in school, was moderately positively related to their
families' SES.
Whereas chronically ill and handicapped children on the average were
described as evidencing a poorer adjustment, this was not displayed consis-
tently in any specific area more than another. Aside from the expected higher
reported frequency of somatic complaints, problems were not reported dis-
proportionately more or less so in other areas consistently across the sam-
ple. The results regarding internalizing and externalizing behavior problems,
for example, were remarkably similar. If problems were evidenced by a given
child, then, this could be in any area or across several areas. The specific
pattern is probably more determined by individual and environmental charac-
teristics than the fact the child has a chronic physical disorder. Consequent-
Adjustment of Chronically III Children 209

ly there appears to be no pattern of behavior problems associated with having

a chronic physical disorder.
These children's deficiencies in social competence in contrast were main-
ly reported by mothers as a lesser involvement in activities, hobbies, and regu-
lar tasks or doing poorly in school than in lacking in peer relationships. It
is reasonable, given the limitations of many of these children, that they are
less physically active and have more difficulties in school than children in
general. Fortunately, this does not seem to affect their peer relations signifi-

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cantly.
Several limitations to this study need to be acknowledged prior to draw-
ing implications from these findings. First, because this study was imbedded
in several independent data collections, the constitution of the sample was
uneven, such as across different chronic physical disorders, age, and sex.
At the same time, this makes even more remarkable the consistent findings
and the general lack of significant differences due to disorder or associa-
tions with age. The obtained sample, furthermore, seemed slightly over-
represented by members of low SES families. This was probably due to the
hospitals involved in this research serving large proportions of families resid-
ing in the inner city. Related to this is the concern over how much SES in-
fluenced the comparisons of this sample with norm samples. However, more
socioeconomically advantaged chronically ill and handicapped children were
still reported to display more adjustment difficulties on the average than
nonclinic-referred community children.
Another limitation is the reliance on mothers as the sole reporters of
these children's adjustment. Maternal perceptions of child behavior are prob-
ably a function of both child and maternal characteristics. For example, Brody
and Forehand (1986) have suggested that parents under stress may tend to
overestimate inappropriate child behavior. This would be of concern espe-
cially for mothers of chronically ill or handicapped children as they likely
experience chronic stress (Wallander, Pitt, & Mellins, 1988). Although there
exist a good deal of validity data for using maternal report on the CBCL
as a measure of child adjustment (Achenbach & Edelbrock, 1983), this limi-
tation must be kept in mind in interpreting the current findings.
On the other hand, a perceived major advantage of this study was in
its measurement of chronically ill and handicapped children's psychological
adjustment using an instrument with well-established acceptable psychometric
properties across various groups of children. Moreover, the consistent utili-
zation of the same instrument across physical disorders was done so as to
control for the possibility that conflicting findings in the previous literature
were an artifact of using different procedures with unknown or varying psy-
chometric properties and incomparable diagnostic categories. Finally,
210 Wallander, Varni, Babani, Banis, and Wilcox

although the total prevalence of children with chronic physical disorders has
been estimated at more than 10% (Pless & Douglas, 1971), many disorders
have a low incidence. By using the same procedure across the different dis-
orders, a larger group of children with various chronic physical disorders
could be studied than has been typical of recent efforts in this area.
Aside from finding that chronically ill and handicapped children as a
group appear to be at risk for developing adjustment problems, the other
noteworthy finding was the general lack of differences in adjustment of chil-

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dren with different chronic disorders. It seems unlikely therefore that the
discrepant findings noted in previous literature regarding these children's ad-
justment is due mainly to single and unique disorders having been studied.
Though a broad cross-section of disorders was represented, admittedly some
types of disorders were not included. Generally the life expectancy for chil-
dren with disorders studied herein is not a major concern, such as it is with
cancer or cystic fibrosis, for example. All disorders included furthermore
have a relatively stable course unlike a progressive disorder such as muscu-
lar dystrophy. Regardless, relative to physically healthy children, children
with different chronic physical disorders share at a general level a variety
of potentially stressful experiences. Examples are the acute exacerbation of
their chronic condition, complex and long-term treatment regimens, multi-
ple clinic visits, periodic hospitalizations, and aversive medical procedures
(Varni, 1983). These experiences also often have negative social ramifica-
tions (Wallander & Hubert, 1987).
The current study also provides some validation for the concept of com-
mon adjustment issues irrespective of the chronic physical disorder. That
is, though these chronic physical disorders vary greatly in their medical and
physical consequences, they may well produce similar general psychosocial
consequences. This suggests that in general the psychosocial challenges faced
by chronically ill and handicapped children may be quite similar regardless
of the specific chronic disorder. This argues for considering the noncategor-
ical approach in studying and treating the psychosocial implications of chronic
physical disorders (Stein & Jessop, 1982; Varni, 1983). Further investigation
into the possibilities are needed, however, especially with additional disord-
ers represented than was possible herein.
Whereas a statistically significant increased amount of adjustment
problems has been found for chronically ill and handicapped children com-
pared to nonclinic-referred community children, the absolute difference be-
tween the two groups is clearly not large. There are also "good" reasons why
they may experience more psychosocial difficulties, given the many additional
stressors they encounter. However, minimizing or rationalizing their difficul-
ties would be a mistake. It is important to realize much data now exist in-
dicating these children are at increased risk for adjustment problems. This
means more of them will display behavior problems at different times as well
Adjustment of Chronically HI Children 211

as frank maladjustment than expected in healthy children. Prevention and

intervention programs are needed to help them achieve an optimal level of
functioning and, at a minimum, avoid long-term unnecessary difficulties.
Several specific suggestions can be made to this end. Psychosocial
screening assessments should be made at regular medical contacts, with an
instrument such as the Child Behavior Checklist and under supervision of
a pediatric psychologist. Moreover, specification of modifiable factors which
differentiate between well and poorly adjusted chronically ill and handicapped

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children will help guide psychological intervention and prevention efforts.
It is unlikely that future research will uncover any one factor to account for
the majority of the variance in chronically ill and handicapped children's ad-
justment. Rather, multivariate models should be posited and explored (Var-
ni & Wallander, 1988). Among the more promising factors to be included
in such models appear to be family psychosocial functioning (Wallander,
Varni, Babani, Banis, & Wilcox, 1988), stressful life events, disease
parameters (Wallander, Varni et al., 1987; Wallander, Feldman, & Varni,
in press), temperament (Wallander, Hubert, & Varni, in press), and individual
competencies such as social (Wallander & Hubert, 1987) and coping (Varni
& Wallander, 1988) skills.

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