a friend in need: the influence of friendship on the
TRANSCRIPT
A Friend in Need: The Influence of Friendship on the Psychosocial Adjustment of Youth
with Chronic Health Conditions
by
Alissa B. Wigdor
Department of Psychology and Neuroscience Duke University
Date:_______________________ Approved:
___________________________
Martha Putallaz, Supervisor
___________________________ Melanie Bonner
___________________________
John Curry
___________________________ Rick Hoyle
___________________________
James Moody
Dissertation submitted in partial fulfillment of the requirements for the degree of Doctor
of Philosophy, in the Department of Psychology and Neuroscience in the Graduate School
of Duke University
2015
ABSTRACT
A Friend in Need: The Influence of Friendship on the Psychosocial Adjustment of Youth
with Chronic Health Conditions
by
Alissa B. Wigdor
Department of Psychology and Neuroscience Duke University
Date:_______________________ Approved:
___________________________
Martha Putallaz, Supervisor
___________________________ Melanie Bonner
___________________________
John Curry
___________________________ Rick Hoyle
___________________________
James Moody
An abstract of a dissertation submitted in partial fulfillment of the requirements for the degree of Doctor of Philosophy, in the Department of
Psychology and Neuroscience in the Graduate School of Duke University
2015
Copyright by Alissa B. Wigdor
2015
iv
Abstract
Friendship has consistently been found to act as a buffer against psychological
maladjustment for healthy youth and youth experiencing difficulties including parental
divorce and natural disasters. Less known is the role of friendship may have for females
coping with a chronic health problem. Therefore, the objective of the current study was
to evaluate the health factors and friendship precursors that may influence friendship,
and in turn, how those friendships may predict psychosocial adjustment. A sample of
chronically ill females (N = 30) was compared to a control group of healthy females (N =
45) on measures of opportunities for social interaction, similarity to their best friend,
social capability, friendship quality, and psychological adjustment. Results revealed that
health condition and friendship precursors were not associated with friendship quality.
However, higher friendship quality was predictive of fewer externalizing symptoms for
healthy girls. Additionally, positive parent relationships predicted fewer internalizing
symptoms for both groups of females. Notably, chronically ill girls noted their
friendships were higher in punishment and lower in companionship than healthy girls.
Further assessment, including objective measures, will elucidate the beneficial processes
of friendships and parent-child relationships that buffer youth from maladjustment.
v
Dedication
For Dakota, who has been part of this journey from the beginning.
vi
Contents
Abstract ......................................................................................................................................... iv
List of Tables ................................................................................................................................. ix
List of Figures ................................................................................................................................ x
Acknowledgements ..................................................................................................................... xi
Introduction ................................................................................................................................... 1
Friendship Quality ................................................................................................................. 3
Benefits of Friendship ............................................................................................................ 5
Necessary Context for Forming and Maintaining Friendships ....................................... 7
Health Challenges and Friendship Precursors ................................................................. 8
Opportunities ........................................................................................................................ 9
Opportunities and Health Challenges .......................................................................... 9
Similarity ............................................................................................................................. 11
Similarity and Health Challenges ................................................................................ 12
Social Capability ................................................................................................................. 13
Social Capability and Health Challenges ................................................................... 14
Framework for Friendship Precursors .............................................................................. 16
Youth with Chronic Health Conditions and Their Friendships .................................... 18
Presence of Friendships ..................................................................................................... 18
The Role of Gender............................................................................................................. 19
Current Study........................................................................................................................ 22
vii
Research Questions and Hypotheses............................................................................... 24
Method ......................................................................................................................................... 26
Participants ............................................................................................................................ 26
Procedure ............................................................................................................................... 28
Measures ................................................................................................................................ 29
Parent Measures ................................................................................................................. 29
Youth Measures .................................................................................................................. 32
Results ........................................................................................................................................... 36
Qualitative Data Description .............................................................................................. 41
The friendships of healthy versus chronically ill girls .................................................. 42
The friendships of chronically ill boys ............................................................................ 52
Research Question One: Predicting friendship quality from health condition and friendship precursors ........................................................................................................... 59
Research Questions Two and Three: Predicting psychosocial adjustment from health condition, relationship quality, and feelings of belonging ............................................. 61
Research Question Four: Healthy and chronically ill girls’ reports on friendship quality and importance beliefs ........................................................................................... 62
Research Question Five: Friendship quality importance beliefs moderating the relation between friendship quality and adjustment ...................................................... 65
Discussion .................................................................................................................................... 69
The Friendships of Boys and Girls ..................................................................................... 69
Impact of Health on Friendship Precursors ...................................................................... 72
Predicting Friendship Quality and Adjustment .............................................................. 74
viii
Impact of Health on Friendship Provisions ...................................................................... 77
Limitations ............................................................................................................................. 78
Future Directions .................................................................................................................. 82
Conclusions .................................................................................................................................. 85
Appendix A.................................................................................................................................. 87
Appendix B .................................................................................................................................. 93
Appendix C ................................................................................................................................ 127
References .................................................................................................................................. 133
Biography ................................................................................................................................... 152
ix
List of Tables
Table 1: The impact of specific chronic illnesses on the three friendship precursors ....... 17
Table 2: Skewness and kurtosis of all outcome variables ...................................................... 37
Table 3: Correlations between similarity reports, opportunity reports, positive and negative mother, father, and friendship relationships .......................................................... 39
Table 4: Means, standard deviations, ranges, and group differences ................................. 41
Table 5: Reasons endorsed for importance of friendship ...................................................... 53
Table 6: What would be changed about youths’ friendships ............................................... 54
Table 7: Best friend differentiation from other friends .......................................................... 54
Table 8: Best friend descriptions ............................................................................................... 55
Table 9: Desired best friend qualities ....................................................................................... 56
Table 10: Amount of interaction with best friend .................................................................. 57
Table 11: Methods of interaction with best friend .................................................................. 58
Table 12: The relation between presence of health condition and friendship provisions 64
Table 13: The relation between presence of health condition and friendship quality importance beliefs ....................................................................................................................... 65
Table 14: Friendship quality and importance beliefs regressions to predict psychosocial adjustment .................................................................................................................................... 68
x
List of Figures
Figure 1: Proposed relation between friendship precursors, quality of friendship, and adjustment. ................................................................................................................................... 16
Figure 2: Reasons for the importance of friendship ............................................................... 43
Figure 3: Reasons why best friend is different from other friends ...................................... 45
Figure 4: How often girls interacted with their best friend .................................................. 47
Figure 5: Where and how girls interacted with their best friend ......................................... 49
xi
Acknowledgements
This work would not have been possible without the support and guidance of
many individuals. First and foremost, Dr. Martha Putallaz has served as my graduate
advisor these past 6 years, and in doing so, has helped shaped me into the scientist I am
today. Martha’s guidance, challenge, dedication, and confidence in me have been
instrumental to my professional development. I am honored by her willingness to
follow me down the proverbial rabbit hole, and her insight and brilliance helped to
illuminate those depths.
I am also profoundly grateful for the members of my dissertation committee,
Drs. Melanie Bonner, John Curry, Rick Hoyle, and James Moody. Their feedback,
guidance, and care have been invaluable, and discussions with these professors have
consistently launched new and exciting ideas. I am also very grateful for the Pediatric
Psychology Service, run by Dr. Melanie Bonner, which has graciously allowed me and
helped me to recruit subjects. Dr. Bonner, as well as her students, Taryn Allen and
Lindsay Anderson, were all extremely helpful while I navigated research in a medical
center for the first time. In that same regard, I am also thankful for Dr. Anna Craig, who
connected me with youth at Duke Children’s Hematology/Oncology clinic. Further, I am
grateful towards the Alex’s Lemonade Stand Foundation and their Pediatric Oncology
xii
Student Training grant, without which I would not have been able to conduct this
investigation.
I would also like to extend a thank you to the Duke Social Development Lab:
Martha, Chris Grimes, Kristen Peairs, Katrina Blomquist, Jessica West, Molly Stroud
Weeks, and Megan Golonka. Further, I owe many thanks to the Duke Developmental
Writing Group: Molly Stroud Weeks, Megan Golonka, Kate Snyder, Janne Valhast, Amy
Dent, and Alison Koenka. It has been an honor to work with such talented and bright
women. I am also tremendously grateful to Dr. Kristi Hardy, who graciously advised me
at Children’s National Medical Center for a summer of research. The opportunity to
conduct research with Dr. Hardy at CNMC launched my interest in pediatrics and my
ideas for my master’s thesis and dissertation. I would also be remiss if I did not thank
Peggy Morrell, who has served as a constant support and pillar of kindness throughout
graduate school. Finally, thank you to the Rubin Lab family at the University of
Maryland, where I discovered I could research friendship(!). I am particularly thankful
to Bridget Trame Fredstrom, who acted as mentor to me during my time at the lab, and
even after I left for graduate school.
My graduate career has also been enriched by wonderful friendships. I am so
fortunate to have made friends with such awe-inspiring, strong, and smart women. I
developed a “friend crush” on Samantha Deffler as soon as I met her, and am so glad I
managed to convince her to become one of my closest friends. She has been an
xiii
incredible support and source of humor, and I cannot imagine a graduate school
experience with her. Further, I am thankful for the following ladies and their friendship,
and all the friendship qualities that entails, in no particular order: Shelley Alonso-
Marsden, Jessica Lake, Lori Keeling, Marissa Gamble, and Lauren Williamson. I am also
grateful for my co-child interns, Angela Tunno and Julia Schechter, for their
encouragement and support during our internship year. In addition to my “grad school”
friends, I am eternally thankful for the girls I love from home: Rachel Menyuk, Carolyn
Englar, Jackie Mackenzie, and Becky Lippy. Each one of these women has helped me
maintain my sanity in some shape or form at some time or another. I love all my friends
dearly, and they each deserve their own soliloquy, but an acknowledgement will have to
suffice.
Thank you to my parents, Marc and Linda, who have supported me and
encouraged me in my educational pursuits. I never doubted my ability to pursue this
dream, because they never doubted me. Thank you to my brother Ross, for helping to
fuel my desire to accomplish my goals. Thank you to my brother Jordan, who never
ceases to remind me how proud of me he is, despite his personal grudge against Duke
basketball. Thank you to Karen and Tom Griffin, and their children, for embracing me as
family.
Finally, a thank you to my future husband Ryan Griffin and our clowder of cats.
Ryan has loved me and supported me during the hardest times of graduate school. He
xiv
has been a steadfast source of comfort, a never ending barrel of laughs, and co-
conspirator on numerous terrible and wonderful decisions. I look forward to legally
binding him to me and insisting he call me Doctor for a full month following a
successful defense. I love you, Ryan, and I am excited for what’s to come for Griffindor.
1
Introduction
Friendship plays an essential role in the lives of children and adolescents, and
has consequences for their future adjustment. Having a close friend in childhood can
buffer youth from maladjustment in adulthood (Bagwell, Newcomb, & Bukowski, 1998;
Bagwell & Schmidt, 2011; Booth-LaForce, Rubin, Rose-Krasnor, & Burgess, 2004), and
the quality of that friendship also plays a role in predicting adjustment outcomes.
Theory and research on peer relations consistently suggest that positive features of
friendship offer important provisions, such as companionship, intimacy, support, and
instrumental aid (Bukowski, Hoza, & Boivin, 1994). Such friendship features tend to be
associated concurrently and longitudinally with indices of positive psychosocial
adjustment (e.g., self-esteem, low levels of loneliness, fewer internalizing symptoms;
Demir & Urberg, 2004; Gaertner, Fite, & Colder, 2010; Keefe & Berndt, 1996; Rudolph &
Rose, 2006; Thomas & Daubman, 2001).
Friendships have also been shown to promote adjustment during times of stress.
For example, social support from peers has been shown to lower the risk of post-
traumatic stress symptoms, and depression and anxiety in children after a hurricane (La
Greca, Silverman, Lai, & Jaccard, 2010; Moore & Varela, 2010; Pina et al., 2008).
Additionally, adolescents exposed to terrorist attacks reported more stress and
depression when their friend support was low, but not when their reported support
2
from friends was high (Henrich & Shahar, 2008; Shahar, Cohen, Grogan, Barile, &
Henrich, 2009). Adolescents of divorce indicated that they receive more social support
from their friends than from any other source (Ehrenberg, Stewart, Roche, Pringle, &
Bush, 2006; Özdemir, 2007), and youth of divorce who feel supported by their friends
reported fewer adjustment problems (Lustig, Wolchik, & Braver, 1992).
Given that friendship plays such an important role in promoting adjustment
under normal circumstances as well as during acute stress, it is logical to examine the
extent to which friendship serves as an aid in adjustment for children and adolescents
with distinguishable health stressors. Surprisingly, research on friendship has focused
almost exclusively on its role in typical development, virtually ignoring the role of
friendship as a protective factor for youth facing ongoing health stressors. Thus, the
populations of youth who may be acutely in need of the benefits of friendships have
rarely been the focus of research investigations.
In order to highlight the gaps in the field and future directions for the current
research, I will review the current research on friendship quality and the benefits of
friendship for both healthy youth and youth with health conditions. Next, I will describe
the necessary context and skills for forming and maintaining friendships, and how these
components are affected by health conditions. Finally, I will present an investigation
3
aimed at furthering the current understanding of the role of friendship in the
psychosocial adjustment of youth with health conditions.
Friendship Quality
Friendships are defined by various qualities, the valence of which can be
summarized as positive or negative. Weiss (1974) proposed that these qualities included
intimate disclosure, a dependable bond, enhancement of worth, companionship, help
and guidance, and nurturance, all of which are recognized as positive qualities. Of these
positive qualities, self-disclosure and intimacy are often viewed as vital components of
friendship because they allow for emotional support (Berndt & Perry, 1986).
Companionship is another important positive quality that is provided by friends across
development, and companionship from friends becomes increasingly important relative
to companionship from parents as youth age (Furman & Buhrmester, 1987). Providing
help and guidance is also a significant positive quality within friendship, and children
report that friends are expected to help one another (Berndt, 1981). Importantly, the
support and help provided by friends distinguish that particular relationship from other
relationships, such as acquaintances. Children rate their friends as more supportive than
acquaintances (Berndt & Perry, 1986). In addition to such positive qualities, other
research has identified and described various negative qualities present in relationships,
such as conflict, power, and rivalry (Furman & Buhrmester, 1985; Wiggens, 1979). How
4
such aspects are managed by the dyad may strongly influence the stability and overall
valence (positive or negative) of the friendship, as well as any associated benefits.
There is some evidence that youth with health problems, or at least those with
cancer, a group who would presumably benefit from friendship, may not develop
friendships marked by high positive quality. For instance, multiple studies have
reported that youth with cancer have lower quality friendships (e.g., less positive quality
and more negative quality) than comparison youth (Barrera, Shaw, Speechley, Maunsell,
& Pogany, 2005; Decker, 2007; Mattsson, Ringnér, Ljungman, & von Essen, 2007; Sloper,
Larcombe, & Charlton, 1994). Interestingly, youth with diabetes have reported feeling
supported by their friends (Helgeson, Reynolds, & Shestak, 2006; Helgeson, Reynolds,
Escobar, Siminerio, & Becker, 2007; La Greca, Auslander, Greco, Spetter, Fisher, &
Santiago, 1995; Seiffge-Krenke, 2000), but this has primarily been assessed through social
support measures, rather than broader assessments of friendship which includes other
relationship qualities (e.g., companionship, help, intimacy, conflict, etc.). Since previous
research has yielded mixed findings, and has not consistently assessed friendship with
appropriate measures, it is still unclear what the quality of friendships is for chronically
ill youth. Further research with more comprehensive assessments aimed at examining
the different relationship qualities for these youth is necessary.
5
Benefits of Friendship
As mentioned earlier, previous research has consistently found benefits of
friendship for healthy youth. One line of research has indicated that the presence of a
friendship is protective against such things as internalizing symptoms (Asher &
Paquette, 2003; Booth-LaForce et al., 2004; Bukowski, Laursen, & Hoza, 2010; Ladd &
Troop-Gordon, 2003; Parker & Asher, 1993; Rubin, Bukowski, & Parker, 2006; Stocker,
1994) and bullying and victimization (Fox & Boulton, 2006; Hodges, Boivin, Vitaro, &
Bukowski, 1999). The presence of a friend has also been found to boost self-esteem
(Berndt & Hanna, 1995; Bishop & Inderbitzen, 1995; Franco & Levitt, 1998; Kingery,
Erdley, & Marshall, 2011; Townsend, McCracken, & Wilton, 1988) and support school
success and promote positive attitudes towards school (Altermatt, 2011; Erath, Flanagan,
& Bierman, 2008). A second line of research has shown that these benefits appear to be
specifically associated with friendships that are high on positive qualities and low on
negative qualities (Bollmer, Milich, Harris, & Maras, 2005; Gaertner et al., 2010; Hartup,
1993; Hodges et al., 1999; Kingery & Erdley, 2007; Malcolm, Jensen-Campbell, Rex-Lear,
& Waldrip, 2006; Parker & Asher, 1993; Rubin et al., 2006). Thus, prior research has not
only demonstrated that having a friend is beneficial for healthy youth, but that the
quality and valence of that friendship is also important for determining potential
benefits.
6
There is currently some research on how friendships can influence the
adjustment outcomes of health-stressed youth, but that research has been limited.
Similar to the research on typical developing youth, one investigation found that the
presence of a friend helped youth with cancer feel less anxious and depressed (Corey,
Haase, Azzouz, & Monahan, 2008). However, most of the research on the adjustment
outcomes associated with friendship for chronically ill youth has focused on one
medical benefit: adherence to treatment. For instance, friends of diabetic youth help
support adherence to their medical regimens (Bearman & La Greca, 2002; Helgeson et
al., 2007; La Greca et al., 1995; La Greca & Thompson, 1998). While such findings are
informative, it is limited by only illuminating one aspect from the medical domain as
opposed to considering a broader set of benefits. Another shortcoming of prior research
is that it has often not included a broader examination of friendship qualities as
predictors of adjustment. Instead, past research has focused on a felt sense of social
support from a friend or peers in general, instead of utilizing more comprehensive
friendship assessments that measure the various qualities associated with a particular
friendship (Helgeson et al., 2006; Helgeson et al., 2007; La Greca et al., 1995; Seiffge-
Krenke, 2000). Indeed, it remains an unanswered question if the overall quality of
friendship is beneficial to this particular vulnerable population.
7
Another important avenue to pursue is whether different qualities of friendship
are more important for youth with chronic health conditions than for healthy youth, and
if friends are necessarily the source of those qualities. For instance, youth with health
conditions may particularly seek out friendships that provide support or instrumental
advice regarding treatments. A friendship that provides support and instrumental aid
may be more important to youth with health conditions than a friendship that provides
companionship or fun. It is also possible that such youth would seek and garner this
support or help from other relationships, such as from parents, making the attainment of
certain qualities from a friendship relationship less important. At this time it is unclear
whether certain qualities are more desired by health-stressed youth than healthy youth
in a friendship and whether the desire for certain qualities would influence the effect of
friendship on their overall adjustment.
Necessary Context for Forming and Maintaining Friendships
In order to experience the potential benefits of friendship, youth must first make
and then maintain their friendships. Three conditions seem necessary to achieve this
end. To make friends, children must interact with peers, thus allowing them
opportunities to form dyadic relationships. Furthermore, the similarity-attraction
hypothesis suggests that youth tend to be friends with peers who are similar to
themselves, and dislike peers who are dissimilar to themselves. Additionally, children
8
need someone in the peer group to like them enough to engage in a mutual relationship,
so they would have to behave in a manner that is likeable and encouraging of continued
interaction. Therefore, three important components (which will be referred to as
friendship precursors) for friendship formation include: 1) opportunities to interact in
person on a regular basis, 2) similarity with peers, and 3) displaying some level of social
capability.
Health Challenges and Friendship Precursors
Each of these friendship precursors for making and maintaining friendships may
be influenced by health challenges. For instance, there is the possibility that youth with
health conditions will have fewer opportunities to make friends if their health conditions
mean they are around their peers less. Due to a health condition, youth may look or
behave differently, reducing their apparent similarity to peers and increasing the
challenges for them to make and keep potential friends. Furthermore, their health
conditions may affect their level of social capability, as their physical or cognitive
abilities may be negatively impacted by their health conditions, which, in turn, may
influence how they behave or process social information. Such disadvantages could
mean fewer or no friends, and/or lower quality friendships. All of these possibilities
could potentially mean that friendship, a relationship that appears so valuable for youth
9
in times of stress, may not be available to a group that could so obviously benefit from
its positive effects.
Opportunities
The first friendship precursor to consider is the most basic for forming a
friendship: having a chance to spend time with peers. Opportunities to interact within
the peer group means access to social networks. Social networks can be viewed as
“social capital” which means there is value in social networks (Kadushin, 2012). The
value may be access to potential friends (e.g., larger network means more potential
friends) as “a friend of a friend is a friend,” insinuating that opportunities for friendship
are expanded by the friends of one’s friend (Cotterell, 1996; Cotterell, 2007). Thus,
simply being a part of a network, whether it is through a school environment, a camp
setting, or a neighborhood, allows for opportunities to engage ones’ peers on a regular
basis and make and maintain friends.
Opportunities and Health Challenges
Youth with chronic health conditions may not have as much social capital as
their healthy counterparts. Their conditions may often result in absences (due to their
illness or requisite treatment) or an inability to participate in various activities for health
reasons. In particular, youth with diabetes (La Greca, 1990), cancer (Decker, 2007;
Fraser, 2003; Gerhardt, Vannatta, Valerius, Correll, & Noll, 2007; Katz, Leary, Breiger, &
10
Friedman, 2011; Mulhern, Wasserman, Friedman, & Fairclough, 1989; Noll, Bukowski,
Davies, & Koontz, 1993; Noll, LeRoy, Bukowski, & Rogosch, 1991; Novakovic, Fears,
Wexler, McClure, Wilson, McCalla, et al., 1996; Olson, Boyle, Evans, & Zug, 1993;
Pendley, Dahlquist, & Dreyer, 1997; Sawyer, Crettenden, & Toogood, 1986), brain
tumors (Bamford, Morris-Jones, Pearson, Ribeiro, Shalet, et al.,1976; Carpentieri,
Mulhern, Douglas, Hanna, & Fairclough, 1993; Fossen, Abrahamsen, & Storm-Mathisen,
1998; Vannatta, Gartstein, Short, & Noll, 1998) and sickle cell disease (Barbarin, 1999;
Gustafson, Bonner, Hardy, & Thompson, 2006; Lemanek, Buckloh, Woods, & Butler,
1995; Morgan & Jackson, 1986; Schuman, Armstrong, Pegelow, & Routh, 1993) struggle
in their peer environment due to missed opportunities to interact, potentially leading to
fewer chances to learn peer norms and practice social competencies.
Furthermore, youth recognize their absences as problematic socially. When
looking back on their childhood friendships, young adults with diabetes reported
feeling isolated from their peers, indicating that they also perceived a disconnect
between themselves and other youth their age (Gee, Smith, Solomon, Quinn, & Lipton,
2007). Youth with cancer reported that their illness negatively impacted their social lives
and goals due to the disruptions in their daily routine for hospital and clinic visits
(Decker, 2007; Dolgin, Somer, Buchvald, & Zaizov, 1999; Gray et al., 1992; Green, Zevon,
& Hall, 1991). It is not clear, however, what those social goals were, and if their
11
friendships were particularly affected. Thus, it appears that chronic medical conditions
interrupt opportunities for peer interaction, but what these missed opportunities for
peer interaction mean for friendship for these children remains unknown.
Similarity
After opportunities, the next precursor to friendship is physical and behavioral
similarities. Research has indicated that similarity predicts liking, and that it is
rewarding because it validates one’s own attitudes and beliefs, and it allows people to
jointly participate in activities they enjoy (Aboud & Mendelson, 1996; Byrne & Griffitt,
1973). Not surprisingly, then, children are friends with peers who behave in a similar
manner to themselves (Rubin, Coplan, Chen, Buskirk, & Wojslawowicz, 2005; Rubin,
Lynch, Coplan, Rose-Krasnor, & Booth, 1994). Friends are often more similar to each
other than nonfriends with regards to humor, politeness, sociability, play style, play
complexity, prosocial and antisocial behavior, shyness, victimization, group acceptance,
depressive symptoms, academic achievement, and sociability (Altermatt & Pomerantz,
2003; Gifford-Smith & Brownell, 2003; Hartup, 1995; Haselager, van Lieshout, & Riksen-
Walraven 1998; Kupersmidt, DeRosier, & Patterson, 1995; Rubin et al., 2005; Rubin et al.,
2006; Rubin et al., 1994). Children tend to dislike peers who are different from
themselves, and friendships that do form with such peers are more likely to dissolve
(Rubin et al., 2006; Poulin & Boivin, 2000). Furthermore, children tend to be friends with
12
other youth based on more obvious similarities. For instance, children and their friends
are often similar in terms of demographic characteristics such as their age, sex, and race
(Aboud & Mendelson, 1996; Finkelstein & Haskins, 1983; Furman & Buhrmester, 1985;
Furman & Buhrmester, 1992; Hartup & Abecassis, 2002; Maccoby, 1998; McCandless &
Hoyt, 1961; Rubin et al., 2006; Singleton & Asher, 1979).
Similarity and Health Challenges
Certain youth with health problems struggle in their peer environment because
of their obvious physical and behavioral dissimilarities. Visibility of a disease, such as
the medical equipment required of diabetes, is often associated with more dislike, as
reported by teachers (Alderfer, Wiebe, & Hartmann, 2002). Interestingly, the teachers in
this study reported that peer dislike was more likely when the diabetes was highly
visible, despite how positive the diabetic youths’ behavior was (Alderfer et al., 2002).
Other research on youth with cancer has indicated that physical appearance differences,
as caused by the disease or its associated treatment, also results in an unpleasant peer
environment. For example, parents of youth with cancer report that their children’s
altered physical appearance influences their children’s peer relationships in negative
ways (e.g., victimization, difficulty maintaining friendships, and being friends with
desirable playmates) (Fraser, 2003).
13
Looking different is not the only aspect that sets youth with health conditions
apart from their healthy peers. In fact, even the label of a disease can also serve to mark
these youth as dissimilar. Research on youth with sickle cell disease indicated that peers’
knowledge of youth having the disease, without any additional visible differences,
resulted in their being viewed as more sickly by their peers, and being seen as less
sociable (Noll, Reiter-Purtill, Vannatta, Gerhardt, & Short, 2007; Noll, Vannatta, Koontz,
& Kalinyak, 1996). Thus, having the disease label and/or having visible effects of the
disease or treatment has the potential to reduce the chances of making and maintaining
friends. However, while the likelihood of making and maintaining friends is decreased
by dissimilarity, it is still unclear what dissimilarity would mean for the friendships of
these youth.
Social Capability
When interacting with peers, youth need to display competent social behaviors.
Research has indicated that competent peer interaction behaviors include cooperating,
resolving conflict, displaying positive affect, equality, mutual liking, and loyalty, and
being capable of perspective-taking, self-regulating, effectively entering groups, and
communicating (Gifford-Smith & Brownell, 2003; Laursen & Hartup, 2002; Newcomb &
Bagwell, 1995; Oden & Asher, 1977; Putallaz, 1983). Thus, being skilled at these
behaviors would help children to form and maintain friendships (Hartup, 1996; Selman,
14
1981), and it has been suggested that such skillfulness will also result in higher quality
friendships (Aikins, Bierman, & Parker, 2005).
In addition to positive behavior, there is also a cognitive process necessary for
peer interaction. Social information processing involves mentally encoding cues,
interpreting cues accurately, clarifying goals, generating responses, selecting responses,
acting out responses, and evaluating outcomes (Crick & Dodge, 1994; Dodge, 1986;
Dodge, Pettit, McClaskey, & Brown, 1986; McFall, 1982; McFall & Dodge, 1982; Rubin &
Krasnor, 1986). Skillfully engaging in this process is expected to lead to competent
behaviors. More competent behaviors would likely mean more positive and less
negative peer interactions, thereby enhancing the likelihood of forming friendships and
maintaining.
Social Capability and Health Challenges
One group of youth that particularly illustrate this struggle are those facing
disorders of the central nervous system (CNS; e.g., brain, spinal cord). For example,
cancers of the CNS or treatments that affect the CNS appear to impact cognitive
functioning, which could influence social capability. Most evidence regarding pediatric
cancer survivors find that they are viewed as less socially competent than their healthy
peers (Mulhern et al., 1989; Olson et al., 1993; Sawyer, Crettenden, & Toogood, 1986),
except for Newby and colleagues who excluded youth with brain tumors (Newby,
15
Brown, Pawletko, Gold & Whitt, 2000). A number of studies have highlighted potential
social deficits among children with brain tumors. These include having difficulty
relating to peers (Bamford et al., 1976), displaying lower levels of social competence (as
reported by parents; Carpentieri et al., 1993; Fossen et al., 1998), being more isolated (as
reported by teachers; Noll, Ris, Davies, Bukowski, & Koontz, 1992), and being less
socially accepted (as reported by youth with brain tumors, their peers, and teachers;
Mulhern, Carpentieri, Shema, Stone, & Fairclough, 1993; Mulhern, Hancock, Fairclough,
& Kun, 1992; Vannatta et al., 1998; Vannatta, McNamara, Valerius, & Gerhardt, 2005).
In addition to the disease’s impact on social capability, treatment for these health
conditions may also interfere with their social functioning. For instance, the treatment
for brain tumors has resulted in youth reporting feeling less socially accepted, less
physically attractive, and less athletically capable than their peers, in addition to
reporting lower self-esteem (Hardy, Williard, Waltral, & Bonner, 2010). Altogether, the
current research indicates that chronic illnesses and/or their associated treatments that
impact the central nervous system may have negative effects on cognitive processing,
which in turn, can impair social functioning. Yet again, though, the impact of impaired
social functioning of health stressed youth on friendship is yet to be determined.
16
Framework for Friendship Precursors
While it is evident that health conditions affect the three friendship precursors, it
is less clear how variability may exist in a model where friendship precursors predict
friendship quality.
Figure 1: Proposed relation between friendship precursors, quality of
friendship, and adjustment.
Table 1 provides specific examples by health condition that illustrates how such
conditions may affect one or more of these precursors.
17
Table 1: The impact of specific chronic illnesses on the three friendship
precursors
Opportunities Similarities Social Capabilities
Asthma X X
Obesity X
Diabetes X X
Sickle Cell Disease X X
Cancer X X X
Brain Tumors X X X
As illustrated in Table 1, there will likely be variability between health conditions
on whether different chronic conditions will affect particular friendship precursors. For
example, a child with asthma may have fewer opportunities to interact with his/her
peers if he/she is not allowed to participate in sports due to their condition.
Furthermore, a child with asthma may carry an inhaler, which could set him/her apart
from his/her peers. However, there is no reason to expect that asthma would impact
cognitive functioning, thereby leaving social capability unaffected. In comparison, it
would be expected that a child with a brain tumor will experience missed opportunities
due to treatment and time in the hospital, will look different due to treatments, and may
experience poorer cognitive functioning.
18
Youth with Chronic Health Conditions and Their Friendships
Variability of effects on friendship precursors will likely have variable effects on
friendship quality, which, in turn, will result in differential psychosocial outcomes (see
Figure 1 for model). However, that hypothesis has yet to be examined within healthy or
chronically ill populations. As youth with chronic health conditions are at risk for
adjustment difficulties and potential victimization, it is natural and important to
examine the role that friendship might play in buffering children with health conditions
from psychosocial stress.
Presence of Friendships
Despite their apparent disadvantage in the peer environment, it should be noted
that many of these groups of health-stressed youth do have friends. As demonstrated by
the prior research, children with diabetes, cancer, brain tumors, or sickle cell disease
have friends, although (with the exception of diabetes) they usually have fewer friends
than healthy youth (Barrera et al., 2005; Chao, Chen, Wang, Wu, & Yeh, 2003; Falkner,
Neumark-Sztainer, Story, Jeffery, Beuhring, & Resnick, 2001; Helgeson et al., 2006;
Helgeson et al., 2007; Noll et al., 1991; Noll et al., 1996; Seiffge-Krenke, 2000; Strauss &
Pollack, 2003; Zbikowski & Cohen, 1998).
One major drawback to the previous research is that all of the friendship
assessments were limited to friendships within the school setting (with the exception of
19
a cancer camp study by Bluebond-Langner, Perkel, & Goertzel, 1991). However, it may
be necessary to rethink the context of friendship nominations for this population of
youth as they are often absent from school due to their health condition. School absences
may result in fewer friends at school, but exclusive use of in-school assessments would
not capture whether they have developed relationships outside of the school setting,
which may mean not assessing their highest quality friendships. By including
opportunities to nominate friends from beyond the school environment, researchers
may be better able to capture a richer, more accurate picture of the nature of friendships
for children with health stressors.
The Role of Gender
For healthy youth, gender differences are present in friendship. At the dyadic
level, boys and girls spend time with their friends differently. In particular, girls spend
more time engaged in intimate, self-disclosing conversations than boys and the
difference in self-disclosure intensifies with age (Burhmester & Furman, 1987;
Camarena, Sarigiani, & Peterson, 1990; Crockett, Losoff, & Petersen, 1984; Furman &
Buhrmester, 1985; Lansford & Parker, 1999; Lempers & Clark-Lempers, 1992; McNelles
& Connolly, 1999; Parker & Asher, 1993; Rose, 2002; Rose & Rudolph, 2006; Rubin et al.,
2006; Zarbatany, Lynne, McDougal, & Hymel, 2000). In contrast to girls, boys tend to
play more roughly and in larger groups (Maccoby, 1990). The most common finding
20
regarding gender differences in friendship is that girls report and demonstrate higher
quality friendships than boys (Aikins et al., 2005; Parker, Rubin, Erath, Wojslawowicz, &
Buskirk, 2006; Rubin et al., 2005; Rubin et al., 2006). Girls’ friendships are described as
being more prosocial and involving more intimate disclosure than those of boys
(Buhrmester, 1990; Jones & Dembo, 1989; Rose & Rudolph, 2006; Parker et al., 2006;
Rubin et al., 2005; Rubin et al., 2006). Girls also report their friendships to be closer, more
nurturing, to have more trust, more security, more validation, and more enhancement of
worth than boys’ friendships (De Goede, Branje, & Meeus, 2009; Hartup, 1992; Pagano &
Hirsch, 2007; Reisman, 1985; Rose & Rudolph, 2006). Thus, the dyadic relationship may
be especially important to girls, whereas group affiliation and belonging may be more
important to boys.
With regard to youth with medical conditions, very little is known about gender
differences in friendship. Inconsistent results have arisen regarding gender differences
in the friendships of diabetic youth. One study reported that diabetic adolescent girls
perceived less support from their friends than boys (de Dios, Avedillo, Palao, Ortiz &
Agud, 2003), whereas others found that diabetic females reported receiving more
support from friends than boys (Helgeson et al., 2007; La Greca et al., 1995).
Understanding the discrepancy in such findings is made more difficult by the use of
different instruments to assess perceived friendship support (e.g., a support for diabetic
21
care questionnaire [Méndez, Bermejo, Ros, Hidalgo, & Beléndez, 2000 in de Dios et al.,
2003] vs. Berndt & Keefe (1995) friendship questionnaire in Helgeson et al., 2007 vs. the
Diabetes Social Support Questionnaire and Perceived Social Support questionnaire
[Procidano & Heller, 1983 in La Greca et al., 1995]).
Also with regard to youth with diabetes, support from friends was only
predictive of better psychological health (e.g., depression) for males, but not for females
(Helgeson et al., 2007). A possibility is that support is expected in female friendships, so
the presence of support does not provide additional benefits. However, if males rely on
group interactions, support from a friend for males might be an extra, unanticipated,
positive experience. Notably, negative aspects of friendship (e.g., conflict and
dominance) predicted poorer adjustment (e.g., depression and anxiety) over time for
both boys and girls (Helgeson et al., 2007; Helgeson, Lopez, & Kamarck, 2009). This
initial work indicates that friendship may be helpful, particularly for males, but can
definitely lead to worse outcomes for both males and females if the relationship is high
in negative quality.
Pediatric medical conditions and their subsequent treatment also appear to play
a role in differential social functioning among males and females. Youth treated for
pediatric brain tumors with either cranioradiation therapy (CRT) or chemotherapy
and/or surgery were evaluated on their ability to detect low and high intensity facial
22
expressions (Willard, Hardy, & Bonner, 2009). The researchers found that female
survivors who did not have cranioradiation therapy made fewer low-intensity errors,
meaning that females who did receive CRT had more difficulty recognizing complex
facial expressions (Willard, et al., 2009). Furthermore, the researchers found that for
female survivors of pediatric brain tumors, difficulties with recognizing facial
expressions was associated with more social problems as reported by their parents
(Willard et al., 2009). Thus, it is possible that chronic medical conditions and their
associated treatments may have a particular negative social impact on girls.
Current Study
The current study builds upon and extends the current foundation of research on
the friendships of typical developing youth to those friendships of youth with chronic
health conditions. Specifically, the current investigation explores how chronic health
conditions may influence the precursors to friendship (e.g., opportunities to interact,
social functioning, and similarity) and their subsequent prediction of friendship quality.
At this time there is a significant gap in current research on how health conditions may
influence overall friendship quality, and whether certain friendship precursors and any
negative influence on those precursors have an effect on friendship quality. Another aim
of this study is to explore whether health condition, and/or friendship quality predict
psychological adjustment for chronically ill and healthy youth. Currently, it is unclear
23
whether high quality friendships for youth with chronic health conditions act as buffers
against psychological maladjustment. Additionally, the current research aims to explore
whether certain friendship qualities are more valued by youth with chronic conditions
than healthy youth. The current study furthers the understanding of an important
relationship, friendship, for youth with chronic health conditions, as well as lay the
groundwork for developing means of interventions for enhancing this particular
relationship’s with the goal of enhancing adjustment. See Figure 1 for further illustration
of this model.
Importantly, the current study focuses more specifically on the friendships of
healthy and chronically ill females. Given that prior research has highlighted the
importance of dyadic friendships for healthy girls, we determined it was necessary to
begin the exploration of the impact of chronic illness on friendships of girls alone. This
decision was further bolstered as recent research (Willard, et al., 2009) has suggested
chronic illnesses and/or their treatments may particularly impact girls’ social capability.
A brief exploration of chronically ill males’ friendships will also be included to begin to
assess whether gender differences appear in the friendships of chronically ill males and
females.
24
Research Questions and Hypotheses
RQ1. How will health condition, and friendship precursors predict friendship
quality?
A. Friendship Precursors. Fewer opportunities, more dissimilarity, and the poorer
social functioning girls display will be associated with lower positive
friendship quality and higher negative friendship quality.
B. Health Condition. The presence of a health condition will be associated with
lower positive friendship quality and higher negative friendship quality as
compared to the absence of a health condition.
C. Friendship Precursors and Health Condition. The presence of a chronic health
condition will interact with (e.g., increase the effect of) each of the friendship
precursors to be associated with lower positive friendship quality and higher
negative friendship quality.
RQ2. How will health condition and friendship quality interact to predict
psychosocial adjustment outcomes?
It is expected that healthy females with high quality friendships will have better
adjustment than chronically ill females with high quality friendships.
RQ3. Will relationship quality with parents or feelings of group belongingness
account for additional variability in psychosocial adjustment?
25
An additional exploratory aim of this proposed investigation is to examine
whether different relationships replace the need for friendship qualities. For instance,
missed opportunities with peers may indicate more time with parents, which in turn,
could enhance adjustment if the relationship with the parent is high quality. Indeed,
parent support may be more beneficial than friendship in terms of adjustment in light of
a chronic illness.
RQ4. How will healthy girls and chronically ill girls differ on what qualities
they report to be important in the friendships? Will there be differences between
healthy girls and chronically ill girls in how they rate the qualities of their
friendships? How will chronically ill boys describe their friendships?
One exploratory aim of this proposed investigation is to examine the importance
of specific friendship qualities to chronically ill girls and healthy girls. Furthermore, the
quality of friendship may be different for healthy girls as compared to chronically ill
girls. As there is currently no research guiding whether to expect a difference between
these groups regarding friendship quality and friendship quality preference, no specific
hypotheses were posited.
An additional exploratory aim of the proposed investigation is to begin to
highlight and understand how chronically ill boys view their friendships. Of particular
26
interest for the current study is how boys describe their friends, why they seek
friendship, and how they interact with their friends.
RQ5.Will friendship quality preferences influence the relation between
friendship quality and adjustment for all girls?
It is expected that girls’ importance beliefs with regards to different friendship
qualities will moderate the relation between friendship quality and adjustment.
Method
Participants
Seventy-five girls and 75 parents (one for each girl) completed the survey. Child
respondents ranged in age from 9 to 17 (M = 12.07, SD = 2.46). A final sample of 45
healthy (i.e., had not been previously diagnosed with a chronic illness, nor was there a
current concern for a chronic illness) girls participated in the study (100% consent rate;
77.59% completed after consent). Healthy girls were 53.33% Caucasian, 31.11% African
American, 13.33% multi-/biracial, and 2.22% Hispanic and had an average age of 11.98
years (SD = 2.59, range 9 to 17 years) at the time of study. Socioeconomic status was
calculated using the Hollingshead Index (Hollingshead, 1975) and was found to range
from 9 to 66 (M = 44.79, SD = 16.09).
A final sample of 30 chronically ill girls participated in the study (96.77% consent
rate; 78.95% completed after consent). Chronically ill girls were 70.00% Caucasian,
27
23.33% African American, 3.33% multi-/biracial, and 3.33% Asian American, and had an
average age of 12.20 years (SD = 2.28, range 9 to 17 years) at the time of the study. With
regard to medical condition, the diagnoses included 26.67% brain tumor, 20.00%
epilepsy, 10.00% non-CNS cancer, 6.67% sickle cell disease, and 36.67% other (single
cases of autoimmune encephalitis, lupus, diabetes, mitochondrial disorder,
neurofibromatosis 1, thyroid condition, etc.). Socioeconomic status was calculated using
the Hollingshead Index (Hollingshead, 1975) and was found to range from 14 to 66 (M =
42.02, SD = 15.55). A final sample of 10 chronically ill boys participated in the study for
the initial exploration of gender differences. Chronically ill boys were 100% Caucasian
and had an average age of 12.50 (SD = 2.92, range 9 to 17) at the time of the study. With
regard to medical condition, the diagnoses included 50.00% brain tumors, 20.00% non-
CNS cancer, and 30.00% other (single cases of SCID, autoimmune disorders, etc.).
In order to examine whether chronically ill girls and healthy girls differed on the
basis of race, a 4 (race) by 2 (health condition) chi square analysis was conducted. The
chi-square analysis conducted to determine whether groups differed with regard to race
was nonsignificant (χ2 = 5.32, p = 0.26). Univariate ANOVAs were conducted to
examine whether girls differed with regard to age and SES, and both analyses were
nonsignificant (age: F (1, 73) = 0.15, p = 0.70; SES: F (1, 73) = 0.55, p = 0.46). Thus, healthy
28
girls and chronically ill girls were not significantly different with regard to race, age or
SES.
Procedure
The study was administered from the end of December 2013 through March
2015. Data collection took place via an online survey using the Qualtrics survey
program. Chronically ill participants were recruited during their regularly scheduled
appointments at Duke University Medical Center’s Pediatric Psychology Service and
Duke Children’s Hospital Hematology/Oncology Clinic. Healthy participants were
recruited though online advertisements on the Duke Clinical Trials Healthy Volunteers
website and Craigslist Volunteers website (see Appendix A for advertisement). Patients
were eligible to participate if they could read at a third grade level, spoke and read
English fluently, did not have a traumatic brain injury, and had access to a computer
with internet. Parents were asked to provide consent for themselves and their children
(see Appendix A), and youth older than 12 years older provided assent on the same
form. Additionally, the youth were asked to identify their best friend, the identity of
whom was shared with their parents, as the girls’ parents would also be reporting about
that specific friend. The parent with the most knowledge about their daughter’s peer
relationships was asked to participate along with their child.
After reading the consent form and making sure all of their questions about the
29
study were answered (via phone for healthy participants; in-person for chronically ill
participants), all participants completed the survey questions online in the same order.
The study took most youth one hour or less to complete and most parents 30 minutes or
less to complete. All child participants were compensated with $10 for completing the
study.
Measures
Separate surveys were administered to the participating members of the family:
one for the parent and a second for the youth. The female youth completed the full
battery, the male youth only completed the open-ended survey questions about
friendship. These measures are described below in the order that they appeared in the
survey (see Appendix B for full measures).
Parent Measures
Demographics. This questionnaire consisted of 18 items assessing the following
variables: parent education and occupation, income, family members living in the home,
child’s date of birth, sex, weight, height, and for the parents of chronically ill children,
medical diagnosis, age of onset and diagnosis, medical regimen, and physical
impairment (e.g., use of equipment for mobility).
Similarity to Best Friend. Parents completed similarity ratings between their child
and their child’s best friend. These questions were created for the current study and
30
assessed similarity on weight, height, appearance, aggression, sense of humor,
outgoingness, behavioral maturity, academic achievement, prosocial behavior,
victimization, and peer acceptance. These qualities were selected according to previous
research indicating that friends tend to be similar on these domains (Aboud &
Mendelson, 1996; Altermatt & Pomerantz, 2003; Finkelstein & Haskins, 1983; Furman &
Buhrmester, 1985; Furman & Buhrmester, 1992; Gifford-Smith & Brownell, 2003; Hartup,
1995; Hartup & Abecassis, 2002; Haselager, van Lieshout, & Riksen-Walraven 1998;
Kupersmidt, DeRosier, & Patterson, 1995; Maccoby, 1998; McCandless & Hoyt, 1961;
Rubin et al., 2005; Rubin et al., 2006; Rubin et al., 1994; Singleton & Asher, 1979). Ratings
were used to assess the parents’ perceptions of how similar their child was to their best
friend on each characteristic (e.g., “How similar is your child to their best friend on their
weight?”) along a 5-point Likert scale (1 = not at all, 2 = a little, 3 = some, 4 = a lot, 5 =
very). A single composite score was created by averaging all items (α = 0.83).
Opportunities for Social Interaction. The Opportunities for Social Interaction
Questionnaire (created for this study) assessed whether the youths’ current health had
influenced their opportunities to engage in such social interactions as extracurricular
activities, school attendance, time with friends during the week and weekend, school
field trips, summer camps, online interactions, and sleepovers (e.g., “How much has
your child’s health affected their school attendance?”). Responses are rated along a 5-
31
point Likert scale (1 = not at all, 2 = a little, 3 = some, 4 = a lot, 5 = very). A single
composite score was created by averaging all items (α = 0.71).
Child Behavior Checklist. The Child Behavior Checklist (CBCL; Achenbach, 1991;
Achenbach & Rescorla, 2001) was used to assess youths’ social functioning and
externalizing symptoms. The YSR is a 113-item measure assessing behavioral and
emotional problems during childhood and adolescence. Items are rated on a 3-point
Likert scale ranging from “not true at all” (response of 0) to “very true” (response of 2).
Internal consistency has been found to range from 0.78 to 0.97 (Achenbach, 1991;
Achenbach & Rescorla, 2001). All items were administered, but for the present study, the
Social Problems (which was used to represent youths’ social capability) and
Externalizing Problems subscales are of particular interest. For each subscale of interest,
the items within the subscale were summed and then converted to T-scores that
reflected the appropriate age and gender of the respondent’s child. For the Social
Problems scale, T-scores equal to or above 70 are considered clinically significant
(indicating problem levels above the 97th percentile), and T-scores between 65 and 70
are considered in the Borderline Clinical range (indicating problem levels above the 93rd
percentile). For the Externalizing Problems scale, T-scores equal to or above 64 are
considered clinically significant, and T-scores between 60 and 63 are considered in the
Borderline Clinical range.
32
Youth Measures
Similarity to Best Friend. Participating youth also rated their similarity to their best
friend (see the parent measure for more information). A single composite score was
created by averaging all items (α = 0.83).
Friendship Information. In order to explore the experience of friendship for youth,
all participating youth were asked additional questions about their best friend. These
questions included how the child met this friend, how long they had been friends, how
often they interacted, and how they interacted (e.g., in-person, online, text messaging,
etc.). The additional friendship questions were structured such that specific responses
were given (e.g., adjectives only, or clubs only, etc.), which allowed for simple and
focused coding. The open-ended responses were coded and the coding scheme can be
found in Appendix C. Coding of the responses was informed by previous research and
the responses generated in the current study.
Opportunities for Social Interaction. Youth also completed their own ratings for
Opportunities for Social Interaction (see the parent measure for more information). A
single composite score was created by averaging all items (α = 0.64).
Network of Relationships Inventory. The Network of Relationships Inventory (NRI;
Furman & Buhrmester, 1985) was used to assess the girls’ perceptions of their parent
and friend relationship quality. The 33-item NRI comprises 11 conceptually distinct
33
subscales that load onto two factors for each relationship: positive relationship quality
(i.e., companionship, instrumental help, satisfaction, intimacy, nurturance, affection,
enhancement of worth, and reliable alliance) and negative relationship quality (i.e.,
conflict, punishment, and power). Each item is asked about the mother, father, and
friend, with a 5-point Likert response provided for an answer. Sample items include
"How much do you and this person get upset with each other or mad at each other?”
(from the conflict subscale), “How much do you tell this person everything?” (from the
intimate disclosure subscale), and “How much does this person treat you like you're
admired and respected?” (from the enhancement of worth subscale). The 11 distinct
quality subscale scores for each relationship are created by averaging the individual
items that form each subscale (e.g., there will be 11 distinct quality subscales for mother,
father, and friend). The positive and negative relationship quality factors are created by
averaging the subscales that comprise that factor, resulting in a positive and negative
relationship quality factor for the mother, father, and friend. Internal consistency for this
measure has been found to be high, with alphas above .60 for all subscales, and an
average across subscales of α = .90 (Furman & Buhrmester, 1985). Internal consistency
for the current study was found to be middle to high (Mother: Support: α = 0.87;
Negative Interactions: α = 0.51; Father: Support: α = 0.92, Negative Interactions: α = 0.82;
Friend: Support: α = 0.83, Negative Interactions: α = 0.69).
34
Network of Relationships Inventory – Importance Beliefs. The Network of
Relationships Inventory – Importance Beliefs was created for the current study. These
items were used to assess how important girls believed particular qualities are within
their parent and friend relationships. The NRI-IB assessed 8 distinct positive qualities
that are also assessed in the NRI: companionship, instrumental help, satisfaction,
intimacy, nurturance, affection, enhancement of worth, and reliable alliance. The three
negative qualities were not included as they did not make conceptual sense. Each item
asks about the mother, father, and friend, with a 5-point Likert response provided for an
answer. Sample items include, "How important is it that you tell this person
everything?” (from the intimate disclosure subscale), and “How important is it that this
person treats you like you're admired and respected?” (from the enhancement of worth
subscale).The 8 distinct quality belief subscales for each relationship are created by
averaging the individual items that form each subscale (e.g., there will be 8 distinct
quality belief subscales for mother, father, and friend). The scales of interest for this
investigation included the friend subscales only (Companionship α = 0.65, Instrumental
Aid α = 0.72, Satisfaction α = 0.83, Intimate Disclosure α = 0.85, Nurturance α = 0.67,
Affection α = 0.80; Reassurance of Worth α = 0.65, Reliable Alliance α = 0.87).
Feelings of Belongingness. The Feelings of Belonging Scale (Weeks, Asher, &
McDonald, 2012) was used to assess each girl’s sense of connection to a group with
35
whom they were involved. Girls were asked to identify such a group (i.e., sports team,
religious youth organization, club, etc.) and then rate their felt belongingness to that
group along a 5-point Likert scale (1 = Strongly Disagree, 5 = Strongly Agree). The scale
consists of 9 items including “I feel like I belong in this group,” and “I feel connected to
this group.” A single composite score was formed by averaging the 9 items. Internal
consistency (α) for this measure ranged from 0.92 to 0.94 (Weeks et al., 2012) and was
0.71 for the current investigation.
Revised Child Anxiety and Depression Scale. The Revised Child Anxiety and
Depression Scale (RCADS; Chorpita, Yim, Moffit, Umemoto, & Francis, 2000) is a 47-
item questionnaire with the following subscales: separation anxiety disorder, social
phobia, generalized anxiety disorder, panic disorder, obsessive compulsive disorder,
and major depressive disorder. Girls rate items along a 4-point Likert scale from 0
(never) to 3 (always). Internal consistency (α) has been found to range from 0.78 to 0.83
(Chorpita et al., 2000), and was 0.98 for the current study. Of interest for the current
study is the total internalizing scale. The total internalizing scale was calculated by
adding all of the responses together. The sum was then converted to a T-score that
reflected the appropriate age and gender of the respondent. T-scores of 65 or above are
considered clinically significant.
36
Results
No participant elected to prematurely terminate completion of the survey;
however, four participants left individual items regarding father relationship quality
blank. There were no other missing data.
Skewness and kurtosis were calculated for all outcome variables and were found
to fall below 3 in skew and below 8 in kurtosis, with the exception of the Negative
Interactions – Friend scale. A log transformation was conducted on this variable, which
resulted in the normalization of the variable. Skewness and kurtosis for all of the
outcome variables can be found in Table 2.
37
Table 2: Skewness and kurtosis of all outcome variables
Outcome Variable Skewness Kurtosis Internalizing Symptoms 0.97 0.11 Externalizing Problems 0.65 -0.36 Positive Friendship Quality -0.70 1.42 Negative Friendship Interactions a 2.07 8.61 Friendship Domains Companionship -0.80 0.26 Conflict 1.46 3.80 Instrumental Aid 0.24 -0.83 Intimate Disclosure -0.62 0.00 Nurturance -0.36 -0.54 Affection -1.55 3.07 Reassurance of Worth -0.91 0.07 Reliable Alliance -1.70 4.18 Relative Power 1.01 1.30 Satisfaction -1.61 2.76 Punishment 1.88 4.99 Friendship Importance Beliefs Companionship -1.55 3.72 Instrumental Aid -0.81 0.14 Intimate Disclosure -0.81 1.05 Nurturance -0.57 -0.22 Affection -1.85 4.32 Reassurance of Worth -1.52 3.32 Reliable Alliance -1.55 2.62 Satisfaction -2.21 6.78
a Log transformation: skewness = 0.38; kurtosis = 0.38
In an effort to combine highly correlated variables that measured the same
construct and reduce multicollinearity, bivariate correlations between study variables
were conducted. More specifically, the correlations between (1) parent and child report
of similarities to best friend, (2) parent and child report of opportunities, (3) mother and
38
father positive relationship quality, and (4) mother and father negative relationship
quality were found to be highly correlated and significant (all < 0.05). Therefore, each of
those correlated variables were averaged to create the following singular variables:
similarity to best friend, opportunities for peer interaction, positive parent relationship
quality, and negative parent relationship quality. For the four participants that did not
report on the relationship quality with their father, their relationship quality with their
mother alone was used for the parent positive and negative relationship quality scores.
Positive and negative friendship quality were not significantly correlated; therefore, a
composite variable for friendship quality was made by subtracting negative quality from
positive quality to create a total friendship quality variable and to reduce the number of
variables in future analyses, thereby preserving power. The correlations between these
variables can be found in Table 3.
39
Table 3: Correlations between similarity reports, opportunity reports, positive
and negative mother, father, and friendship relationships
1 2 3 4 5 6 7 8 9 10
1 Sim.– girl - 2 Sim. –
parent 0.49** -
3 Opp. – girl 0.39** 0.18 - 4 Opp. –
parent 0.06 0.25* 0.51** -
5 Positive
rel. quality –
mother
0.21 0.12 0.44** -0.06 -
6 Positive
rel. quality
father
0.21 0.30* 0.39** 0.10 0.54** -
7 Negative
rel. quality -
mother
-0.31** -0.29* -0.07 -0.16 -0.20 -0.07 -
8 Negative
rel. quality –
father
-0.02 -0.22 -0.11 -0.15 0.02 -0.02 0.40** -
9 Positive
friendship
quality
0.21 0.11 0.40** -0.03 0.30** 0.15 0.13 -0.09 -
10 Negative
friendship
quality
-0.25* -0.09 -0.10 -0.12 -0.11 -0.04 0.42** 0.16 -0.05 -
* p < 0.05 ** p < 0.01
To further characterize the data, means and standard deviations of all continuous
variables were calculated. Furthermore, univariate ANOVAs were conducted to
determine whether the healthy girls and the chronically ill girls differed on the variables
not identified as criterion (e.g., dependent) variables in Research Questions 1 through 5
(see Table 4). Of note, power on the majority of the analyses fell below .80, suggesting a
40
potential underestimation of group differences. Significant differences were noted
between groups on the opportunities scale (F (1, 73) = 10.30, p = 0.002, η2 = 0.12) and
negative parent relationship quality scale (F (1, 73) = 4.93, p = 0.03, η2 = 0.06). More
specifically, healthy girls (M = 3.53, SD = 0.54) had more opportunities to interact with
their peers than chronically ill girls (M = 3.11, SD = 0.55). Additionally, chronically ill
girls reported experiencing greater negative parent relationship quality (M = 3.10, SD =
0.66) than healthy girls (M = 2.72, SD = 0.78). The ANOVA examining social competence
was marginally significant, F (1, 73) = 2.81, p = 0.09, η2 = 0.04. Examination of the means
indicated that healthy girls (M = 49.84, SD = 10.34) were described by their parents as
having better social functioning than chronically ill girls (M = 45.83, SD = 9.84).
41
Table 4: Means, standard deviations, ranges, and group differences
M SD Range F η2 Observed
power
Social Ability - Total 48.24 10.27 32 – 89 2.81 0.04 0.38 Healthy 49.84 10.34 32 – 89 Chronically Ill 45.83 9.84 26 – 64 Similarities - Total 3.31 0.64 2.00-4.75 0.28 0.00 0.08 Healthy 3.34 0.69 2.00-4.75 Chronically Ill 3.26 0.63 1.83-4.58 Opportunities - Total 3.36 0.58 1.78-4.61 10.30** 0.12 0.89 Healthy 3.53 0.54 1.89-4.61 Chronically Ill 3.11 0.55 1.78-3.94 Pos. Parent Quality -
Total
4.13 0.61 2.33-5.00 2.42 0.03 0.34
Healthy 4.04 0.63 2.33-5.00 Chronically Ill 4.26 0.56 2.64-5.00 Neg. Parent Quality -
Total
2.87 0.76 1.17-4.75 4.93* 0.06 0.59
Healthy 2.72 0.78 1.17-4.50 Chronically Ill 3.10 0.66 1.83-4.75 Intern. Symptoms -
Total
46.51 15.25 26 – 80 1.95 0.03 0.28
Healthy 44.51 15.56 26 – 80 Chronically Ill 49.50 14.52 29 – 80 Extern. Symptoms -
Total
46.62 10.29 34 - 74 2.48 0.03 0.34
Healthy 45.11 10.69 34 -74 Chronically Ill 48.90 9.36 34 – 63 * p < 0.05 ** p < 0.01
Qualitative Data Description
As previous research has not fully characterized the differences between the
friendships of healthy girls and chronically ill girls, we first aimed to explore how each
group would describe their friendships, and how those descriptions might differ.
42
Furthermore, we were interested in exploring whether chronically ill girls and
chronically ill boys also differed in their descriptions of their friendships, allowing some
initial insight into potential gender differences. In order to examine these qualitative
differences a number of chi-squares analyses and Fisher’s exact tests were conducted on
the coded responses of the open-ended friendship questions.
The friendships of healthy versus chronically ill girls
All of the girls reported on how important it was for them to have a friendship,
and most girls indicated it was important or extremely important (90.67%), whereas only
5.33% described it as kind of important, 2.67% described it as not really important, and
only 1.33% described it as not at all important (N = 1). A follow-up question was why it
was important to have friends, and girls were allowed to list multiple reasons. Girls
overwhelming reported friendship being important for reasons of companionship
(53.33%) and support (49.33%), with comfort (5.33%), understanding their health
condition (2.66%), and other miscellaneous reasons (9.33%) also cited (see Figure 2).
43
Figure 2: Reasons for the importance of friendship
Two separate follow up chi-square analyses were conducted to determine
whether differences existed between the two groups on the reasons of companionship
and support, as these variables were the only ones with cell sizes greater than five. Both
of the chi-squares were nonsignificant.
Girls reported on whether they would change anything about their friendships,
and what in particular they would change. Most participants indicated they were happy
with their friendships and would not change anything about them (34.66%, N = 26), or
that they would want to spend more time with their friends (32.00%, N = 24).
Participants also reported wanting their friends to get along better with each other
(16.00%, N = 12), for their friends’ personalities to change (9.33%, N = 7), to be
geographically closer to their friends (5.33%, N = 4), or other reasons (2.66%, N = 2).
After collapsing categories with cell values less than 5, a 2 (health condition) by 4
44
(change reasons) chi-square was conducted to determine whether differences existed
between healthy girls and chronically ill girls on what they would change about their
friendships, which was nonsignificant, χ2 (3) = 5.12, p = 0.16.
The difference between their best friends and other friends was also described by
the participants, and they selected one reason as to what made their best friend different
from other friends. Girls described being closer to and trusting their best friend more
than other friends (24.00%), knowing their best friend longer than other friends (21.33%),
and spending more time with their best friend than other friends (18.67%). Additionally,
best friends differed from other friends as they were more likeable (9.33%), more
supportive (6.67%), more similar to the participant (6.67%), and understood the
participant’s health condition (2.67%). Two girls reported their best friend was their only
friend (2.67%), and 8.00% of the reasons were miscellaneous (see Figure 3). Categories
with cell values less than five were collapsed accordingly: similarity with likeability;
supportive with closeness/trust; no other friends and health with other. Thus, five
categories in total remained: time spent together, closeness/trust/support,
similarity/likability, known for a long time, and other. A 2 (health condition) by 5
(reasons of what makes their best friend different) chi-square conducted to determine
whether differences existed between healthy girls and chronically ill girls on what made
45
their best friendship different than other friendships was nonsignificant, χ2 (4) = 4.79, p =
0.31.
Figure 3: Reasons why best friend is different from other friends
Each participant described her identified best friend and was allowed to use
multiple adjectives. Most girls labeled their best friend as kind or nice or loving (61.33%,
N = 46) or funny or fun to be around (53.33%, N = 40). Best friends were also described
as supportive and helpful (24.00%, N = 18), loyal (14.67%, N = 11), brave/outspoken
(13.33%, N = 10), and smart (9.33%, N = 7). Participants also provided descriptions of
their best friend’s hobbies, physical attributes, honesty, anger, athleticism, and
“coolness” (52.00%, N = 39).
To determine whether differences existed between healthy females and
chronically ill females on the qualities they ascribed to their best friend, chi-squares were
conducted for variables where cell sizes were greater than 5 and Fisher’s exact tests were
46
conducted for variables where cell sizes were less than 5. All of the chi-squares and
Fisher’s exact tests, with the exception of the description of brave/outspoken, were
nonsignificant. The Fisher’s exact test examining the difference between healthy females
and chronically ill females on the description of their best friend as brave/outspoken was
significant, p = 0.04. Healthy girls (N = 9) were more likely to identify their best friends
as brave or outspoken than chronically ill girls (N = 1).
All the female participants nominated the qualities they viewed as important in a
friendship in general, as well as how much their best friend exhibited that quality
specifically. Girls were allowed to nominate as many qualities as they wished. Most girls
reported that a best friend should be caring, kind, nice, and friendly (80.00%, N = 60), as
well as funny or fun to be around (64.00%, N = 48). Girls also indicated that best friends
should be loyal and trustworthy (36.00%, N = 27), as well as honest (30.67%, N = 23), and
helpful or supportive (24.00%, N = 18). Less commonly reported was a best friend being
smart (9.33%, N = 7) or mature (4.00%, N = 3). On average, girls reported that their
friends more often than not displayed their desired friendship qualities on a scale from
not at all (1) to very much (5) (M = 4.56, SD = 0.57). Given the small cell sizes, Fisher’s
exact tests were conducted on variables where N < 5 to determine whether differences
existed between healthy females and chronically ill females on the qualities they felt a
best friend should exhibit. All of the Fisher’s exact tests were nonsignificant.
47
Girls also indicated how often they interacted with their best friend and the ways
in which they interacted. Most girls and their best friends interacted with each other
every day or at least all weekdays (52.00%), though some reported seeing their friend
less than five times a week (29.33%) (see Figure 4). Even fewer girls noted that they see
their best friend only once a week (6.67%), every other week (4.00%), once a month
(2.70%), or less than once a month (5.33%).
Figure 4: How often girls interacted with their best friend
Girls also reported on the various ways they interact with their best friend (see
Figure 5), and were allowed to identify multiple settings and methods. Most girls saw
their best friend at school (68.00%), however, girls also noted interacting with their best
friend at each other’s’ homes (25.33%), in their neighborhood (21.33%), through sports
teams (22.67%), at stores (6.67%), and at church (5.33%). As for modes of
communication, girls indicated they either spoke with their best friend on the phone
48
(58.67%) or exchanged text messages with their best friend (56.00%). Girls also interacted
with their best friends through social networking websites or applications (e.g.,
Facebook, Snapchat, Instagram; 32.00%), instant message (26.67%), and email (17.33%).
Chi-squares were conducted on variables where cell values were greater than 5 to
determine whether differences existed between healthy females and chronically ill
females on where and how they spent time with their best friend, along with how often
they see their best friend. All of the chi-squares were nonsignificant.
49
Figure 5: Where and how girls interacted with their best friend
A total of 7 girls indicated that their health had gotten in the way of their best
friendship, and half of those (N = 4) had been diagnosed with a chronic illness. Given
that cell values were less than 5, a Fisher’s exact test was conducted to determine
whether differences existed between healthy females and chronically ill females on
whether they reported their health interfered with their friendships, which was
50
nonsignificant, p = 0.43. Of those seven girls, most noted their health problems had a lot
or a major effect on their friendship (71.40%, N = 5). Overall, the vast majority of the
chronically ill girls (N = 26, 86.67%) did not view their health as impacting their best
friendship.
All of the girls reported on the types of activities they participated in. Most girls
participated in sports (48.00%, N = 36), clubs (36.00%, N = 27), and the performing arts
(34.67%, N = 26). Less commonly reported was going to church or church youth groups
(13.33%, N = 10) or having no activities (12.00%, N = 9). Very few girls reported spending
their time volunteering (5.33%, N = 4), studying (4.00%, N = 3), or shopping (1.33%, N =
1). Chi-squares were conducted on variables where cell sizes were greater than 5 to
determine whether differences existed between healthy females and chronically ill
females on types of activities they participated in. All of the chi-squares were
nonsignificant.
All of the girls also reported on why they could not take part in desired activities.
Most girls indicated there was no reason, since they were able to participate in any
activity they wished (25.33%, N = 19). However, other girls reported they were unable to
participate in various activities because they did not have the time (17.33%, N = 13), it
was cost prohibitive (14.67%, N = 11), their health prevented them (14.67%, N = 11), the
activity was not available (12.00%, N = 9), they lacked the ability (6.67%, N = 5), and/or
51
they were too young or too shy (2.66%, N = 2). Chi-squares were conducted on variables
where cell values were greater than 5, and Fisher’s exact tests were conducted on
variables where cell values were not greater than 5 to determine whether differences
existed between healthy females and chronically ill females on what prevented them
from activity participation. A trend was exhibited such that healthy girls (N = 11) were
more likely to report not having enough time to participate in activities than chronically
ill girls (N = 2) (Fisher’s exact test, p = 0.06). Additionally, chronically ill girls (N = 10)
were more likely to endorse their health interfering with activity participation than
healthy girls (N = 1) (Fisher’s exact test, p = 0.00). All other chi squares and Fisher’s exact
tests were not significant.
Overall, a great deal of similarity was found between healthy girls and
chronically ill girls in their descriptions of their friends and social functioning.
Friendship was found to be an important relationship, primarily for support and
companionship. Girls were also generally happy with their friendships, or wished to
spend more time with their best friends. They were also concerned with whether their
friends got along with one another. Best friends were found to be different from other
friends due to there being greater closeness and trust with their best friend, as well as
knowing their best friend longer and seeing them more often. In general, girls described
their best friends similarly, noting their best friends were kind, funny, supportive, loyal,
52
and smart. Healthy girls were more likely to describe their best friend as brave or
outspoken than chronically ill girls. Similar to how the girls described their particular
best friend, they nominated necessary qualities for a friendship including being kind,
funny, trustworthy, loyal, honest, and helpful. Girls saw their best friends often,
typically at school, and often used technology to interact with their best friends. The
majority of the healthy and chronically ill girls reported their health did not impact their
friendships. Girls also identified a variety of activities they participated in. Of note,
healthy girls were more likely to report not having enough time to participate in all they
activities they wished to be a part of, and chronically ill girls were more likely to note
their health interfered with activity participation.
The friendships of chronically ill boys
Friendship questions were also fully completed by 10 chronically ill males to
provide an initial gender comparison on friendship descriptions. Given the small sample
size of the chronically ill boys, statistical analyses were not permitted. However, the
sample did provide some initial insight into potential differences regarding the role of
friendship for chronically ill boys and girls. With regard to how important it is to have a
friendship, most boys indicated it was important or extremely important (90.00%),
whereas only 10.00% described it as not at all important (N = 1). Boys overwhelming
reported friendship being important for reasons of companionship (80.00%), with
53
support (40.00%) and health understanding (10.00%) also cited. As can be seen in Table
5, chronically ill boys identified companionship as an important reason for friendship
more often than chronically ill girls. Further, chronically ill girls identified friendship as
an important source of support and help, whereas this was less commonly endorsed by
chronically ill males.
Table 5: Reasons endorsed for importance of friendship
Quality
Boys
(% of total sample)
Girls
(% of total sample)
Companionship 8 (80.00%) 14 (46.67%) Health Understanding 1 (10.00%) 2 (6.67%) Support 4 (40.00%) 17 (56.67%) Comfort 0 (0.00%) 0 (0%) Other 0 (0.00%) 2 (6.67%)
With regard to what they would change about their friendships, boys reported
they were happy with their friendships and would not change anything about them
(40.00%, N = 4), or that they would want to spend more time with their friends (40.00%,
N = 4). Boys also reported wanting their friends to behave differently (e.g., be less
annoying or listen better) (20.00%, N = 2). As can be seen in Table 6, both chronically ill
boys and girls either desired more time with their friends or were content with their
friendships. Chronically ill girls, however, were more concerned about their friends
getting along with each other, whereas this was not a concern for chronically ill boys.
54
Table 6: What would be changed about youths’ friendships
Desired Friendship Changes
Boys
(% of total sample)
Girls
(% of total sample)
More time 4 (40.00%) 9 (30%) Friend behave differently 2 (20.00%) 2 (6.67%) Friends get along better with each other 0 (0.00%) 8 (26.67%) Distance 0 (0.00%) 1 (3.33%) Nothing 4 (40.00%) 10 (33.33%)
With regard to how their best friend differed from their other friends, boys
described spending more time with their best friend (30.00%), feeling closer to their best
friend (20.00%), liking their best friend more (20.00%), knowing their best friend longer
(10.00%), and their best friend understanding their health more (10.00%). Compared to
chronically ill girls (see Table 7), boys were more likely to spend more time with their
best friend than girls, and girls felt closer and trusted their best friend more than boys.
Girls also were more likely than boys to indicate that knowing their best friend longer
made that person different from other friends.
Table 7: Best friend differentiation from other friends
Best Friend Differences
Boys
(% of total sample)
Girls
(% of total sample)
Understands health 1 (10.00%) 1 (3.33%) Time spent together 3 (30.00%) 3 (10.00%) Closeness/trust 2 (20.00%) 10 (33.33%) Similarity 1 (10.00%) 2 (6.67%) Likability 2 (20.00%) 3 (10.00%) Length of time known 1 (10.00%) 5 (16.67%) Other 0 (0.00%) 5 (16.67%)
55
With regard to describing their best friend, most boys labeled their best friend as
fun or funny (50.00%), kind or caring (50.00%), supportive (40.00%), and athletic
(40.00%). Compared to chronically ill girls (see Table 8), best friends were commonly
described as funny, nice, and supportive. Boys, however, were more likely to mention
their best friend’s athletic ability than girls, and girls were more likely to mention their
best friend’s interests.
Table 8: Best friend descriptions
Exhibited Best Friend Qualities
Boys
(% of total sample)
Girls
(% of total sample)
Funny/funny 5 (50.00%) 18 (60.00%) Brave/outspoken 1 (10.00%) 1 (3.33%) Kind/nice 5 (50.00%) 20 (66.67%) Supportive/Helpful 4 (40.00%) 8 (26.67%) Smart 1 (10.00%) 3 (10.00%) Physical description 1 (10.00%) 2 (6.67%) Athletic 4 (40.00%) 0 (0.00%) Loyal/trustworthy 0 (0.00%) 3 (10.00%) Cool 0 (0.00%) 1 (3.33%) Honest 0 (0.00%) 2 (6.67%) Hobby description 1 (10.00%) 5 (16.67%) Angry 0 (0.00%) 1 (3.33%) Other 1 (10.00%) 4 (13.33%)
Most boys reported a best friend should be caring or kind (70.00%) and funny
(70.00%), as well as supportive or helpful (40.00%) and honest (30.00%). Health
understanding, loyalty, and intelligence each received one nomination as a preferred
best friendship quality (30.00% total). On average, boys reported that their friends more
56
often than not displayed their desired friendship qualities on a scale from not at all (1) to
very much (5) (M = 4.63, SD = 0.39). As shown in Table 9, boys and girls both highly
valued kindness and caring within a best friend, and similarly endorsed a desire for
support and honesty. However, boys were more likely to report a desire for their best
friend to be fun or funny than girls, whereas girls were more likely to nominate loyalty
and trust as an important best friend quality than boys.
Table 9: Desired best friend qualities
Desired Best Friend Qualities
Boys
(% of total sample)
Girls
(% of total sample)
Understand health 1 (10.00%) 0 (0.00%) King/caring/nice 7 (70.00%) 26 (86.67%) Loyal/trustworthy 1 (10.00%) 8 (26.67%) Fun/funny 7 (70.00%) 16 (53.33%) Supportive/helpful 4 (40.00%) 9 (30.00%) Mature 0 (0.00%) 2 (6.67%) Honest 3 (30.00%) 7 (23.33%) Smart 1 (10.00%) 2 (6.67%) Other 1 (10.00%) 8 (26.67%)
With regard to how often boys interacted with their best friend, most boys
interacted with their best friend every day or at least all weekdays (70.00%), though
some reported seeing their friend less than five times a week (20.00%) and one indicated
only once a week (10.00%). This was similar to chronically ill girls, who reported seeing
their best friend every day or all weekdays (see Table 10).
57
Table 10: Amount of interaction with best friend
Amount of Interaction
Boys
(% of total sample)
Girls
(% of total sample)
Every day 7 (70.00%) 11 (36.67%) A few times a week 2 (20.00%) 12 (40.00%) Once a week 1 (10.00%) 3 (10.00%) Every other week 0 (0.00%) 1 (3.33%) Once a month 0 (0.00%) 1 (3.33%) Less than once a month 0 (0.00%) 2 (6.67%)
With regard to how boys interacted with their best friend, most boys saw their
best friend at school (80.00%), and less often in the neighborhood (40.00%) and through
sports (30.00%). Boys also interacted with their best friend by text messaging (60.00%),
social media (50.00%), talking on the phone (40.00%), or instant messaging (30.00%).
These results are fairly similar to chronically ill girls, who often saw their friends at
school and through sports (see Table 11). However, chronically ill girls were more likely
to indicate such places as church, each other’s’ homes, and the mall as places where they
saw their best friend. Chronically ill boys and girls also indicated texting with their best
friend and social networking sites as a common method of interaction.
58
Table 11: Methods of interaction with best friend
Methods of Interaction
Boys
(% of total sample)
Girls
(% of total sample)
School 8 (80.00%) 22 (73.33%) Neighborhood 4 (40.00%) 5 (16.67%) Sports 3 (30.00%) 7 (23.33%) Phone 4 (40.00%) 18 (60.00%) Text message 6 (60.00%) 15 (50.00%) Email 0 (0.00%) 7 (23.33%) Instant messaging 3 (30.00%) 5 (16.67%) Social network sites 4 (40.00%) 8 (26.67%) Other 1 (10.00%) 9 (30.00%)
Only one boy indicated their healthy had gotten in the way of their best
friendship. Similarly, few chronically ill girls (N = 4) reported their health condition to
interfere with their friendship.
Overall, a number of interesting similarities and differences in chronically ill
boys’ and girls’ friendships emerged. First, boys and girls endorsed different reasons for
friendship at different rates. More specifically, chronically ill boys endorsed seeking
friendships for companionship more than girls, whereas chronically ill girls endorsed
seeking friendship for support and help more than boys. However, boys and girls were
both either content with their friendships or desired more time with their friends. Girls,
compared to boys, were more concerned about their friends getting along with each
other.
59
In terms of how their best friend differed from other friends, boys identified
spending more time with their best friend more than girls, whereas girls endorsed a
greater level of closeness and trust with their best friend than boys. Commonly listed
desired best friend qualities included kindness and caring, as well as support and
honesty for both boys and girls. However, boys were more likely to report a belief that
friends should be fun or funny, whereas girls were more likely to indicate loyalty and
trust as important qualities. Actual best friends were commonly described as funny,
nice, and supportive by both sexes. However, boys were more attuned to their best
friend’s athletic ability whereas girls were more likely to report their best friend’s
interests. Boys and girls most often interacted with their best friend several times a
week, and often at school or through using technology such as text message or social
networking sites. Finally, most chronically ill boys and girls did not indicate that their
health had gotten in the way of their friendship.
Research Question One: Predicting friendship quality from health condition and friendship precursors
Following the qualitative exploration of girls’ and boys’ friendships, we were
interested in exploring the relations between chronic illness, friendship precursors,
friendship quality, and adjustment. We expected that the presence of a health condition,
fewer opportunities, more dissimilarity, and poorer social functioning would be
associated with lower positive friendship quality and higher negative friendship quality.
60
We also hypothesized that the presence of a health condition would interact with each
friendship precursor to predict lower positive friendship quality and higher negative
friendship quality. To test these hypotheses, two separate hierarchical regressions were
conducted. Each set of analyses included health condition and friendship precursors
(i.e., opportunities, similarities, and social capability) as predictor variables; one of the
analyses included positive friendship quality as the criterion variable, and the other
analysis included negative friendship quality as the criterion variable.
For the first regression analysis predicting positive friendship quality, presence
of a health condition and each friendship precursor (opportunities, similarity, social
capability) were entered as the first step of the analysis. The next step of the analysis
included the following two-way interactions: opportunities by presence of a health
condition, similarity to best friend by presence of a health condition, and social
capability by presence of a health condition. The hierarchical regression for positive
friendship quality was nonsignificant, F (3, 67) = 1.64, p = 0.19, observed power = 0.79. A
second hierarchical multiple regression analysis with negative friendship quality as the
criterion variable was conducted following the same steps as described above. This
analysis was also nonsignificant, F (3, 67) = 1.45, p = 0.24, observed power = 0.76. Thus,
the hypothesis that friendship quality would be predicted by health condition and
friendship precursors was not supported.
61
Research Questions Two and Three: Predicting psychosocial adjustment from health condition, relationship quality, and feelings of belonging
We expected that healthy females with high quality friendships would have
lower internalizing and externalizing symptoms than chronically ill girls with high
quality friendships. Additionally, we wished to explore whether aspects of different
relationships, specifically, parent relationship quality or group belongingness, would
contribute to the psychosocial adjustment of both healthy and chronically ill females. To
investigate these notions, two hierarchical regressions were conducted with health
condition, total friendship quality, positive parent relationship quality, negative parent
relationship quality, and belongingness entered on the first step, and the interaction
between health condition and total friendship quality entered on the second step. Two
separate hierarchical regressions were conducted with externalizing symptoms and
internalizing symptoms as the dependent variables.
For the regression examining externalizing symptoms, the step including the
interaction between health condition and friendship quality was significant, F (6, 68) =
3.91, p = 0.002, observed power = 0.97. This significant interaction was probed following
the procedures outlined by Preacher, Curran, and Bauer (2006). A follow-up regression
conducted for chronically ill girls only was nonsignificant, F (1, 28) = 0.66, p = 0.42,
observed power = 0.13. However, a follow-up regression conducted for healthy girls
62
only was significant, F (1, 43) = 12.31, p = 0.001, observed power = 0.95. Examination of
the slopes for healthy girls only indicated that friendship quality was negatively
associated with externalizing symptoms (b = -0.47, p = 0.001).
For the regression examining internalizing symptoms, the step including the
interaction between health condition and friendship quality was significant, F (6, 68) =
2.55, p = 0.03, observed power = 0.85. Examination of the slopes indicated that positive
parent relationships were negatively associated with internalizing symptoms (b = -0.36, p
= .003). Notably, the interaction variable was nonsignificant (p = 0.36), negating the need
to probe the interaction. Altogether, the hypotheses were partially supported. More
specifically, higher quality friendships predicted fewer externalizing problems for
healthy girls, but were unrelated to externalizing problems for chronically ill girls. High
quality friendships were not found to be related to internalizing problems. However,
higher parent relationship quality predicted fewer internalizing problems for both
healthy and chronically ill girls.
Research Question Four: Healthy and chronically ill girls’ reports on friendship quality and importance beliefs
One exploratory aim of the current investigation was to compare the friendship
quality and friendship quality importance beliefs of chronically ill and healthy girls. No
specific hypotheses were posited, as no prior research provided guidance on expected
differences. To explore the relation between chronic illness and friendship quality, a
63
MANOVA was conducted with health condition entered as the predictor variable and
the 11 subscales of the friendship quality measure entered as the criterion variables.
Follow-up univariate ANOVAs were conducted when the analysis approached or
reached significance at the multivariate level. All means and standard deviations, along
with F values and estimated effect sizes (η2) are shown in Tables 12 and 13.
The MANOVA (healthy females vs. females with a medical condition) examining
differences in various friendship provisions (listed in Table 4) was significant, F (11, 63)
= 1.96, p = 0.048, η2 = 0.26, observed power = 0.85. Follow-up univariate ANOVAs for
punishment was significant [F (1, 73) = 5.23, p = 0.03, η2 = 0.07, observed power = 0.62],
and a trend was exhibited for companionship [F (1, 73) = 3.13, p = 0.08, η2 = .04, observed
power = 0.42]. Females with a chronic illness reported more punishment in their
friendships (M = 1.81, SD = 0.92) than healthy females (M = 1.42, SD = 0.55). Additionally,
healthy girls reported their friendships to be higher in companionship (M = 3.93, SD =
0.59) than chronically ill girls (M = 3.57, SD = 1.01).
64
Table 12: The relation between presence of health condition and friendship
provisions
Healthy
(N = 45)
Chronically Ill
(N = 230)
M (SD) M (SD) F η2
Observed
Power
Companionship 3.93 (0.69) 3.57 (1.01) 3.13† 0.04 0.42 Conflict 1.96 (0.76) 2.20 (1.08) 1.24 0.02 0.20 Instrumental Aid 3.40 (0.80) 3.44 (0.77) 0.06 0.00 0.06 Intimate Disclosure 3.97 (0.80) 3.77 (0.98) 0.99 0.01 0.17 Nurturance 3.73 (0.85) 3.79 (0.83) 0.08 0.00 0.06 Affection 4.39 (0.74) 4.43 (0.61) 0.06 0.00 0.06 Reassurance of Worth
4.26 (0.71) 4.15 (0.79) 0.35 0.01 0.09
Relative Power 2.19 (0.84) 2.31 (1.29) 0.23 0.00 0.08 Reliable Alliance 4.28 (0.83) 4.48 (0.66) 1.19 0.02 0.19 Satisfaction 4.45 (0.70) 4.55 (0.57) 0.45 0.01 0.10 Punishment 1.42 (0.55) 1.81 (0.92) 5.23* 0.07 0.62 †p<.10, *p<.05
A second MANOVA was performed to examine whether friendship quality
importance beliefs differed between healthy girls and chronically ill girls. This
MANOVA was conducted with health condition as the predictor variable, and the eight
subscales for the friendship quality importance beliefs entered as the criterion variables.
Follow-up univariate ANOVAs were conducted when the analysis approached or
reached significance at the multivariate level. The second MANOVA was nonsignificant,
F (8, 66) = 1.26, p = 0.28, η2 = 0.13, observed power = 0.54. Thus, healthy girls and
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chronically ill girls held similar beliefs with regards to the importance of various
friendship qualities.
Table 13: The relation between presence of health condition and friendship
quality importance beliefs
Healthy
(N = 45)
Chronically Ill
(N = 30)
M (SD) M (SD) F η2
Observed
Power
Companionship 4.28 (0.73) 4.60 (0.66) 3.26† 0.05 0.47 Instrumental Aid 4.09 (0.84) 4.28 (0.76) 0.98 0.01 0.16 Intimate Disclosure 3.77 (0.89) 3.88 (0.77) 0.29 0.04 0.08 Nurturance 4.18 (0.69) 4.47 (0.69) 3.00† 0.04 0.40 Affection 4.56 (0.67) 4.70 (0.55) 0.97 0.01 0.16 Reassurance of Worth
4.44 (0.67) 4.38 (0.64) 0.19 0.00 0.07
Reliable Alliance 4.57 (0.66) 4.67 (0.52) 0.45 0.01 0.10 Satisfaction 4.61 (0.66) 4.72 (0.56) 0.54 0.01 0.11 †p<.10, *p<.05
Research Question Five: Friendship quality importance beliefs moderating the relation between friendship quality and adjustment
We expected that youths’ friendship quality importance beliefs would moderate
the relation between friendship quality and adjustment. To examine this hypothesis,
eight separate hierarchical regressions were conducted with a composite of internalizing
symptoms and externalizing symptoms as the criterion variable. For each regression,
one distinct positive friendship quality subscale was entered in the first step. The next
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step included the corresponding friendship importance belief subscale. The following
step included the interaction between the friendship quality subscale and the friendship
quality belief subscale. For example, one regression would begin with nurturance in the
friendship and the importance of nurturance within the friendship on the first step, and
the next step would be the interaction between the two variables. All significant two-
way interactions would be probed following the procedures outlined by Preacher,
Curran, and Bauer (2006) and would indicate moderation.
The second step, which examined the interaction effect between a specific
friendship quality and its associated importance belief, was nonsignificant for all
regressions (see Table 14). Thus, the hypothesis that friendship quality importance
beliefs would moderate the relation between friendship quality and adjustment was not
supported. While the interaction effect was nonsignificant for all of the analyses, several
of the analyses indicated significant main effects.
The first step for the companionship regression was significant, suggesting
significant main effects, F (2, 72) = 3.32, p = 0.04, observed power = 0.64. Examination of
the slopes indicated a trend that the quality of companionship was negatively associated
with internalizing and externalizing symptoms (b = -0.19, p = 0.12). Additionally, the
first step for the affection regression was significant, suggesting significant main effects,
F (2, 72) = 3.66, p = 0.03, observed power = 0.68. Examination of the slopes indicated that
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the affection importance belief was negatively associated with internalizing and
externalizing symptoms (b = -0.38, p = .02). Also, the first step for the reassurance of
worth regression was significant, suggesting significant main effects, F (2, 72) = 5.22, p =
0.01, observed power = 0.84. Examination of the slopes indicated that the quality of
reassurance of worth was negatively associated with internalizing and externalizing
symptoms (b = -0.29, p = .03). Finally, the first step for the satisfaction regression was
significant, suggesting significant main effects, F (2, 72) = 3.53, p = 0.03, observed power =
0.66. Examination of the slopes indicated a trend that the satisfaction importance belief
was negatively associated with internalizing and externalizing symptoms (b = -0.28, p =
.07). Altogether, the qualities of companionship, reassurance of worth, and satisfaction
were associated with fewer internalizing and externalizing symptoms. Additionally, the
importance belief associated with affection was also related to fewer internalizing and
externalizing symptoms.
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Table 14: Friendship quality and importance beliefs regressions to predict
psychosocial adjustment
Quality F η2 Observed Power
Companionship 1st Step 3.32* 0.08 0.64 2nd Step 0.18 0.09 0.65 Instrumental Aid 1st Step 1.24 0.03 0.27 2nd Step 0.11 0.03 0.28 Intimate Disclosure 1st Step 0.20 0.01 0.07 2nd Step 0.20 0.01 0.09 Nurturance 1st Step 0.27 0.01 0.09 2nd Step 0.57 0.01 0.14 Affection 1st Step 3.66* 0.09 0.68 2nd Step 0.08 0.09 0.69 Reassurance of
Worth 1st Step 5.22** 0.13 0.84 2nd Step 0.36 0.13 0.85 Reliable Alliance 1st Step 2.08 0.05 0.44 2nd Step 0.12 0.06 0.45 Satisfaction 1st Step 3.53* 0.09 0.67 2nd Step 0.01 0.09 0.67 †p<.10, *p<.05
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Discussion
The purpose of the current study was to further our understanding of the impact
of friendship for chronically ill females through the completion of three study goals. The
first goal was to explore differences in friendships and to qualitatively describe the
friendships of healthy and chronically ill girls, with chronically ill boys serving as an
additional comparison group. The second goal of this research was to determine if
having a health condition influenced the precursors to friendship: opportunities,
similarities, and social capability. Furthermore, we were interested in determining
whether the presence of a health condition and friendship precursors were associated
with friendship quality. The third goal was to examine whether friendship quality or
other factors (e.g., parent relationship quality, group belongingness, importance beliefs
for friendship provisions) influenced the psychosocial adjustment of chronically ill girls
similar to healthy girls.
The Friendships of Boys and Girls
The first exploratory aim of the current study was to describe the friendships of
chronically ill girls, chronically ill boys, and healthy girls, and whether similarities or
differences existed between healthy and chronically ill girls, as well as between
chronically ill boys and girls. Overall, most of the participating girls indicated that
friendship was important to them and most reported being satisfied with their
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friendships. While no differences were present with regard to the importance beliefs
girls held about their friendships, healthy girls did indicate that they particularly sought
out friendships for comfort more than chronically ill girls reported. Indeed, healthy girls
often reported they appreciated having someone to turn to when they feel down. All of
the females described their best friendships in terms such as trust, kindness, and time
spent with their friend. Both groups of girls indicated having regular contact with their
best friend (daily or all weekdays), and that they interacted with their best friend
through similar ways (school, phone/text message, social networking media). Notably,
while health problems did interfere with activity participation, chronically ill girls did
not indicate that their health impacted their ability to engage in their friendship.
With regard to gender, several similarities emerged between chronically ill boys’
and girls’ descriptions of their friendships. Most boys identified friendships as a
particularly important relationship and were generally happy with their friendships,
much like chronically ill girls. Similar to chronically ill girls, they reported wishing they
had more time with their friends when asked specifically about what they were
dissatisfied with. Both sexes agreed that closeness and time spent with their best friend
made that relationship special. Boys and girls reported interacting with their friends in
similar ways, such as at school, through sports, as well as through technology.
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Notable differences were also present in their descriptions of friendship. For
instance, boys and girls both reported companionship and support as important reasons
for having a friend, however, boys were more likely to endorse companionship whereas
girls were more likely to endorse support. Indeed, the difference between someone to
have fun with versus someone to be there for you continued, as boys were more likely to
report that a friend should be fun or funny and girls were more likely to report loyalty
and trust as important characteristics in a friend. Further, when describing their actual
best friends, boys appeared to be more aware of their friend’s athletic ability, which is
typically displayed during group sports. Comparatively, girls were more likely to
describe interactional qualities of their best friend (e.g., kind, supportive). These
differences may be highlighting the previously identified difference between boys and
girls, such that girls are more focused on dyadic friendships and boys are more focused
on group activities (Maccoby, 1990). Further, these initial results suggest that friendship
may serve different functions for chronically ill boys and girls. Boys may be seeking
friendships that consist of fun and activities, whereas girls may be seeking friendships
more for emotional support.
These desired friendship qualities may be indicative of different coping styles for
chronically ill boys and girls, such that boys may desire distraction and girls may wish
to process their experience more. Given that potential coping difference, friends may act
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as an important source of coping support for boys, whereas parents may be a better
source of coping support for girls. Parents may have a better understanding of their
daughter’s needs and chronic illness experience, allowing them to help their daughter
process their experience more effectively than a friend could help. Indeed, results from
the current study do suggest that positive parent relationships are associated with fewer
internalizing symptoms for their daughters.
Impact of Health on Friendship Precursors
Analyses revealed, as hypothesized, that chronically ill females had significantly
fewer opportunities to interact with peers than healthy females. These results are
consistent with previous research where youth with cancer report that their illness
disrupts their social lives and goals (Decker, 2007; Dolgin et al., 1999; Gray et al., 1992;
Green, Zevon, & Hall, 1991). It is also consistent with research suggesting that youth
with cancer, diabetes, brain tumors, and sickle cell disease experience missed
opportunities to spend time with other youth their age (Bamford et al.,1976; Barbarin,
1999; Carpentieri et al., 1993; Fossen, Abrahamsen, & Storm-Mathisen, 1998; Fraser, 2003;
Gerhardt, Vannatta, Valerius, Correll, & Noll, 2007; Gustafson et al., 2006; Katz et al.,
2011; La Greca, 1990; Mulhern et al., 1989; Lemanek et al., 1995; Morgan & Jackson, 1986;
Noll et al., 1993; Noll et al., 1991; Novakovic et al., 1996; Olson et al., 1993; Pendley,
Dahlquist, & Dreyer, 1997; Sawyer, Crettenden, & Toogood, 1986; Schuman et al., 1993;
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Vannatta, Gartstein et al., 1998). Notably, when the girls had an opportunity to describe
the activities they participated in, both healthy and chronically ill girls identified similar
activities in which they were engaged (e.g., sports, clubs, performing arts). However,
when all of the girls reported on why they could not participate in activities they were
interested in pursuing, chronically ill girls indicated their health impeded them
significantly more than healthy girls. Thus, the current study links fewer social
opportunities, one of the identified friendship precursors, with specific chronic illness
interference.
Additionally, results suggest support for the hypothesis that chronically ill
females have lower social competency, as reported by their parents, than healthy girls.
Past research has indicated that youth with CNS-impacting cancers are often viewed as
less socially competent than their healthy peers by parents, teachers, their peers, and
themselves (Bamford et al., 1976; Carpentieri et al., 1993; Fossen et al., 1998; Mulhern et
al., 1989; Mulhern, Carpentieri, Shema, Stone, & Fairclough, 1993; Mulhern, Hancock,
Fairclough, & Kun, 1992; Olson et al., 1993; Sawyer, Crettenden, & Toogood, 1986;
Vannatta et al., 1998; Vannatta, McNamara, Valerius, & Gerhardt, 2005). Given that
observed power for this analyses was quite low (0.38), further exploration of this
potential difference is warranted.
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While chronically ill girls and healthy girls differed with regard to social
opportunities and social competency, the analyses did not support the hypothesis that
healthy girls would be more similar to their friends than chronically ill girls. Indeed,
when provided with the opportunity to describe their best friend in the open-ended
questions, both healthy girls and chronically ill girls identified their best friend as
similar to themselves. It is possible that chronically ill girls were reporting on
friendships that began prior to their diagnosed condition, and therefore their friendships
were based on initial similarity. Indeed, 50% of chronically ill girls knew their friend for
more than five years, and 40% knew their best friend for two to five years. Furthermore,
half of the chronically ill girls (N = 15) had been friends with their best friend for two or
more years prior to their disease onset.
Predicting Friendship Quality and Adjustment
While significant differences existed between the two groups on two of the three
friendship precursors, the analyses did not support the hypothesis that friendship
precursors would predict positive and negative friendship quality. Furthermore, health
condition did not further influence the precursors’ association with overall friendship
quality. While observed power on both of these analyses was below .80, (.79 and .76),
these results suggest that the hypothesized friendship precursors did not predict
friendship quality for this sample. It may be that friendship precursors better predict the
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likelihood of developing a friendship, rather than quality of the friendship developed.
Indeed, past research has suggested chronically ill youth are less accepted by their peers
and have fewer friends than healthy youth (Alderfer et al., 2002; Barrera et al., 2005;
Chao et al., 2003; Noll et al., 1991; Noll et al., 1996; Reiter-Purtill, Vannatta, Gerhardt,
Correll, & Noll, 2003; Vannatta, Garstein et al., 1998; Vannatta, Zeller, Noll, & Koontz,
1998; Vannata et al., 2005). Thus, friendship precursors and the impact of health on those
precursors may be influencing peer acceptance and friendship development rather than
friendship quality.
The hypotheses were partially supported with regards to friendship acting as a
buffer against psychological maladjustment. More specifically, having a higher quality
friendship was associated with fewer externalizing symptoms for healthy girls only,
whereas higher quality friendships were not associated with externalizing symptoms for
chronically ill girls. Notably, previous research has suggested that youth with high
quality friendships are less likely to engage in antisocial behaviors (e.g., bullying) or
exhibit behavior problems (Bollmer, et al., 2005; Kendrick, Jutengren, & Stattin, 2012;
Hartup, 1995). However, adding to past research, the results of the current investigation
suggest these benefits afforded by friendships are specific for healthy girls and not
chronically ill girls. Thus, with regard to their externalizing behavior, healthy girls with
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high quality friendships display better adjustment than chronically ill girls with high
quality friendships.
Interestingly, positive parent relationship quality was significantly associated
with fewer internalizing problems for both healthy and chronically ill girls. This result
suggests that parents play a major role in the adjustment of their daughters, and likely
their children more broadly. Prior research focusing on healthy youth has also indicated
that high quality parent-child relationships have a buffering effect on internalizing
symptoms (Alegre, Benson, & Perez-Escoda, 2014; Fanti, Henrich, Brookmeyer, &
Kupermic, 2008; Rubin, Dwyer, Booth-LaForce, Burgess, & Rose-Krasnor, 2004),
including in the context of stressful life events (Forehand, Wierson, Thomas, Armistead,
Kempton, & Neighbors, 1991; Willemen, Schuengel, & Koot, 2011). Additionally,
consistent with previous research on youth coping with cancer, high quality
relationships with parents and cohesive family functioning were associated with better
adjustment, including fewer internalizing symptoms (Noojin, Causey, Gros, Bertolone,
& Carter, 1999; Orbuch, Parry, Fritz, & Repetto, 2005; Varni, Katz, Colegrove, & Dolgin,
1996). Indeed, interventions focused on children coping with a chronic illness and their
parents have found that including parents in active treatment reduces behavioral and
internalizing problems (Scholten, et al., 2015; Fedele, et al., 2013). Thus, high quality
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parent-child relationships are likely an essential component to positive adjustment for
youth coping with chronic illnesses.
Impact of Health on Friendship Provisions
The current study also aimed to explore potential differences between healthy
girls and chronically ill girls on the friendship provisions within their best friendship
and whether they valued friendship provisions differently. While there were no
differences with regard to girls’ importance beliefs for friendship provisions, there was a
significant difference between the two groups with respect to specific friendship
provisions. In particular, chronically ill girls reported their friendships to have more
punishment and less companionship than healthy girls. These results suggest that while
overall reported friendship quality may not differ between healthy and chronically ill
girls, significant differences in specific friendship provisions may exist. These friendship
quality differences are especially informative as previous research on differences
between groups on overall friendship quality and support has been mixed (Barrera et
al., 2005; Helgeson et al., 2006; Katz et al., 2011; Manne & Miller, 1998; Mattsson et al.,
2007; Noll et al., 2010; Rechner, 1990; Seiffge-Krenke, 2000; Sloper, Larcombe, &
Charlton, 1994; Stern, Norman, & Zevon, 1993). These results raise the question as to
whether chronically ill girls may be settling for less desirable friendships, or if their
health may negatively impact their friendships. Indeed, if friendship precursors and
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health condition impact friendship development rather than friendship quality, then
chronically ill girls may be settling for less desirable friendships. Further exploration of
this process is warranted to determine whether chronically ill girls are in less desirable
friendships or if their health is negatively impacting the quality of their friendship.
An additional exploratory aim was to examine whether importance beliefs
influenced friendship provisions’ prediction of adjustment. While no significant
interactions were present, individual beliefs and provisions were found to be associated
with internalizing and externalizing symptoms. More specifically, higher levels of
companionship, reassurance of worth, and satisfaction were associated with better
adjustment. Additionally, the more the girls valued affection in their friendships, the
fewer internalizing and externalizing symptoms were endorsed. Recent research on
youth with cystic fibrosis and diabetes suggest that positive friendship quality in
particular is associated better quality of life and less psychological distress (Helgeson,
Mascatelli, Reynolds, Becker, Escobar, & Siminerio, 2015; Helms, Dellon, & Prinstein,
2015). Thus, specific positive friendship qualities, rather than overall positive friendship
quality, may be the better predictor of youths’ adjustment.
Limitations
While the current study highlighted important associations between
relationships and adjustment, as well as differences between healthy and chronically ill
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girls with regard to their friendships, the results must interpreted in light of a number of
limitations. First, the most notable limitation would be the small sample size, which
resulted in low power for many of the analyses. Specifically, a total of 30 chronically ill
girls completed the surveys, while power analyses suggested a total of 45 chronically ill
participants (90 total: 45 healthy and 45 chronically ill girls) would be necessary to
detect significant differences. Indeed, several analyses indicated power far below .80.
While the majority of chronically ill girls approached for the study consented and
completed surveys (96.77% and 78.95% respectively), the population to recruit from was
smaller than anticipated. Due to necessary exclusion criteria, chronically ill girls who
could not read at a third grade level were not recruited. Such girls likely represented a
more impaired population of females with a chronic illness. Thus the impact of a chronic
illness on friendships and psychological adjustment may have been underestimated due
to the size and type of the chronically ill population captured. Future investigations
would benefit from assessing larger samples, as well as including means of assessing
more impaired youth.
A second limitation is the diversity of chronic illnesses within the chronically ill
group. Specifically, 8 girls were diagnosed with a brain tumor, 6 were diagnosed with a
seizure disorder, 3 with non-CNS cancer, 2 with sickle cell disease, and 11 were
individual cases of various chronic illnesses. Due to these small numbers, comparisons
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between specific illness and healthy youth were not possible. Notably, the various
conditions included are associated with different experiences and treatments. For
instance, youth with CNS-affecting conditions experience greater difficulties with social
competency (Bamford et al., 1976; Carpentieri et al., 1993; Fossen, Abrahamson, &
Storm-Mathisen, 1998; Hensler et al., 2014; Lennon, Klages, Amaro, Murray, &
Holmbeck, 2015; Mullhern et al., 1989; Mullhern et al., 1992; Mullhern et al., 1993; Noll et
al., 1992; Olson et al., 1993; Sawyer, Crettenden, & Toogood, 1986; Schulte, Bartels,
Bouffet, Hamilton, & Barrera, 2010; Vannatta et al., 1998; Vannata et al., 2005), and these
difficulties can be further exacerbated by CNS-impacting treatments (Bonner et al., 2008;
Hardy et al., 2010; Kullgren, Morris, Morris, & Krawiecki, 2003). As such, it is possible
that the psychosocial functioning of youth in the current study was overestimated due
to the inclusion of non-CNS conditions. Therefore, the current study is limited in the
conclusions that can be made about the psychosocial functioning across specific chronic
illnesses, and future studies should aim to recruit larger samples of specific chronic
illnesses to allow for a more refined comparison. In particular, a comparison between
CNS conditions and non-CNS conditions may elucidate concerns regarding social
capability, and in turn, the impact of social capability on friendship quality.
Another limitation lies with the selection of measures. More specifically, only
parent report was utilized to assess social competency in the current investigation.
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Notably, parents have difficulties with being objective with regard to reporting on their
child’s social functioning as they often lack a comparison for their children (Junttila,
Voeten, Kaukiainen, & Vauras, 2006; Schneider & Byrne, 1989). Furthermore, parents
only see their children in a limited set of social situations, as they typically do not
observe their children in class or at recess. Additionally, the specific measure for social
competence utilized in the current study is noted to assess a select set of skills for
competency, and therefore might not fully address competency in social situations
(Drotar, Stein, & Perrin 1995). Indeed, it would be useful for future studies to include
additional teacher and peer reports of social functioning, as they each may provide a
more nuanced view (Merrell, 2001; Renk & Phares, 2004).
Additionally, an objective measure of friendship quality may also help to further
understand the friendships of chronically ill youth. Observational research on friendship
avoids the problems inherent in self-report methods (e.g., social desirability, lack of
verbal fluency and cognitive capability, reiteration of friendship rules and norms, and
lack of awareness of actual actions) (Parker & Gottman, 1989). Furthermore,
observational research captures aspects and processes of friendships that may not be
well-assessed through self-report, such as displayed positive and negative affect,
cooperation, reciprocity, and conflict. As friendship measures have typically been
developed within healthy populations, observational research may allow for researchers
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to identify interaction behaviors that may be unique to chronically ill children. Thus,
combining self-reports from children, which assess their perspective of the relationship,
with more objective observational findings, which assess features beyond a child’s
cognitive understanding, would help to create a full picture of the quality of a
friendship, particularly within an understudied population.
Future Directions
The current study aimed to better understand the quality of friendships for
chronically ill youth and the potential impact of that relationship on psychosocial
adjustment. Results of the current investigation highlighted the differences in
friendships between healthy girls and chronically ill girls, and the impact of a chronic
health condition on social competence and social opportunities. While the current
investigation elucidated some of these differences, further research is required to fully
delineate the friendship quality and social experiences of youth with chronic illnesses.
Indeed, future research may benefit from exploring friendships and social experiences
within and between more exclusive samples (e.g., CNS-cancer only, epilepsy only,
diabetes only). More defined samples would allow for better understanding of social
experiences, and better targeting for interventions.
An additional aim of future research would be to more fully assess social
competence. Including peer and teacher report would help to capture the social
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capability of chronically ill peers (Merrell, 2001; Renk & Phares, 2004). Additionally, as
other reports of social competence may be biased, objective measures of social
functioning would also enhance our understanding of social functioning in chronically
ill youth. In particular, observations of youth with familiar and unfamiliar peers may
help to elucidate chronically ill youths’ social abilities. Indeed, previous research has
highlighted socially competent behaviors such as cooperating, resolving conflict,
displaying positive affect, equality, mutual liking, and loyalty, and being capable of
perspective-taking, self-regulating, effectively entering groups, and communicating
(Gifford-Smith & Brownell, 2003; Laursen & Hartup, 2002; Newcomb & Bagwell, 1995;
Oden & Asher, 1977; Putallaz, 1983). Objectively assessing these skills through
playgroups and at schools would allow for a more in-depth understanding of
chronically ill youths’ social competency. Furthermore, recent research has linked
executive and neurocognitive functioning with social capability (Hensler et al., 2014;
Holbein, Lennon, Kolbuck, Zebracki, Roache, & Holmbeck, 2015). Therefore, it would
continue to be useful to assess cognitive ability along with social capability. This will be
particularly essential for youth who may experience cognitive late effects associated
with cancer treatment (Maurice-Stam, Grootenhuis, Caron, & Last, 2007; Patenaude &
Kupst, 2005), which has been known to impact their friendships (Gerhardt et al., 2007).
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In order to further understand friendship precursors and their impact on
friendship development and quality, it may be useful to assess chronically ill youths’
peer status, their friends’ peer status, and their friendships longitudinally. This effort
could help to delineate whether chronically ill youth have less desirable peers as friends,
which could result in lower quality friendships, or if a chronic medical condition
predicts decreases in their friendship quality over time. Past research has suggested that
friends of youth with brain tumors are less accepted themselves by peers (Vannatta et
al., 2005), however, it is unknown if lower acceptance by peers translates into a less
desirable and lower quality friendship for chronically ill youth.
Notably, positive parent-child relationships were found to be a buffer against
internalizing symptoms for both healthy and chronically ill girls in the current study.
Furthermore, past research targeting parents in interventions for chronically ill youth
has found associations with better youth adjustment (Scholten, et al., 2015; Fedele, et al.,
2013). Future investigations may wish to explore the role of parents through
observational means and self-report of individual relationship provisions to better
understand what parent-child relationship qualities are associated with positive
adjustment.
Lastly, the currently study focused primarily on females due to the potential of
greater importance of the dyadic relationship for girls than boys. However,
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understanding the role of friendship and social processes is also important for
chronically ill males. Further examination of chronically ill males’ social experiences and
adjustment may be especially important if they find themselves unable to participate in
social opportunities like chronically ill females. Indeed, as boys spend more time in
groups and group activities (Maccoby, 1990), being unable to participate in such
experiences may result in greater maladjustment. Thus, it is necessary for future
research to explore whether chronically ill males are also experiencing difficulties with
participating in social opportunities and activities, and if such difficulties exist, how
those difficulties are impacting them psychosocially.
Conclusions
The purpose of the current study was to increase understanding of potential
friendship precursors and the impact of chronic health conditions on friendship and
psychological adjustment. By assessing friendship and psychological adjustment, the
current paper aimed to provide a direction of inquiry for future research into the
psychosocial adjustment of chronically ill youth. We were able to identify social
competency and social opportunities as key aspects of social functioning that were
impaired by chronic illnesses. Furthermore, the current investigation highlighted
different relationships that may buffer maladjustment in the face of a chronic illness.
Indeed, future studies of social and psychological functioning of youth with chronic
86
illness should focus on delineating social skills differences, as well as objective
measurements of friendship and parent-child relationship quality. Further
understanding of beneficial aspects of relationships will ultimately contribute to
potential interventions aimed at improved quality of life for youth with pediatric
conditions.
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Appendix A
Appendix A1: Online advertisement for healthy participants
The Pediatric Neuropsychology Clinic is conducting a research study regarding social relationships in different groups of children.
Eligibility Requirements
If your daughter is between the ages of 9 and 17, without any major medical or psychiatric illness, can read at a third-grade level, and has access to a home computer with internet, she may be eligible to participate in the study.
Study Requirements
This study requires about 30 minutes of time from the parent to complete surveys, and about 60 minutes from the child to complete surveys. The surveys can be completed at a home computer.
Compensation
Children and their parent or caregiver will receive $10 for their time.
For more information or to participate, contact Alissa B. Wigdor (study coordinator) at 919-660-5689 or email at [email protected].
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Appendix A2: Consent form
Consent To Participate In A Research Study
Friendship and Psychosocial Adjustment of Chronically Ill Youth
You and your child are being asked to take part in this research study because your child may have a pediatric health condition. We are investigating the friendships of youth with and without a pediatric health condition.
Research studies are voluntary and include only people who choose to take part. Please read this consent form carefully and take your time making your decision. As your study doctor or study staff discusses this consent form with you, please ask him/her to explain any words or information that you do not clearly understand. We encourage you to talk with your family and friends before you decide to take part in this research study. The nature of the study, risks, inconveniences, discomforts, and other important information about the study are listed below.
Please tell the study doctor or study staff if you are taking part in another research study. Alissa Wigdor, M.A. will conduct the study and it is funded by Alex’s Lemonade Stand Foundation. The sponsor of this study, Alex’s Lemonade Stand Foundation, will pay Duke University to perform this research, and these funds may reimburse part of Alissa Wigdor’s salary.
Previous studies have suggested that friendship is important to healthy youth, and can provide benefits for their psychological adjustment. As youth with a chronic health condition are experiencing additional stress, the current study aims to examine the role of friendship and its potential for aiding adjustment.
WHO WILL BE MY CHILD’S DOCTOR ON THIS STUDY?
If you decide to participate, your primary care physician will continue to be your doctor for the study.
WHY IS THIS STUDY BEING DONE?
The purpose of this study is to determine the quality of friendships for youth with chronic health conditions and assess whether friendships aid in the psychological adjustment of such youth. We are also interested in exploring how other relationships (such as parent-child, and group belonging) may help to support youth during an acute stressor.
HOW MANY PEOPLE WILL TAKE PART IN THIS STUDY?
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Approximately 100 children, ages 9 to 17, will take part in this study at Duke University Medical Center.
WHAT IS INVOLVED IN THE STUDY?
If you agree to be in this study, you will be asked to sign and date this consent form. Your child will be asked to identify their best friend, with you present. Then you will be asked to provide an email address for you and your child to receive the study surveys.
Upon receiving a link in an email to the study surveys, you and your child will be asked to complete the surveys online. Once you and your child have completed the surveys, you will be asked to submit them.
If you attended an appointment at the Pediatric Neuropsychology Clinic, we also ask that we have permission to access a particular survey (the Child Behavior Checklist) that you completed at your appointment. By granting access to this survey, you will not be asked to complete it again for the study. Only this survey from the appointment will accessed, and no other information from your appointment or your child’s medical records will be accessed.
HOW LONG WILL I AND MY CHILD BE IN THIS STUDY?
The parent surveys will take 1-2 hours to complete, and the child surveys will take 1-2 hours to complete. There will not be a follow-up study.
You and your child can choose to stop participating at any time without penalty or loss of any benefits to which you or your child are entitled.
WHAT ARE THE RISKS OF THE STUDY?
There are no physical risks associated with this study. There is, however, the potential risk of loss of confidentiality. Every effort will be made to keep your information confidential; however, this cannot be guaranteed. Some of the questions we will ask you as part of this study may make you feel uncomfortable. You may refuse to answer any of the questions and you may take a break at any time during the study. You may stop your participation in this study at any time.
ARE THERE BENEFITS TO TAKING PART IN THE STUDY?
If you agree to take part in this study, there are no direct medical benefits to you. We hope that in the future the information learned from this study will benefit other youth with health conditions.
WHAT ARE ALTERNATIVES TO PARTICIPATING IN THIS STUDY?
Instead of being in this study, you have these options: • Choosing not to take part in this study
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• Taking part in another study
WHAT ABOUT RESEARCH RELATED INJURIES?
Immediate necessary medical care is available at Duke University Medical Center in the event that you are injured as a result of your participation in this research study. However, there is no commitment by Duke University, Duke University Health System, Inc., or your Duke physicians to provide monetary compensation or free medical care to you in the event of a study-related injury.
For questions about the study or research-related injury, contact Alissa Wigdor at 919-660-5689 during regular business hours and at 301-814-3935 after hours and on weekends and holidays.
WHAT ARE THE COSTS? There will be no additional costs to you as a result of being in this study. Neither you nor your insurance company will be charged for any of the procedures in this study. However, you and/or your insurance company will be responsible for any payments for typical medical care that you would receive outside of this study.
WHAT ABOUT COMPENSATION?
You will be reimbursed up to $10 for your expenses related to your participation (e.g., time).
WHAT ABOUT MY RIGHTS TO DECLINE PARTICIPATION OR WITHDRAW
FROM THE STUDY?
You may choose for you and your child not to be in the study, or, if you agree to be in the study, you/your child may withdraw from the study at any time. If you/your child withdraw from the study, no new data about you/your child will be collected for study purposes other than data needed to keep track of you/your child’s withdrawal. All data that have already been collected for study purposes will be sent to the study sponsor.
Your/your child’s decision not to participate or to withdraw from the study will not involve any penalty or loss of benefits to which you are entitled, and will not affect your access to health care at Duke. If you do decide to withdraw, we ask that you contact Alissa Wigdor in writing and let her know that you are withdrawing from the study. Her mailing address is [email protected].
We will tell you about new information that may affect your health, welfare, or willingness to stay in this study.
WILL MY INFORMATION BE KEPT CONFIDENTIAL?
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A record of you and your child’s participation in this study will be kept in a locked confidential file in Dr. Melanie Bonner’s office at the Pediatric Neuropsychology Clinic at Duke University. Study records that identify you and your child will be kept confidential as required by law. Except when required by law, neither you nor your child will be identified by name, social security number, address, telephone number or any other direct personal identifier in study records disclosed outside of Duke University Health System (DUHS). Neither you nor your child will be identified by name in the study records. Your/your child’s records will be assigned a unique code number, and the key to the code will be kept in a separate, locked file.
Your/your child’s records may be reviewed in order to meet federal or state regulations. Organizations that may look at and/or copy your research records for research, quality assurance and data analysis include Duke University Health System Institutional Review Board and the Duke Cancer Center Protocol Committee.
The study results will be retained in your child’s research record until your child reaches the age of 21 years or until after the study is completed, whichever is longer. If your child enrolls at age 17, his/her record will be kept until age 23 or until after the study is completed, whichever is longer. At that time the research information not already in your child’s medical record will be destroyed or your name and other identifying information will be removed from such study results at Duke University Health System. Any research information in your child’s medical record will be kept indefinitely.
WHOM DO I CALL IF I HAVE QUESTIONS OR PROBLEMS?
For questions about the study or a research-related injury, or if you have problems, concerns, questions or suggestions about the research, contact Alissa Wigdor, M.A. at 301-814-3935 during regular business hours and after hours and on weekends and holidays. You may also contact Dr. Melanie Bonner at 919-681-0024 or Dr. Martha Putallaz at 919-668-9108.
For questions about your/your child’s rights as a research participant, or to discuss problems, concerns or suggestions related to the research, or to obtain information or offer input about the research, contact the Duke University Health System Institutional Review Board (IRB) Office at (919) 668-5111.
STATEMENT OF CONSENT
"The purpose of this study, procedures to be followed, risks and benefits have been explained to to my child and me. I have been allowed to ask questions, and my questions have been answered to my satisfaction. I have been told whom to contact if I have questions, to discuss problems, concerns, or suggestions related to the research, or to obtain information or offer input about the research. I have read this consent form and agree for my child to be in this study, with the understanding that I may withdraw
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my child at any time. We have discussed the study with my child, who agrees to be in the study. I have been told that I will be given a signed and dated copy of this consent form."
__________________________________________ ___________ Signature of Subject Date __________________________________________ ___________ Signature of Person Obtaining Consent Date (Optional) ____________________________________ _______________________ Signature of Principal Investigator Date (If applicable, add or substitute any of the following:) __________________________________________ ___________ Signature of Subject (if 12 years or older) Date __________________________________________ ___________ Signature of Parent/Guardian Date __________________________________________ ___________ Signature of Parent Date
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Appendix B
Appendix B1: Demographics (created for this study)
Parent Information:
1. Mother’s Occupation:
2. Mother’s highest level of education
a. Some high school
b. High school degree
c. Some college
d. Associate degree
e. College degree
f. Some graduate school
g. Graduate degree
3. Father’s Occupation:
4. Father’s highest level of education
a. Some high school
b. High school degree
c. Some college
d. Associate degree
e. College degree
f. Some graduate school
g. Graduate degree
Family Information:
Please name all the individuals that live in your home:
NAME SEX AGE RELATION TO YOUR CHILD
______ ___ ____ ___________________
______ ___ ____ ___________________
______ ___ ____ ___________________
______ ___ ____ ___________________
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______ ___ ____ ___________________
______ ___ ____ ___________________
______ ___ ____ ___________________
______ ___ ____ ___________________
Information about your participating child:
5. Date of birth:
6. Sex: ___M ___F
7. Race:
8. Height:
9. Weight:
10. Medical diagnosis:
11. Age of onset:
12. Age at diagnosis:
13. Medical regimen (i.e., Does your child take medication? Does your child have to
draw blood or administer shots? How often? Is s/he able to complete her/his medical
regimen on her/his own?)
14. Does your child’s condition require any medical equipment?(i.e., inhaler, brace,
helmet) __ No __Yes
If yes, what?
15. Does your child’s condition cause physical impairments?
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__ No __Yes
If yes, what?
16. Has your child’s medical condition affected his/her physical appearance?
___ No ___Yes
If yes, rate:
0 1 3 4 5
(little to no effect) (a little) (some) (a lot) (major effect)
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Appendix B2: Your Child’s Similarity to His/Her Best Friend (created for this study)
PARENT INSTRUCTIONS:
The next questions are about how your child is like or unlike their best friend:
How similar is your child to (BEST FRIEND’S NAME) in terms of…
OR
CHILD INSTRUCTIONS:
How similar are you to (BEST FRIEND’S NAME) in terms of…
1 = not at all 2 = a little 3 = some 4 = a lot 5 = very
17. Weight
1 2 3 4 5
18. Height
1 2 3 4 5
19. Looks
1 2 3 4 5
20. Aggression
1 2 3 4 5
21. Humor
1 2 3 4 5
22. Friendliness?
1 2 3 4 5
23. Maturity
1 2 3 4 5
24. Academic Achievement
1 2 3 4 5
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25. Kind Behavior
1 2 3 4 5
26. Shyness
1 2 3 4 5
27. Picked on/Bullied/
Victimized
1 2 3 4 5
28. How well other kids like them
1 2 3 4 5
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Appendix B3: Opportunities for Social Interaction (created for this study)
PARENT INSTRUCTIONS: The next questions are about your child’s opportunities for social activities: How often does your child … OR CHILD INSTRUCTIONS: The next questions are about your opportunities for social activities: How often do you… 1 = Never 2 = A little 3 = Sometimes 4 = Often 5 = A lot
1 2 3 4 5 Participate in extracurricular activities (e.g., clubs, sports, religious groups)
1 2 3 4 5
Attend school 1 2 3 4 5 Spend time with friends during the weekdays
1 2 3 4 5
Spend time with friends during the weekend
1 2 3 4 5
Participate in school field trips 1 2 3 4 5 Attend summer camps 1 2 3 4 5 Interact with friends online 1 2 3 4 5 Attend sleepovers 1 2 3 4 5 Spend time with peers in the neighborhood
1 2 3 4 5
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Appendix B4: Children’s Behavior Checklist (Achenbach, 1991; Achenbach &
Rescorla, 2001)
I. Please list the sports your child most likes to take part in.
II. Please list any favorite hobbies, activities, and games, other than sports.
III. Please list any organizations, clubs, teams, or groups your child belongs to.
IV. Please list any jobs or chores your child has.
V. 1. How many close friends does your child have? (Do not include brothers and
sisters)
a. None, 1, 2 or 3, 4 or more
2. How many times a week does your child do things with any friends outside of
regular school hours?
a. Less than 1, 1 or 2, 3 or more
3. Compared to other kids, who well does your child:
a. Get along with his/her brothers and sisters?
b. Get along with other kids?
c. Get along with you?
d. Does things by his/herself?
VI. Does your child have any illness, disability, or handicap?
VII. Please describe any concerns or problems you have about your child’s schooling.
VIII. Please describe any other concerns you have for your child.
IX. Please describe the best things about your child.
Below is a list of items that describe children and youth. For each item
that describes your child now or within the past 6 months, please circle the 2 if
the item is very true or often true of your child. Circle the 1 if the item is
somewhat true or sometimes true of your child. If the item is not true of your
child, circle the 0. Please answer all items as well as you can, even if some do not
seem to apply to your child.
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0 = Not True (as far as you know)
1 = Somewhat or Sometimes True
2 = Very True or Often True
1. Acts too young for his/her age 0 1 2
2. Drinks alcohol without parent’s approval 0 1 2
3. Argues a lot 0 1 2
4. Fails to finish things he/she starts 0 1 2
5. There is very little he/she enjoys 0 1 2
6. Bowel movements outside toilet 0 1 2
7. Bragging, boasting 0 1 2
8. Can’t concentrate, can’t pay attention for long 0 1 2
9. Can’t get his/her mind off certain thoughts; obsessions 0 1 2
10. Can’t sit still, restless, or hyperactive 0 1 2
11. Clings to adults or too dependent 0 1 2
12. Complains of loneliness 0 1 2
13. Confused or seems to be in a fog 0 1 2
14. Cries a lot 0 1 2
15. Cruel to animals 0 1 2
16. Cruelty, bullying, or meanness to others 0 1 2
17. Day-dreams or gets lost in his/her thoughts 0 1 2
18. Deliberately harms self or attempts suicide 0 1 2
19. Demands a lot of attention 0 1 2
20. Destroys his/her own things 0 1 2
21. Destroys things belonging to his/her family or others 0 1 2
22. Disobedient at home 0 1 2
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23. Disobedient at school 0 1 2
24. Doesn’t eat well 0 1 2
25. Doesn’t get along with other kids 0 1 2
26. Doesn’t seem to feel guilty after misbehaving 0 1 2
27. Easily jealous 0 1 2
28. Breaks rules at home, school, or elsewhere 0 1 2
29. Fears certain animals, situations, or places other than 0 1 2
school
30. Fears going to school 0 1 2
31. Fears he/she might think or do something bad 0 1 2
32. Feels he/she has to be perfect 0 1 2
33. Feels or complains that no one loves him/her 0 1 2
34. Feels others are out to get him/her 0 1 2
35. Feels worthless or inferior 0 1 2
36. Gets hurt a lot, accident-prone 0 1 2
37. Gets in many fights 0 1 2
38. Gets teased a lot 0 1 2
39. Hangs around with others who get in trouble 0 1 2
40. Hears sounds or voices that aren’t there 0 1 2
41. Impulsive or acts without thinking 0 1 2
42. Would rather be alone than with others 0 1 2
43. Lying or cheating 0 1 2
44. Bites fingernails 0 1 2
45. Nervous, highstrung, or tense 0 1 2
46. Nervous movements or twitching 0 1 2
47. Nightmares 0 1 2
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48. Not liked by other kids 0 1 2
49. Constipated, doesn’t move bowels 0 1 2
50. Too fearful or anxious 0 1 2
51. Feels dizzy or lightheaded 0 1 2
52. Feels too guilty 0 1 2
53. Overeating 0 1 2
54. Overtired without good reason 0 1 2
55. Overweight 0 1 2
56. Physical problems without known medical cause:
a. Aches or pains (not stomach or headaches) 0 1 2
b. Headaches 0 1 2
c. Nausea, feels sick 0 1 2
d. Problems with eyes (not if corrected by glasses): 0 1 2
e. Rashes or other skin problems 0 1 2
f. Stomachaches 0 1 2
g. Vomiting, throwing up 0 1 2
h. Other (describe): ___________________________ 0 1 2
57. Physically attacks people 0 1 2
58. Picks nose, skin, or other parts of body 0 1 2
59. Plays with own sex parts in public 0 1 2
60. Plays with own sex parts too much 0 1 2
61. Poor school work 0 1 2
62. Poorly coordinated or clumsy 0 1 2
63. Prefers being with older kids 0 1 2
64. Prefers being with younger kids 0 1 2
65. Refuses to talk 0 1 2
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66. Repeats certain acts over and over; compulsions 0 1 2
67. Runs away from home 0 1 2
68. Screams a lot 0 1 2
69. Secretive, keeps things to self 0 1 2
70. Sees things that aren’t there 0 1 2
71. Self-conscious or easily embarrassed 0 1 2
72. Sets fires 0 1 2
73. Sexual problems 0 1 2
74. Showing off or clowning 0 1 2
75. Too shy or timid 0 1 2
76. Sleeps less than most kids 0 1 2
77. Sleeps more than most kids during day and/or night 0 1 2
78. Inattentive or easily distracted 0 1 2
79. Speech problem 0 1 2
80. Stares blankly 0 1 2
81. Steals at home 0 1 2
82. Steals outside the home 0 1 2
83. Stores up too many things he/she doesn’t need 0 1 2
84. Strange behavior 0 1 2
85. Strange ideas 0 1 2
86. Stubborn, sullen, or irritable 0 1 2
87. Sudden changes in mood or feelings 0 1 2
88. Sulks a lot 0 1 2
89. Suspicious 0 1 2
90. Swearing or obscene language 0 1 2
91. Talks about killing self 0 1 2
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92. Talks or walks in sleep 0 1 2
93. Talks too much 0 1 2
94. Teases a lot 0 1 2
95. Temper tantrums or hot temper 0 1 2
96. Thinks about sex too much 0 1 2
97. Threatens people 0 1 2
98. Thumb-sucking 0 1 2
99. Smokes, chews, or sniffs tobacco 0 1 2
100. Trouble sleeping 0 1 2
101. Truancy, skips school 0 1 2
102. Underactive, slow moving, or lacks energy 0 1 2
103. Unhappy, sad, or depressed 0 1 2
104. Unusually loud 0 1 2
105. Uses drugs for nonmedical purposes (don’t include
alcohol or tobacco) 0 1 2
106. Vandalism 0 1 2
107. Wets self during the day 0 1 2
108. Wets the bed 0 1 2
109. Whining 0 1 2
110. Wishes to be of opposite sex 0 1 2
111. Withdrawn, doesn’t get involved with others 0 1 2
112. Worries 0 1 2
113. Please write in any problems your child has that were not
listed above: ____________________________________ 0 1 2
______________________________________________ 0 1 2
______________________________________________ 0 1 2
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Appendix B5: Friendship Survey (created for this study)
1. How important is it to you to have a friend? Why? a. 1 = Not at all important b. 2 = Not really important c. 3 = Kind of important d. 4 = Important e. 5 = Extremely Important
2. Who are your friends? A friend is someone that you like and may spend time with. Please do not include any brothers or sisters as a friend.
Friend (Please report on at least 1 friend)
Is your friend: Older, Younger, About the Same Age
How long have you known this friend?
How did you meet? How did you become friends?
How often do you see each other?
What kinds of things do you do together?
Why do you think you are friends?
How happy are you with this friendship?*
1. 2. 3. 4. 5. 6.
* Use this rating scale: a. 1 = Very unhappy b. 2 = Unhappy c. 3 = Kind of happy d. 4 = Happy e. 5 = Very happy
3. If you could change anything concerning your friendships, what would you change? 4. Why? 5. Who is your best friend?(Remember, this is the person mentioned in the email that linked
you to this survey, the friend you named earlier) _____________________ 6. How is this best friendship different from your other friendships? 7. What kind of person is your best friend? Write at least 3 sentences describing her/him. 8. What makes him/her similar to you? How is he/she different than you? 9. If you could choose any boy or girl to be your best friend, would _____ be the one you would pick as your best friend?
a. 0 = No
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b. 1 = Yes 10. Why? 11. How often do you interact with your best friend?
___ Every day ___ A few times a week ___ Once a week ___ Every other week ___ Once a month ___ Less than once a month 12. How do you spend time with your best friend (check all that apply)
___ In school ___ In the neighborhood ___ At a sport/team event ___ Phone ___ Text Message ___ Email ___ Instant Messaging ___ Social Networking Site (e.g., Facebook) ___ Other…..Describe: 13. Do you feel that your health has gotten in the way of your friendship?
___ No ___Yes
If yes, rate: 1 2 3 4 5 (little to no effect) (a little) (some) (a lot) (major effect)
How has your health gotten in the way of your friendship?
14. What qualities make a good friend? Please name at least 3 qualities.
a. * More than three slots will be available for them to list more 15. How much does your best friend display (e.g., show) this quality?
a. *These will autofill from the previous question Never A little Sometimes Often A lot
Quality 1
Quality 2
Quality 3
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16. Describe what an average weekend is like for you, from Friday night to Sunday evening. Please write at least two sentences each for Friday, Saturday, and Sunday. 17. What activities do you participate in (e.g., sports, drama club, Boy Scouts)? These activities can be anything you do on the weekend or after school. 18. What things do you wish you could take part in but can’t? Why can’t you do these things?
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Appendix B6: Network of Relationships Inventory (Furman & Buhrmester, 1985)
Everyone has a number of people who are important in his or her life. For example, your parents, brothers or sisters, other relatives, teachers, and friends are people who might be important to you. The questions below are about your relationships with your family members and friends. The next questions ask about your relationships with each of the following people: 1) your mother or step-mother (if you have both, describe your relationship with the one
you feel closest to); 2) your father or step-father (if you have both, describe your relationship with the one you feel closest to); and 3) your friend. If, for some reason (for example, a parent has died) you cannot fill out the scale for someone, you don’t have to. Answer each of the following questions for each person. Sometimes the answers for different people may be the same; sometimes they may be different. When answering questions about your friend, please think about the person named on the previous page, whom you’ve been answering questions about. Will you be answering these questions about your? Mom ____ Step-mom ____ Dad ____ Step-dad ____
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1. How much free time do you spend with this person? None Little Some A lot Almost all
Mother 1 2 3 4 5 Father 1 2 3 4 5 Friend 1 2 3 4 5 2. How much do you and this person get upset with each other or mad at each other? None Little Some A lot Almost always Mother 1 2 3 4 5 Father 1 2 3 4 5 Friend 1 2 3 4 5 3. How much does this person teach you how to do things that you don't know how to do? None Little Some A lot Almost always Mother 1 2 3 4 5 Father 1 2 3 4 5 Friend 1 2 3 4 5 4. How satisfied are you with your relationship with this person? Not A little Somewhat Very Extremely satisfied satisfied satisfied satisfied satisfied Mother 1 2 3 4 5 Father 1 2 3 4 5 Friend 1 2 3 4 5 5. How much do you tell this person everything? Tell Tell Tell some Tell a lot of Tell all
nothing a little things things Mother 1 2 3 4 5 Father 1 2 3 4 5 Friend 1 2 3 4 5
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6. How much do you help this person with things she/he can't do by her/himself? Not at all A little Somewhat A lot Almost always Mother 1 2 3 4 5 Father 1 2 3 4 5 Friend 1 2 3 4 5 7. How much does this person like or love you? Not at all A little Somewhat A lot Very much Mother 1 2 3 4 5 Father 1 2 3 4 5 Friend 1 2 3 4 5 8. How much does this person punish you? Not at all A little Somewhat A lot Very much Mother 1 2 3 4 5 Father 1 2 3 4 5 Friend 1 2 3 4 5 9. How much does this person treat you like you're admired and respected? Not at all A little Somewhat A lot Very much Mother 1 2 3 4 5 Father 1 2 3 4 5 Friend 1 2 3 4 5 10. How often does this person tell you what to do? Never Seldom Sometimes Often Always Mother 1 2 3 4 5 Father 1 2 3 4 5 Friend 1 2 3 4 5 11. How sure are you that this relationship will last no matter what? Not at all A little Somewhat Very Extremely
sure sure sure sure Mother 1 2 3 4 5 Father 1 2 3 4 5 Friend 1 2 3 4 5
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12. How much do you play around and have fun with this person? Not at all A little Somewhat A lot A ton Mother 1 2 3 4 5 Father 1 2 3 4 5 Friend 1 2 3 4 5 13. How much do you and this person disagree and quarrel? Not at all A little Somewhat A lot A ton Mother 1 2 3 4 5 Father 1 2 3 4 5 Friend 1 2 3 4 5 14. How much does this person help you figure out or fix things? Not at all A little Sometimes A lot The most
Mother 1 2 3 4 5 Father 1 2 3 4 5 Friend 1 2 3 4 5 15. How happy are you with the way things are between you and this person? Not happy A little Somewhat Very Extremely happy happy happy happy
Mother 1 2 3 4 5
Father 1 2 3 4 5 Friend 1 2 3 4 5 16. How much do you share your secrets and private feelings with this person? Never A little Sometimes Often Very often Mother 1 2 3 4 5 Father 1 2 3 4 5 Friend 1 2 3 4 5 17. How much do you protect and look out for this person? Never A little Sometimes Often Very often Mother 1 2 3 4 5 Father 1 2 3 4 5 Friend 1 2 3 4 5
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18. How much does this person really care about you? Not at all A little Somewhat A lot Very much
Mother 1 2 3 4 5 Father 1 2 3 4 5 Friend 1 2 3 4 5 19. How much does this person discipline you for disobeying him/her? Not at all A little Somewhat A lot Very much Mother 1 2 3 4 5 Father 1 2 3 4 5 Friend 1 2 3 4 5 20. How much does this person treat you like you're good at many things? Not at all A little Somewhat A lot Very much Mother 1 2 3 4 5 Father 1 2 3 4 5 Friend 1 2 3 4 5 21. How often is this person the boss in your relationship? Never Seldom Sometimes Often Always Mother 1 2 3 4 5 Father 1 2 3 4 5 Friend 1 2 3 4 5 22. How sure are you that your relationship will last even if you have fights? Not at all A little Somewhat Very Extremely
sure sure sure sure
Mother 1 2 3 4 5 Father 1 2 3 4 5 Friend 1 2 3 4 5 23. How often do you go places and do enjoyable things with this person? Never Seldom Sometimes Often Always Mother 1 2 3 4 5 Father 1 2 3 4 5 Friend 1 2 3 4 5
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24. How much do you and this person argue with each other? Not at all A little Sometimes A lot Very much
Mother 1 2 3 4 5 Father 1 2 3 4 5 Friend 1 2 3 4 5 25. How often does this person help you when you need to get something done? Never Seldom Sometimes Often Always Mother 1 2 3 4 5 Father 1 2 3 4 5 Friend 1 2 3 4 5 26. How good is your relationship with this person? Bad A little Good Very Great
bad good
Mother 1 2 3 4 5 Father 1 2 3 4 5 Friend 1 2 3 4 5 27. How much do you talk to this person about things that you don't want others to know? Not at all A little Some A lot Very much
Mother 1 2 3 4 5 Father 1 2 3 4 5 Friend 1 2 3 4 5 28. How much do you take care of this person? Not at all A little Some A lot Very much Mother 1 2 3 4 5 Father 1 2 3 4 5 Friend 1 2 3 4 5 29. How much does this person have a strong feeling of affection (love or liking) toward you? Not at all A little Some A lot Very much
Mother 1 2 3 4 5 Father 1 2 3 4 5 Friend 1 2 3 4 5
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30. How much does this person scold you for doing something you're not supposed to do? Not at all A little Some A lot Very much Mother 1 2 3 4 5 Father 1 2 3 4 5 Friend 1 2 3 4 5 31. How much does this person like or approve of the things you do? Not at all A little Some A lot Very much Mother 1 2 3 4 5 Father 1 2 3 4 5 Friend 1 2 3 4 5 32. How often does this person take charge and decide what should be done? Never Seldom Sometimes Often Always Mother 1 2 3 4 5 Father 1 2 3 4 5 Friend 1 2 3 4 5 33. How sure are you that your relationship will continue in the years to come?
Not at all A little Somewhat Very Extremely
sure sure sure sure sure
Mother 1 2 3 4 5 Father 1 2 3 4 5 Friend 1 2 3 4 5
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Appendix B7: Importance Beliefs for Relationships (created for this study)
The next questions ask about how important different parts of your relationships are with each of the following people TO YOU: 1) your mother or step-mother; 2) your father or step-father; and 3) your friend. Answer each of the following questions for each person. Sometimes the answers for different people may be the same; sometimes they may be different. Remember to answer these questions about the same people you answered for on the last questions. 1. How important is it that you spend free time with this person? Not
Important
A Little
Important
Somewhat
Important
Important Very
Important
Mother 1 2 3 4 5 Father 1 2 3 4 5 Friend 1 2 3 4 5 2. How important is it that this person teaches you how to do things that you don't know how to do? Not
Important
A Little
Important
Somewhat
Important
Important Very
Important
Mother 1 2 3 4 5 Father 1 2 3 4 5 Friend 1 2 3 4 5 3. How important is it that you are satisfied with your relationship with this person?
Not
Important
A Little
Important
Somewhat
Important
Important Very
Important
Mother 1 2 3 4 5 Father 1 2 3 4 5 Friend 1 2 3 4 5
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4. How important is it that you tell this person everything? Not
Important
A Little
Important
Somewhat
Important
Important Very
Important
Mother 1 2 3 4 5 Father 1 2 3 4 5 Friend 1 2 3 4 5 5. How important is it that you help this person with things she/he can't do by her/himself?
Not
Important
A Little
Important
Somewhat
Important
Important Very
Important
Mother 1 2 3 4 5 Father 1 2 3 4 5 Friend 1 2 3 4 5 6. How important is it that this person like or love you? Not
Important
A Little
Important
Somewhat
Important
Important Very
Important
Mother 1 2 3 4 5 Father 1 2 3 4 5 Friend 1 2 3 4 5 7. How important is it that this person treats you like you're admired and respected? Not
Important
A Little
Important
Somewhat
Important
Important Very
Important
Mother 1 2 3 4 5 Father 1 2 3 4 5 Friend 1 2 3 4 5
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8. How important is it that you are sure that this relationship will last no matter what? Not
Important
A Little
Important
Somewhat
Important
Important Very
Important
Mother 1 2 3 4 5 Father 1 2 3 4 5 Friend 1 2 3 4 5 9. How important is it that you play around and have fun with this person? Not
Important
A Little
Important
Somewhat
Important
Important Very
Important
Mother 1 2 3 4 5 Father 1 2 3 4 5 Friend 1 2 3 4 5 10. How important is it that this person helps you figure out or fix things? Not
Important
A Little
Important
Somewhat
Important
Important Very
Important
Mother 1 2 3 4 5 Father 1 2 3 4 5 Friend 1 2 3 4 5 11. How important is it that you are happy with the way things are between you and this person?
Not
Important
A Little
Important
Somewhat
Important
Important Very
Important
Mother 1 2 3 4 5 Father 1 2 3 4 5 Friend 1 2 3 4 5
118
12. How important is it that you share your secrets and private feelings with this person? Not
Important
A Little
Important
Somewhat
Important
Important Very
Important
Mother 1 2 3 4 5 Father 1 2 3 4 5 Friend 1 2 3 4 5 13. How important is it that you protect and look out for this person? Not
Important
A Little
Important
Somewhat
Important
Important Very
Important
Mother 1 2 3 4 5 Father 1 2 3 4 5 Friend 1 2 3 4 5 14. How important is it that this person really cares about you? Not
Important
A Little
Important
Somewhat
Important
Important Very
Important
Mother 1 2 3 4 5 Father 1 2 3 4 5 Friend 1 2 3 4 5 15. How important is it that this person treats you like you're good at many things? Not
Important
A Little
Important
Somewhat
Important
Important Very
Important
Mother 1 2 3 4 5 Father 1 2 3 4 5 Friend 1 2 3 4 5
119
16. How important is it that you are sure that your relationship will last even if you have fights? Not
Important
A Little
Important
Somewhat
Important
Important Very
Important
Mother 1 2 3 4 5 Father 1 2 3 4 5 Friend 1 2 3 4 5 17. How important is it that you go places and do enjoyable things with this person? Not
Important
A Little
Important
Somewhat
Important
Important Very
Important
Mother 1 2 3 4 5 Father 1 2 3 4 5 Friend 1 2 3 4 5 18. How important is it that this person helps you when you need to get something done? Not
Important
A Little
Important
Somewhat
Important
Important Very
Important
Mother 1 2 3 4 5 Father 1 2 3 4 5 Friend 1 2 3 4 5 19. How important is it that this relationship is good?
Not
Important
A Little
Important
Somewhat
Important
Important Very
Important
Mother 1 2 3 4 5 Father 1 2 3 4 5 Friend 1 2 3 4 5
120
20. How important is it that you talk to this person about things that you don't want others to know? Not
Important
A Little
Important
Somewhat
Important
Important Very
Important
Mother 1 2 3 4 5 Father 1 2 3 4 5 Friend 1 2 3 4 5 21. How important is it that you take care of this person? Not
Important
A Little
Important
Somewhat
Important
Important Very
Important
Mother 1 2 3 4 5 Father 1 2 3 4 5 Friend 1 2 3 4 5 22. How important is it that this person has a strong feeling of affection (love or liking) toward you? Not
Important
A Little
Important
Somewhat
Important
Important Very
Important
Mother 1 2 3 4 5 Father 1 2 3 4 5 Friend 1 2 3 4 5 23. How important is it that this person likes or approves of the things you do? Not
Important
A Little
Important
Somewhat
Important
Important Very
Important
Mother 1 2 3 4 5 Father 1 2 3 4 5 Friend 1 2 3 4 5
121
35. How important is it that you are sure that your relationship will continue in the years to come?
Not
Important
A Little
Important
Somewhat
Important
Important Very
Important
Mother 1 2 3 4 5 Father 1 2 3 4 5 Friend 1 2 3 4 5 36. How important is this relationship to you?
Not
Important
A Little
Important
Somewhat
Important
Important Very
Important
Mother 1 2 3 4 5 Father 1 2 3 4 5 Friend 1 2 3 4 5
122
Appendix B8: Feelings of Belongingness (Weeks, Asher, and McDonald, 2012)
Sometimes there are groups or communities that you might feel a connection
with. This could include a club, a sports team, a youth/religious group, a gaming society,
and so on.
Name a group or community you feel connected to: _____________
These next questions ask about your connection to that group:
1. I feel like I belong at this (NAME OF GROUP). 1 2 3 4 4
Strongly Disagree
Disagree Neither Agree nor Disagree
Agree Strongly Agree
2. I feel connected to this (NAME OF GROUP).
1 2 3 4 4
Strongly Disagree
Disagree Neither Agree nor Disagree
Agree Strongly Agree
3. I feel welcome at this (NAME OF GROUP).
1 2 3 4 4
Strongly Disagree
Disagree Neither Agree nor Disagree
Agree Strongly Agree
4. This (NAME OF GROUP) makes me feel like I belong.
1 2 3 4 4
Strongly Disagree
Disagree Neither Agree nor Disagree
Agree Strongly Agree
123
5. This (NAME OF GROUP) fits me well. 1 2 3 4 4
Strongly Disagree
Disagree Neither Agree nor Disagree
Agree Strongly Agree
6. This is definitely my (NAME OF GROUP).
1 2 3 4 4
Strongly Disagree
Disagree Neither Agree nor Disagree
Agree Strongly Agree
7. It’s hard for me to fit in here.
1 2 3 4 4
Strongly Disagree
Disagree Neither Agree nor Disagree
Agree Strongly Agree
8. This is definitely the right (NAME OF GROUP) for me. 1 2 3 4 4
Strongly Disagree
Disagree Neither Agree nor Disagree
Agree Strongly Agree
9. I’m glad I came to this (NAME OF GROUP). 1 2 3 4 4
Strongly Disagree
Disagree Neither Agree nor Disagree
Agree Strongly Agree
124
Appendix B9: Revised Child Anxiety and Depression Scale (Chorpita, Yim, Moffit,
Umemoto, & Francis, 2000)
Please put a circle around the word that shows how often each of these things happen to
you. There are no right or wrong answers.
N = Never
S = Sometimes
O = Often
A = Always
1. I worry about things N S O A 2. I feel sad or empty N S O A 3. When I have a problem, I get a funny feeling in my stomach
N S O A
4. I worry when I think I have done poorly at something
N S O A
5. I would feel afraid of being on my own at home N S O A 6. Nothing is much fun anymore N S O A 7. I feel scared when I have to take a test N S O A 8. I feel worried when I think someone is angry with me
N S O A
9. I worry about being away from my parents N S O A 10. I get bothered by bad or silly thoughts or pictures in my mind
N S O A
11. I have trouble sleeping N S O A 12. I worry that I will do badly at my school work N S O A 13. I worry that something awful will happen to someone in my family
N S O A
14. I suddenly feel as if I can't breathe when there is no reason for this
N S O A
15. I have problems with my appetite N S O A 16. I have to keep checking that I have done things right (like the switch is off, or the door is locked)
N S O A
17. I feel scared if I have to sleep on my own N S O A 18. I have trouble going to school in the mornings because I feel nervous or afraid
N S O A
19. I have no energy for things N S O A
125
20. I worry I might look foolish N S O A 21. I am tired a lot N S O A 22. I worry that bad things will happen to me N S O A 23. I can't seem to get bad or silly thoughts out of my head
N S O A
24. When I have a problem, my heart beats really fast
N S O A
25. I cannot think clearly N S O A 26. I suddenly start to tremble or shake when there is no reason for this
N S O A
27. I worry that something bad will happen to me N S O A 28. When I have a problem, I feel shaky N S O A 29. I feel worthless N S O A 30. I worry about making mistakes N S O A 31. I have to think of special thoughts (like numbers or words) to stop bad things from happening
N S O A
32. I worry what other people think of me N S O A 33. I am afraid of being in crowded places (like shopping centers, the movies, buses, busy playgrounds)
N S O A
34. All of a sudden I feel really scared for no reason at all
N S O A
35. I worry about what is going to happen N S O A 36. I suddenly become dizzy or faint when there is no reason for this
N S O A
37. I think about death N S O A 38. I feel afraid if I have to talk in front of my class N S O A 39. My heart suddenly starts to beat too quickly for no reason
N S O A
40. I feel like I don’t want to move N S O A 41. I worry that I will suddenly get a scared feeling when there is nothing to be afraid of
N S O A
42. I have to do some things over and over again (like washing my hands, cleaning or putting things in a certain order)
N S O A
43. I feel afraid that I will make a fool of myself in front of people
N S O A
44. I have to do some things in just the right way to stop bad things from happening
N S O A
126
45. I worry when I go to bed at night N S O A 46. I would feel scared if I had to stay away from home overnight
N S O A
47. I feel restless N S O A
127
Appendix C
Friendship Survey Coding Scheme
How important is it to you to have a friend?
a. Not at all important
b. Not really important
c. Kind of important
d. Important
e. Extremely Important
Why?
Who are your friends? A friend is someone that you like and may spend time with.
Please do not include any brothers or sisters as a friend.
Is your friend:
Older, Younger, About the Same Age?
1 = younger 2 = same age 3 = older
How long have you known this friend?
Enter in months
How did you meet? How did you become friends?
1 = school / daycare 2 = parents /family connection [not a family member] 3 = family member 4 = church 5 = mutual friend 6 = no answer/other
How often do you see each other? 1 = daily
A = 1 B = 2 C = 3 D = 4 E = 5
1 = COMPANIONSHIP: feels good/have fun/company/play/like them/do things with/hang out with/ be sad without them 2 = HEALTH UNDERSTANDING = knows about health problem/understands it 3 = SUPPORT: stick up for you, give advice, help, have someone outside of family 4 = COMFORT: can be self with them 5 = OTHER
128
2 = weekly 3 = monthly 4 = yearly 5 = less than once a year
What kinds of things do you do together?
1 = talk 2 = sports 3 = hang out/play [interactive] 4 = hang out [not interactive, e.g., movies, tv] 5 = technology 6 = church 7 = school 8 = other 9 = nothing
Why do you think you are friends? 1 = amount of time together/do certain things together a lot/known for a long time 2 = supportive/nice/get along well /caring 3 = fun 4 = similarity/connection 5 = family connection 6 = school 7 = other
How happy are you with this friendship?
1 = Very unhappy 2 = Unhappy 3 = Kind of happy 4 = Happy 5 = Very happy
129
If you could change anything concerning your friendships, what would you change?
Why?
Who is your best friend?(Remember, this is the person mentioned in the email that linked you
to this survey, the friend you named earlier) _____________________
How is this best friendship different from your other friendships?
What kind of person is your best friend? Write at least 3 sentences describing her/him.
1 = TIME: Spend more time together/see more/hang out more 2 = PERSONALITY: be less annoying 3 = GET ALONG BETTER: friends would get along with each other 4 = MORE INVOLVED IN FRIENDSHIP: less into others, better listener 5 = DISTANCE: would live closer 6 = OTHER
1 = Understands health experience 2 = Time spent together 3 = SUPPORTIVE: sticks up for me more, helpful 4 = CLOSENESS/TRUST: closer, trust more 5 = SIMILARITY: have more in common 6 = LIKABILITY: like the most, kindest, easy to talk to 7 = Known for a long time 8 = No other friends 9 = OTHER
1 = FUN/FUNNY 8 = LOYAL 2 = BRAVE/OUTSPOKEN 9 = COOL 3 = KIND/NICE/LOVING/CARING 10 = HONEST 4 = SUPPORTIVE/HELPFUL 11 = HOBBY DESCRIPTION 5 = SMART 12 = ANGRY 6 = PHYSICAL DESCRIPTION 13 = ANNOYING 7 = ATHLETIC 14 = OTHER
130
How often do you interact with your best friend?
How do you spend time with your best friend (check all that apply)
If other….describe:
Do you feel that your health has gotten in the way of your friendship?
1 = Every day
2 = A few times a week
3 = Once a week
4 = Every other week
5 = Once a month
6 = Less than once a month
1 = In school
2 = In the neighborhood
3 = At a sport/team event
4 = Phone
5 = Text Message
6 = Email
7 = Instant Messaging
8 = Social Networking Site (e.g., Facebook)
9 = Other
1 = At each other’s homes 2 = Church 3 = Stores/shopping
0 = No 1 = Yes
131
If yes, rate:
What qualities make a good friend? Please name at least 3 qualities.
How much does your best friend display (e.g., show) this quality?
For all qualities:
1 = little to no effect
2 = a little effect
3 = some effect
4 = a lot effect
5 = major effect
1 = Understands health problems 2 = Caring / kind /nice /respectful /thoughtful /friendly 3 = Loyal/faithful/dependable/nonjudgmental 4 = Funny/fun 5 = Helpful/supportive 6 = Maturity: “drama-free” 7 = Trustworthy/honest 8 = Smart 9 = Other
1 = not at all 2 = a little 3 = some 4 = a lot 5 = very much
132
What activities do you participate in (e.g., sports, drama club, Boy Scouts)? These
activities can be anything you do on the weekend or after school.
What things do you wish you could take part in but can’t? Why can’t you do these things?
1 = Church 2 = Clubs 3 = Music /chorus /dance 4 = Sports 5 = Volunteer 6 = Shopping 7 = Studying 8 = Other 9 = Nothing
1 = Money 2 = Age 3 = Shy/anxious 4 = Time 5 = Health 6 = Not good enough 7 = Not offered 8 = Other 9 = Nothing
133
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Biography Alissa Brooke Wigdor was born on December 19th, 1984 in Columbia, Maryland.
She received a B.S. in Honors Psychology from the University of Maryland – College
Park in 2007, graduating summa cum laude. In the Fall of 2009 Alissa began her doctoral
studies and training at Duke University in Child Clinical Psychology and received her
M.A. in 2012. Throughout her time at Duke, Alissa earned several Conference Travel
Awards, the Ann McDougall Memorial Award from the Women Studies Department,
the Sulzberger-Levitan Policy Graduate Research Fellowship through the Center for
Child and Family Policy at Duke University, and a Summer Research Fellowship from
The Graduate School to support her research. She was recognized as an Honorable
Mention for the National Science Foundation’s Graduate Research Fellowship, and was
awarded the Aleane Webb Dissertation Research Award from The Graduate School and
the Pediatric Oncology Student Training Grant from the Alex’s Lemonade Stand
Foundation. Alissa is a student member of the Society of Research in Child
Development, the Society for Research on Adolescence, Society of Clinical Child &
Adolescent Psychology, and Society of Pediatric Psychology. In 2014, Alissa began her
predoctoral internship in Pediatric Child Psychology at Duke University Medical Center
in Durham, NC. She will begin a clinical associate position at Duke University Medical
Center in 2015.