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This is to certify that the

thesis entitled

Coping Responses and Adaptational Outcomes of

Children Undergoing Orthopedic Surgery
presented by

Paul M. Robins

has been accepted towards fulfillment
of the requirements for

Ph.D. degree in School Psychology

 

 

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COPING RESPONSES AND ADAPTATIONAL OUTCOMES OF

CHILDREN UNDERGOING ORTHOPEDIC SURGERY

BY

Paul M. Robins

A DISSERTATION

Submitted to
Michigan State University
in partial fulfillment of the requirements
for the degree of

DOCTOR OF PHILOSOPHY

College of Education

Department of Counseling, Educational
Psychologyr and Special Education

1986

ABSTRACT

COPING RESPONSES AND ADAPTATIONAL OUTCOMES OF
CHILDREN UNDERGOING ORTHOPEDIC SURGERY

BY
Paul M. Robins

This study examined the relationships between
coping responses and adaptational outcomes of children
undergoing elective orthopedic surgery. Knowledge of
these relationships is needed in order to prevent
possible negative reactions due to hospitalization and
surgery.

A sample of 27 children, ages 6 through 17,
undergoing orthopedic surgery at a large, urban
children's hospital participated in the study. The
Roberts Apperception Test for Children, used to measure
surgical coping responses, was administered preceeding
and following surgery. The Revised Behavior Problem
Checklist, used to measure surgical adaptation, was
administered prior to discharge and one month following
discharge. The Personality Inventory for Children, used
to measure cognitive functioning and premorbid
adjustment, was administered immediately prior to
surgery.

Eight hypotheses related to children's responses to

Paul H. Robins
hospitalization and surgery were developed and tested.
Descriptive case analyses were also presented. Children
who scored higher on measures of surgical coping
generally did not exhibit better surgical adaptation
than those who scored lower. However, children who
perceived appropriate and constructive limits placed on
their behaviors exhibited better surgical adaptation one
month later. In addition, children who used greater
numbers of coping responses exhibited less anxiety and
withdrawal after surgery.

Children's coping responses did not significantly
differ preceeding surgery versus following surgery.
Children with higher cognitive functioning, shorter
periods of hospitalization, and fewer hospital
admissions did not exhibit better surgical adaptation.
Girls did not show better surgical adaptation than boys,
nor did older children show better surgical adaptation
than younger children. Children with better premorbid
adjustments showed more positive long-term surgical
adaptations than did children with poorer premorbid
adjustments.

The results suggested that the majority of children
demonstrated significant “stress resistance." Factors
contributing to such resistance and implications for
children at risk for developing psychological

complications were discussed.

ACKNOWLEDGMENTS

Writing a dissertation is much like running a
marathon: ultimately, it is a very lonely experience,
but aid is essential along the route in order to keep
going. I have been fortunate, for a number of_
individuals helped me complete the project.

Don Hamachek functioned as my academic advisor and
dissertation chairperson. His utterly pragmatic
approach in all phases of the research helped me learn
that the dissertation, although a necessity, was only a
starting point in my career. I appreciated his prompt
and careful readings of the manuscripts and his support
for my developing abilities as a researcher and
psychologist.

Steve Raudenbush helped me design the study and
analyze the data. His questions encouraged me to
increasingly clarify my research hypotheses, while his
expertise as a methodologist, but more importantly as a
teacher and scholar, helped me make sense of sometimes
overwhelming amounts of data. Our work sometimes
occured over long distance telephone; he was both
responsive and responsible and was very appreciated.

Harvey Clarizio and Martha Karson also functioned
as committee members. Harvey's academic expertise

and input during long individual discussions, especially

ii

during my early years of graduate study, stimulated my
academic growth and competence. Martha helped me
develop and expand my clinical skills and believe in the
process of psychotherapy and change.

The staff at Children's Hospital of Michigan
assisted me in the nuts and bolts of the research.
Particular appreciation is expressed to Steve Spector,
Director of Psychology Training. He helped me further
refine the study and was instrumental in obtaining the
subject population. Joseph Fischhoff, Chief of
Psychiatry, kindly read and critiqued my proposal, and
sponsored the research. Appreciation is extended to
Richard LaMont, Chief of Orthopedic Surgery, and David
Aronson, Assistant Chief of Orthopedic Surgery, as they
graciously agreed to support the research with their
private and clinic patients. Pat Newman, Department of
Orthopedics, and her office staff helped me recruit and
track subjects, despite many other job obligations.

I am indebted to the children and parents who
participated in the study. Despite anxiety and physical
discomfort they shared their experiences with me in
order to possibly help other children facing similar
operations.

My parents have always encouraged and supported my
goals, both academic and personal. Their belief in me
has never dimmed.

Finally and most important, to Robin I am most

iii

thankful. She shared with me on a daily basis both the
victories and defeats of the dissertation process. Her
love, caring, encouragment, and competence helped
provide the emotional groundwork so necessary in order

for me to see the finish line.

iv

TABLE OF CONTENTS

Page
LIST OF TABLES COO...I00......OOOOOOOOOOOOOOOO..0. Vii

LIST OF FIGURES .0...O0......OOOOOOOOOOOOOOOOOOOOO Viii

Chapter
I. THE PROBLEM ............................... 1
Introduction ............................ 1
Statement of the Problem ................ 2
Need for the Study ...................... 2
Purpose 0.0.00.0...OOOOOOOOOOOOOOOOIOOOOO 4
Theory .0...0......OOOOOOOOOOOOOOOOOOOOOO 5
The Concept of Stress ................. 5
Interactionism as Applied to the

Concepts of Stress and Coping ....... 9

A Cognitive Model of Stress Within an
Interactional Framework ............. 11
Definition Of Terms OOOOOOOOOOOOOOOOOOOOO 15
Hypotheses OOOOOOOOOOOOOOOOOOOOOOOOOOOOOO 16

II. REVIEW OF THE LITERATURE .................. 17

Stress and Children ..................... l7
Hospitalization and Surgery as
Stressors in Childhood ................ 22
The Structure of Coping Responses........ 31
Common Coping Responses................ 31
The Relationships Between Coping
Responses and Outcomes............... 34
Summary of Stress Research............... 44
Conclusions.............................. 46
III. DESIGN OF THE STUDY OOOOOOOOOOOOOOOOOOOOOOO 49
Selection and Description of the Sample . 49
measures 0..OOOOOOOOOOOOOIOOOOOOOOOIIO... 52
Procedures for Collecting Data .......... 63
Design................................... 66
Research Hypotheses ..................... 67
Ana1YSj-S O00......OOOOOOOOOOOOOOOOOOOOOOO 69
Supplementary Descriptive Data Analysis.. 74
summary...000......OOOOOOOOOOOOOOOOOOOOOO 74

Page

Iv. RESULTSOOOOOOOIOCOOOOOOOOOOOOOOOOO00.....0. 77
Summary Statistics of Surgical Coping
and Adaptation......................... 77
Summary Statistics of Intrinsic and
Extrinsic Stress Factors............... 78
Test of the Hypotheses................... 81
Descriptive Case Analysis ............... 91

summary Of the FindinQBOOOOOOIOOI00...... 101

V. DISCUSSION AND CONCLUSION ................. 104

summary OOOOOOOOOO0.000000000000000.0.0.... 104

Discussion of the Hypotheses .............. 107

Limitations Of the Stuay OOOOOOOOOOOOOOOOIO 125

Implications of the Study ................. 127

Directions for Future Research ............ 129

conC1USion O0.0.00000000000COOOOOOOOOOC.0.0 131
APPENDICES

A. CONSENT FORM OOOOOOOOOOOCOIOOOO0.00...0.... 133

B. ROBERTS APPERCEPTION TEST FOR CHILDREN .... 136

C. PERSONALITY INVENTORY FOR CHILDREN ........ 142

D. REVISED PROBLEM BEHAVIOR CHECKLIST ........ 151

LIST OF REFERENCES 0..O...OOOOOOOCOOOOOOOOOOOOOOOO 156

vi

Table

3.1

3.2

4.1

4.2

4.3

4.5

4.6

4.7

4.8

LIST OF TABLES

Page

Description of Subject Sample
Agexsexxnace (N=27) OOOOOOOOOOOOOOOOO 52

Description of Subject Sample by
Hospital History (N=27) ................. 52
Descriptive Statistics for Surgical Coping
and Adaptational Outcome Scales ......... 79

Descriptive Statistics for the
Intrin81c variables OOOOOOOOOOOOOOOOOOOIO 81

Descriptive Statistics for the
Extrinsic Variables ..................... 81

Correlation Coefficients Between the Total
Surgical Coping Scores (RATC) and the
Total Surgical Adaptation Scores (RBPC) . 84

Paired Difference T-test Results for
Presurgical (RATC-l) and Postsurgical
(RATC-Z) Coping Response Scales ......... 86

T-test Results for Postsurgical Adaptation
(RATC-l) and Long-term Surgical
Adaptation (RATC-2) Mean Scores for
Males (M) and Females (F) ............... 89

Summary of Bivariate Correlation
Coefficients for Hypotheses Related to
Intrinsic Stress Factors ................ 89

Summary of Bivariate Correlation

Coefficients for Hypotheses Related to
Extrinsic Stress Factors ................ 91

vii

LIST OF FIGURES

Figure Page
1. An Interactional Model of Stress,

Coping, and Adaptation .................. 12

2. Data Collection Points and Measures ....... 66

viii

CHAPTER 1
THE PROBLEM

Intredngtign

Hospitalization affects millions of children
yearly. Three and a half to four million children under
15 years of age are hospitalized each year and one third
of all young people will be hospitalized once or more by
the time they become adults (Prugh & Jordan, 1975). The
psychological effects of hospitalization on children has
long been an area of inquiry (cf., Vernon, Foley,
Sipowicz, & Schulman, 1965, for review). Children view
hospitalization as a very stressful experience
(Coddington, 1972; Dohrenwend & Dohrenwend, 1980), and
as many as 20—36% of hospitalized children show
demonstrable emotional difficulties after .
hospitalization (Cook, 1967; Davenport & Werry, 1970).

Very little research has examined the correlations
between surgical coping responses and adaptational
outcomes in children undergoing surgery using
psychometrically sound instruments. It is not enough to
know what goes wrong in the lives of children (Blom,
1958; 1984). Much can also be learned by studying how
children successfully cope with the stresses associated

with hospitalization and surgery.

Statement 91 the Preblem

Children experience many emotional problems due to
hospitalization, as documented in the pediatric
literature (Prugh & Jordan, 1975). Aspects of the
hospitalization experience itself are stressful for
children (Cook, 1967; Prugh & Jordan, 1975; Rutter,
1983; Willis, Elliot, 5 Jay, 1982; Wolff, 1973; Wright,
Schaefer, & Solomons, 1979). Furthermore, surgical
procedures add to the perception of stress (Kliman,
1968; Vernon et a1., 1965; Wolff, 1973; Wright et a1.,
1979).

Yet, the vast majority of children do not
experience long-term psychological upset following
hospitalization and surgery. In fact, some children
experience psychological benefit from the experience
(Lambert, 1984; Vernon & Shulman, 1964). What
characteristics differentiate these children from those
who do not cope so well? More specifically, are there
cognitive strategies used by successful copers that

differentiates them from nonsuccessful copers?

Need in: the Stud!
There is a need for this study because of the
following three points:
(1) Although the research on stress and coping over
a 20 year period is voluminous, most studies are based
on adult samples. Except for a few doctoral

dissertations, research on how children cope with

surgery as it occurs is scarce.

(2) Previous research investigating children's
adaptation to surgery has focused strictly on trait or
personality factors of children (Lazarus et a1, 1980;
Monat & Lazarus, 1977). An investigation of cognitive
processes that mediate the impact of surgery and affect
postsurgical adaptation in pediatric populations might
contribute to our knowledge of how children themselves
actively cope with a very stressful experience.
Cognitive processes can be learned (Spivack, Platt, &
Shure, 1976) and are more amenable to intervention than
personality traits. ,

(3) This study investigates how normal, nonreferred
children cope with a severe stressor, i.e., their sense
of mastery (Anthony, 1974) or competency (Garmezy,
1983). Too often research has focused on children
coping poorly with a specific stressor. Pediatric
surgery patients face a very disturbing experience over
which they have little control. An empirical
investigation describing the relationships between
surgical coping responses and postsurgical adaptation
aids in understanding the strategies both good and poor
copers use (Garmezy, 1983; Rutter, 1983). The
information can be used by pediatric psychologists,
physicians, nursing staff, and other hospital personnel
as empirical groundwork to plan and structure more

effective interventions for children experiencing

surgery.

Pnrpeee

The primary purpose of this research is to study
the relationships between coping responses and
adaptational outcomes of hospitalized school-aged
children undergoing elective orthopedic surgery. The
coping responses of children successfully adapting to
hospitalization and surgery will be compared with the
coping responses of children not adapting as well. An
interactional stress model, emphasizing cognitive,
situational (e.g.,1ength of hospital stay and number of
previous hospital admissions) and personality variables
(e.g., presurgery intellectual functioning and premorbid
adjustment) will be employed.

The central hypothesis of this study is that
cognitive processes act as mediators of stress in
children undergoing hospitalization and surgery, such
that children who score higher on measures of surgical
coping exhibit better postsurgical psychological
adaptation. In addition, it is hypothesized that
cognitive processes, individual differences, and
situational variables all affect children's surgical

adaptation.

Theelx
The Ceneept 9f Stress

Coping responses and adaptational outcomes in
children undergoing surgery can best be understood by a
stress and coping model. The application of this model
to the process of pediatric surgery has several
advantages. One, it offers a dynamic and interactive
framework for the study of children's functioning in a
hospital setting. Two, there is practical utility in
the stress and coping model in its focus on the adaptive
process, as opposed to psychopathology. Three, the
model is consistent with current naturalistic approaches
to research on pediatric hospitalization and surgery in
that stress is defined as an event that is subsequently
appraised by the individual, resulting in coping
responses. The present section is theoretical and
briefly presents the concepts of stress, coping, and
adaptation. Included are: a) the concept of stress, b)
interactionism as applied to stress, including coping
and adaptation, and c) a cognitive stress model within
an interactional framework, upon which the present
research is based.

There are three main variations in use of the
concept of stress (Lazarus & Launier, 1978): a) stress
as a form of stimulus, b) stress as a response
condition, and c) stress as a psychological state. Many

researchers define stress as a form of stimulus, a

condition or conditions that disrupt or endanger well-
established personal and social values. Dohrenwend and
Dohrenwend (1980), among others, conceptualize stress as
a series of life events, either inherent in the life
cycle or occuring naturally, e.g., marriage, change of
jobs, illness, separation, and death. Such events are
said to produce change in life patterns or activities of
the individual for better or for worse. Stress is used
to describe situations characterized as new, intense,
quickly changing, and sudden (Appley & Trumbull, 1977).
Numerous researchers have studied stress associated with
life events and have developed scales to assess the
impact of such changes (e.g., Coddington, 1972;
Hefferin, 1982; Holmes 5 Rahe, 1967). An unsettled
issue at this time is whether change per se or the
perceived desirability of the change is the actual basis
for the stressfulness of life events.

Other researchers define stress as a response
condition (e.g., Selye, 1976). The presence of
emotional activity is used post-facto to define the
existence of stress. Stress here refers to any
response, bodily or behavioral, which deviates from
normative value for the individual or an appropriate
reference group (Appley and Trumbull, 1977). Selye
(1976), the ”father“ of stress research, refers to the
physiological manifestations of stress. His model, the

“general adaptation syndrome“ (GAS), exemplifies a total

commitment to the concept of physiological
nonspecificity of stress responses (Monat & Lazarus,
1977).

A third group of researchers, most notably Lazarus
(Lazarus, 1966, 1977; Lazarus & Launier, 1978) and
Sarason and Sarason (1981) refer to stress as a
psychological or mental state describing adaptive
commerce between the person and environment, and
emphasize possible cognitive factors leading to the
evaluation of threat and consequent stress responses.
Here, the individual's interpretation and evaluation of
stimuli functions as the basis for a response to the
stress experience (Scott, Oberst, & Dropkin, 1982).
Emotions and physiological responses are viewed as by-
products of cognition. Cognitive processes determine
the quality and intensity of an emotional reaction which
Lazarus (1977) sees as the mediating variable between
the event and the response.

Each position regarding stress described above has
its adherents and detractors. A stimulus or life events
based definition is incomplete, for a given situation
may or may not be stressful to a person. For example,
why does stress occur in some people but not to others
exposed to the same stimulus? Except for sudden, life
endangering situations (Appley, 1977; Monat & Lazarus,
1977) it is seldom that a particular stimulus is a

stressor to all individuals exposed to it. A definition

which is strictly response based is also incomplete,
inasmuch as an individual may exhibit increased
autonomic nervous system activity at one moment in time,
but fail to do so in the same situation at another
moment in time. What accounts for the difference in the
physiological response to stress? Finally, a cognitive
appraisal approach assumes an internal mechanism not
readily visible to either the individual or an observer,
which, because the processes must be inferred, causes
certain problems when it comes to defining and assessing
stress.

The picture is further complicated in reference to
the concept of stress as applied to children.
Children's tolerance for stress is lower than adults;
they have fewer Options available and thus are more
vulnerable to the effects of stress (Chandler, 1982).
Children are in the process of developing controls that
tend to be more established in adults. Their cognitions
also are egocentric and centered, making awareness of
multiple perceptions difficult (Ginsburg & Opper, 1979).
Cause and effect relationships demand a certain level of
cognitive development, i.e., concrete operations,
something which preschool aged children generally do not
possess. Children's problem-solving strategies are less
planful; they are less apt to be organized sequentially,
are more redundant, and future events are less likely to

be taken into account (Maccoby, 1983). The concept of

stress as applied to children thus raises many issues in
terms of definition and assessment that are unresolved
at this time.

For purposes of this research, definitions of
stress and coping are based on an interactional model,
which focuses on the interplay between the person and
environment, and which is understood and explained
within a cognitive framework (Lazarus, 1966; Lazarus &
Folkman, 1984; Lazarus & Launier, 1978; Sarason &
Sarason, 1981).

”Psychological stress in a particular relationship
between the person and the environment that is appraised
by the person as taxing or exceeding his or her
resources and endangering his or her well-being'I
(Lazarus & Folkman, 1984, p. 19). Coping, a related
term, refers to "constantly changing cognitive and
behavioral efforts to manage specific external and/or
internal demands that are appraised as taxing or
exceeding the resources of the person“ (Lazarus &
Folkman, 1984, p. 141).
Wmnwmmmu
Streasandcmins

All interactional theories make important common
statements. The essential differences between the
theories center on the amount of emphasis on person,
environment, and/or process variables. Heuristically,

interactional theories are useful insofar as they each

10

maintain that a variety of events can occur
simultaneously within and outside of a person and that
an event can only be understood in relation to the
sequence or pattern of which it is a part.

The consequence of stress cannot be understood
merely in terms of the stressful event (Holroyd 8
Lazarus, 1982) or trait factors of the person alone.
Rather, stress is best described in terms of an
interaction between the person and the environment (Laux
& Vossel, 1982). An individual's cognitive appraisal of
a stressful event is crucial to understanding how that
person may respond to the stress, or, for that matter,
whether stress is perceived at all (Magnusson, 1982).

Prediction from trait measures regarding how a
person actually will cope with specific threat
situations is very poor (Lazarus, Cohen, Folkman, Kamer,
& Schaefer, 1980). General coping traits assume a
stable pattern or style of coping in most stressful
situations, but since coping styles show little
generalizability within persons and between situations,
traits are usually poor predictors of how a person will
cope with a given stresssor (Monat & Lazarus, 1977).
Lazarus and Cohen (1974) found that trait measures did
not predict how people coped with children.

Children, due to the very nature of their
cognitive, affective, and physiological development, do

not demonstrate stable personality characteristics. To

11

fully understand children's behavior, one must consider
both the developmental characteristics of the child and
the environmental context in which behavior occurs
(Achenbach, 1974; Quay & Werry, 1974). Unfortunately,
most research investigating children's coping responses
and adaptational outcomes to hospitalization and surgery
have assumed a trait model, thereby limiting the
fruitfulness of much research already completed.

A Cegnitixe Stress Hedel
Hithinanlnteraetienalmmemk

Although stress has been defined as a stimulus, a
response, and a hypothetical state, a generally agreed
on view is that stress is an state, i.e., an interaction
between the person and the environment that is appraised
by the person as taxing or exceeding the resources of
the person (Lazarus & Folkman, 1984). If stress can be
understood in cognitive terms, differential reactions to
stressful situations might be better understood.

Figure 1 depicts the model of stress developed for
purposes of this study. It is based on a theory of
interactionism, whereby stress is defined as the
interaction between the individual, his or her resources
and capabilities, and the demand(s) of the situation.
Stress, thus theorized, is an ongoing process as the
individual moves through situations and time. It is a
chain of events involving two related processes: coping

responses and adaptational outcomes. The model and

12

 

 

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13

related terms are more fully described below.

Coping responses. Coping is here used as a
superordinate heading that refers to the cognitive
processes involved in appraisal. Coping responses refer
to I'constantly changing cognitive and behavioral efforts
to manage specific external and/or internal demands that
are apprasied as taxing or exceeding the resources of
the person“ (Lazarus & Launier, 1984, p.141). Coping
processes are purposeful, require effort, and result in
adaptation, the result of efforts to maintain integrity
by establishing a balance between environmental demands
and the power to deal with these demands (Sutterly &
Donnelly, 1982).

Moos and Billings (1982) and Moos & Tsu (1977) have
been instrumental in conceptualizing and measuring
coping resources and processes. Coping responses can be
classified into three broad domains: a) appraisal-
focused coping, b) problem-focused coping, and c)
emotion-focused coping.

Cognitive appraisal refers to how environmental
events are perceived by the individual. It is the
mental process of placing any event in one of a series
of evaluative categories related either to its
significance for well-being or to the person's available
coping resources and options (Lazarus & Launier, 1978;
Wrubel, Benner, & Lazarus, 1981). It is the central

factor in the selection and utilization of coping

14

responses (Moos & Billings, 1982).

Problem-focused coping refers to attempts to modify
or eliminate the source of stress, deal with the
consequences of the problem, and/or try to change the
self. Examples include seeking information or advice,
taking problem solving actions, and developing
alternative strategies to create new sources of
satisfaction.

Emotion-focused coping refers to attempts to manage
the emotions aroused by the stressor and achieve
equilibrium. Examples include using avoidance,
strategies that direct efforts to control the emotion,
resigned acceptance, and emotional discharge (Moos &
Billings, 1982; Moos & Tsu, 1977).

Adaptstigns Adaptation refers to the
psychological, physiological, and social results of
coping responses for the individual and can be positive
or negative (Lazarus & Folkman, 1984). Integrity is
maintained by establishing a balance between
environmental demands and the individual's appraisal of
his/her resources. White (1976) refers to “strategies
of adaptation;' living systems strive for adaptational
compromise that preserves and permits them to grow or to
increase in both size and autonomoy.

There is increasing evidence that coping responses
are related to adaptational outcomes and more

specifically how successful people are in dealing with

15

physical health or illness (Lazarus & Folkman, 1984;
Levine, 1983). That stress, emotion, and coping are
causal factors in illness is a widely supported premise
(e.g., Jemmott & Locke, 1984). The use of strategies
such as logical analysis, cognitive redefinition,
information seeking, reliance on self, and problem
solving are positively related to indexes of adaptation
(Baan, 1977; Vaillant, 1977). These coping responses
moderate the relationship between stressful events and
indexes of negative mood and physical symptoms (Billings
8 Moos, 1981).

There is a need to further explore relationships
between children's surgical coping responses and
postsurgical psychological adaptation. Such an
understanding may further the search for predictable
relationships between the two and foster the development
of more effective interventions prior to the onset of

the stressor.

Definitionofmms

Stlgfifi: Psychological stress is a particular
relationship between the person and the environment that
is appraised by the person as taxing or exceeding his or
her resources and endangering his or her well-being.

: Constantly changing cognitive and
behavioral efforts to magage specific external and/or
internal demands that are appraised as taxing or
exceeding the resources of the person.

Adaptatign: The psychological results of coping
responses, achieved by establishing a balance between
environmental demands and the individual's appraisal of
his or her resources.

16

- gaping: An evaluative process
that determines why and to what extent a transaction
between the person and the environment is stressful.

* Caping: Attempts to manage or alter
the problem with the environment causing distress.

- Cgping: Attempts to regulate the
emotional responses to the problem causing distress.

W

Eight main hypotheses will be investigated using an
interactional model of stress. These hypotheses are
stated generally in this section and in research form in
Chapter III. The hypotheses to be investigated are:

1) Children who score higher on measures of surgical
coping will exhibit better post- and long-term
surgical adaptation than those who score lower.

2) The number of coping responses used by children will
significantly differ preceeding surgery versus
following surgery.

3) Children with higher intellectual functioning will
show better post- and long-term surgical adaptation
than children with lower intellectual functioning.

4) Children with better premorbid adjustment will show
better post- and long-term surgical adaptation than
children with less positive premorbid adjustment.

5) Different age children will show different post- and
long-term surgical adaptation.

6) Girls will show better post- and long-term surgical
adaptation than will boys.

7) Children with longer periods of hospitalization will
exhibit less successful post and long-term surgical
adaptation than will children with shorter periods
of hospitalization.

8) Children with numerous prior hospital admissions
will exhibit less successful post- and long-term
surgical adaptation than will children with fewer
prior hospital admissions.

CHAPTER II

REVIEW OF THE LITERATURE

The purpose of this literature review is to present
research relevant to children's responses to
hospitalization and surgery as conceptualized from a
stress and coping model. The three broad areas covered
are: a) stress and children, b) hospitalization and
surgery as specific stressors in childhood, and c) the
structure of coping responses. Both a general summary
of stress research and conclusions drawn from the

pediatric research reviewed are provided.

l

StressandChildrsn

Children normatively encounter stressful
experiences and display adjustment difficulties in the
course of growing up. In a developmental context,
childhood consists of a long series of challenges to
cope with reality demands if one is to be happy and
successful (Chandler, 1982). Children's reactions to
stressors are very much linked to changes in their
cognitive functioning. It is necessary to view
childhood stress from a developmental context, for “the
consequences of an event are dependent upon the

structural readiness of the organism" (Kagan, 1983,

17

18

p.192).

In addition to normative stressors, children
encounter psychological emergencies of childhood
(Kliman, 1968), including family crises such as birth,
death, illness, and hospitalization (Arnstein, 1960).
The severity of behavioral disturbances depends on age,
psychological resources, and familial and social support
(Chandler, 1982).

One prominent line of research has looked at life
events as stressors in child and adulthood. Life events
are a potential source of stress to which all children
are exposed. Dohrenwend and Dohrenwend (1980) describe
three characteristics of stressful life events: change
in life patterns or activities of the individual,
undesirability, and upsettingness. Life stress in
adults has been found to relate to a wide range of
variables suggestive of adult physical health and
adjustment problems (Johnson, 1982).

The Schedule of Recent Experiences (SRE), developed
by Holmes and Rahe (1967) has been employed in much of
the adult life stress research. It assesses cumulative
change and allows respondents to indicate events
experienced during a designated period and provides a
method of weighting the impact of these events on the
individual.

The most well—known and widely used life stress

measure for younger age groups is the Life Events

19

Record, developed by Coddington (1972). It is similar
to the SRE, as it consists of a listing of various
events that were judged to be frequently experienced by
children and adolescents. Serious illness requiring
hospitalization of a child was ranked sixth for
preschool age groups and eighth for elementary school
age groups out of a possible 36 life stressors
(Coddington, 1972).

Rania (1979) and Wilcox (1979) have supported the
links between the number and recency of stressful life
events and psychological distress in both adults and
children. However, there are several limitations
associated with life change unit scales germane to this
review. One, these scales yield only an overall index
of life stress and do not provide for separate scores
reflective of positive and negative life change. There
continues to be a controversy whether positive and
negative life changes affect children in similar ways
(Mueller, Edwards, & Yarvis, 1977; Zeiss, 1980) For
example, is a promotion from third grade stressful in
the same manner as an undersired event, such as failing
third grade? It is the undersirable quality of life
events that is most important in understanding their
stressfullness (Johnson, 1982).

Two, the individual's cognitive appraisal of the
event determines the events impact on the person

(Goldstein, 1973; Sarason & Sarason, 1981). “The

20

assessment of life stress using simple life events
scales alone is destined to be replaced by
multifactorial models encompasing individual differences
and situational contexts as well' (Perkins, 1982,
p.327). Future research needs to focus on determining
the nature of those individual differences that mediate
the impact of stressors using an interactional framework
(Johnson, 1982).

Factors that can contribute to a stressful life
experience for children are both internal and external
to the child. Internal factors include congenital
organicity, personality functioning, and perceptions of
the child that are mistaken, unhelpful, and/or self-
defeating (Chandler, 1982; Humphrey 8 Humphrey, 1981;
McNamee, 1982). It is the failure or perceived failure
of the environment to meet the needs of the child that
often is an internal source of stress. For example,
distortions in parent-child relationships are frequent
sources of stress for children (Chandler, 1982). Self-
concerns of children also can be stress inducing,
including those associated with meeting personal goals,
changing values, experiencing success, and concern about
personal competence and ability (Humphrey & Humphrey,
1981).

External factors that contribute to stress are
normal life events and psychological emergencies which

all children experience to some degree. The child

21

vulnerable to stressful events lacks inner resources or
social support and shows extreme reactions (Chandler,
1982). It is both the nature of the problem, e.g.,
environmental, medical, and psychological factors, and
its severity that produces stress in children (Chandler,
1982).

Children's response to stress also can be viewed as
dependent upon both internal and external factors. Much
research has examined the impact of personality
dimensions in children and their response to stress.

For example, Chandler (Chandler, 1982; Chandler &
Lundahl, 1983) has developed a circumplex model of
personality in an attempt to explain children's response
to stress. An activity level dimension (active versus
passive) and an introversion-extroversion dimension
result in four patterns in response to stress, including
dependent, impulsive, passive-aggressive, and repressed
responses.

There is a large and growing body of literature
that examines the role of social supports as external
factors that affect children's response to stress.

There is general agreement that the presence and use of
a wide variety of social resources facilitates
children's adjustment to stressful life events (e.g.,
Elder, 1979; Garmezy, 1983; Rania, 1979; Lefcourt,
Martin, & Salch, 1984; Milgram, 1982; Rutter, 1979;

Wruber, Benner, 8 Lazarus, 1978). In reality, both

22

internal and external factors most likely interact.
Neither knowledge of personality factors or social
supports alone adequately predicts how an individual
child will react to a stressful event (Johnson, 1982;
Rutter, 1983).

The sources and effects of stress on children are
multi-factored and must be viewed within a developmental
framework. Life events research, although providing
much data to support the conclusion that stress does
affect children, is limited, for moderator variables are
not adequately accounted for and hence predictions are
difficult to make. It is increasingly clear that
cognitive coping strategies mediate the impact of a
stressful event and affect adaptational outcomes. The
next section specifically reviews hospitalization and
surgery as specific stressors in childhood.

Hospitalizatignandflxsmas
StressorsinChildhood

Hospitalization and surgery are specific and
dramatic stressors in childhood and adolescence
(Lambert, 1984; Vernon, Foley, Sipowicz, & Schulman,
1965; Vernon, Schulman, & Foley, 1966). Many children
manifest signs of psychological distress before, during,
and/or after hospitalization (Wright, Schaefer, &
Solomons, 1979). Noted behavioral disurbances include
regressive behaviors such as increased dependency, loss

of toilet training, excessive fears, sleep and eating

23

disturbances, perceptual-motor lags, learning
difficulties, school discipline problems, depression,
conversion and dissociative reactions, aggression toward
authority figures, separation anxiety, fears of going to
bed, and tics and mannerisms (Melamed, Robbins, &
Groves, 1982; Prugh & Eckhardt, 1980; Vernon et al.,
1965; 1966; Wright et al., 1979). Furthermore,
operations have been singled out by the majority of
investigators as leading to psychological upset
(Lambert, 1984; Skipper & Leonard, 1968).

Rutter (1983) concluded that the limited number of
longitudinal studies performed supported the result that
many preschool childen exhibited emotional disturbance
at the time of hospital admission and that such
disturbance persisted for some months after the child
returned home. Although there is a wide range of
reported disturbances, researchers report that about 10%
to 35% of the problems precipitated by the hospital
experience lead to serious long-term disturbances
(Melamed el al., 1982). A hospital is stressful for
reasons intrinsic to hospital care and medical
procedures, apart from other factors (Rutter, 1983).

Burstein and Meichenbaum (1979) examined the
relationship involving children's level of anxiety and
defensiveness throughout their hospitalization and
surgery. They found that hospitalization for minor

surgery was highly stressful for children, evidenced by

24

high anxiety levels both prior to and after the surgery.

Sturmer and Rothbaum (1980) examined the effects of
venipuncture on emotional indicators in children's human
figure drawnings. Male and female children, patients in
a private general hospital, were studied. Outcome
measures included Koppitz's Human Figure Drawing. The
children were assigned to four experimental groups:
preparation for venipuncture, no preparation for
venipuncture, venipuncture, and no venipuncture.

Results indicated that emotional indicants were induced
by stress associated with venipuncture and increases in
emotional indicants were mediated by the psychological
meaning of the stressful event. Children who were
prepared for the venipuncture did not show an increase
in the number of emotional indicants, implying that both
the effect of the current stress and the child's
understanding of the stress must be assessed.

On the other hand, Davenport and Werry (1970)
examined the effect of general anesthesia,
hospitalization and surgery upon the behvior of 145
children, ages 1-15 years, compared with same-aged
controls. No overall differences between treatment and
control groups regarding behavioral adjustment were
found. However, the hospital stays were limited to
three days or less. In addition, a strictly linear
model of causality was used.

Kashani, Venzke, and Millar (1981) found higher

25

rates of depression in children admitted to the hospital
for orthopedic procedures, primarily surgery. One
hundred children between the ages of 7 and 12, admitted
to a surgical hospital, were interviewed pre and
postsurgery. Their medical charts were also reviewed.
Depression was diagnosed in 23 children using DSM III
diagnostic criteria.

There has recently been increased research
demonstrating that psychological factors influence the
course of illness and bodily response to stress.

Melamed et al., (1982) in a review of the literature,
concluded that psychological factors have been shown to
influence recovery from pediatric surgery.

Psychological factors such as patients' expectations and
anxiety about recovery, trait anxiety, coping style, and
health locus of control are seen to influence
postoperative indexes (Burstein & Meichenbaum, 1979:
Cohen & Lazarus, 1973; Ray & Fitzgibbon, 1981:
Spielberger, Auerbach, Wadsworth, Dunn, & Taulbee,
1973).

There are numerous reasons why hospitalization and
surgery are stressful for children. One major stress
associated with hospitalization is fear related to
separation from parents (Lambert, 1984: Melamed et al.,
1982: Prugh & Eckhardt, 1980: Ray & Fitzgibbon, 1981:
Vernon et al., 1965, 1966: Willis, Elliot, 5 Jay, 1982:
Wolff, 1973; Wright, Schaefer, & Solomons, 1979). Also

26

significant are the distress of unfamiliar surroundings
(Melamed et al., 1982: Wright et al., 1979), anxiety
about painful or unanticipated medical procedures
(Melamed et al., 1982: Wright et al., 1979),
restrictions on physical activity or immobilization
(Willis et al., 1982; Wright et al., 1979), forced
dependency, and loss of control, autonomy, and
competence (Lambert, 1984: Melamed et al., 1982: Vernon
et al., 1965: Wright et al., 1979). Furthermore,
specific aspects of surgical procedures have been cited
as variables, including preoperative medication,
transport to the operating room, and anesthesia
induction (Lambert, 1984). Hospitalization as a
stressor is unique, as it pairs several sources of
stress simultaneously, e.g., separation with illness,
anxiety without outlet, and suddeness (Cook, 1967: Moos
& Tsu, 1977).

Unfamiliarity as a source of stress receives
considerable support from investigations of
psychological preparation (Vernon et al., 1965). It is
generally believed that preparing the child for surgery
and hospitalization decreases the incidence of
psychological distress in the posthospital period,
although notable exceptions are present (e.g., Bronheim,
1982; Sturmer & Rothbaum, 1980).

Melamed et a1. (1982) reviewed studies concerning

preparation of the child and parents for procedures

27

involved in hospitalization. Although the research
reviewed had many methodological and theoretical
shortcomings, appropriate psychological treatments
proved effective for preparing children for
hospitalization and medical procedures. Such treatments
included traditional puppet therapy, behavioral
programs, modeling procedures, systematic
desensitization, and exposure therapy. In addition,
studies focusing on contextual variables such as parent
involvement, nursing involvement, and home preparation
were reviewed, demonstrating the relative efficacies of
various preparation procedures. Many of the stresses
associated with hospitalization were reduced when
preparation reduced the anxiety associated with
unfamiliarity.

Separation is an important source of stress and has
a real effect which is distinguishable from the effects
of illness. The disturbing effects of short separation
are most evident during hospitalization, but also
persist for several weeks following hospitalization.
Long term traumatic sequelae are much less frequent
(Cook 1967; Rutter, 1983: Wolff, 1973; Wright et al.,
1979).

Parent-child contacts during hospitalization are
helpful in reducing the level of stress experienced by
both parents and child (Peterson, Mori, 8 Carter, 1985).

For example, Prugh and Eckhardt (1980) and Prugh and

28

Jordon (1975) demonstrated that children who were not
separated from their parents during hospitalization
,showed less emotional upset through use of liberal
visiting and parental participation in the care of the
hospitalized child. Although separation is most
critical for the child 6 months to 4 years of age
(Rutter, 1983), separation is also a critical factor
associated with stress for children through adolescence
(Maccoby, 1983). Greater attention needs to be given to
age factors, discussed below, and hospitalization as a
stressful event.

Age factors appear to be significantly related to
the stress of hospitalization. Vernon et al. (1966)
evaluated changes in 387 children's behavior following
hospitalization. A 28 item questionnaire was filled out
by parents a week after discharge. Age was
significantly related to one or more types of behavioral
responses. The age period of greatest risk with respect
to hospital admission is about 6 months to 4 years.
Children below the age of 6 or 7 months have not yet
developed selective attachments, while children above
the age of 4 years are less vulnerable because they have
cognitive skills necessary to c0pe with the separation
and medical procedures involved in hospital admission
(Rutter, 1983).

Lambert (1984), in a review of the literature,

found that developmental factors affect the school-age

29

child's reactions to hospitalization and surgery,
including cognitive ability, view of illness, separation
from a peer group, and the child's need to maintain
control and strive toward independence. Curry and Russ
(1985), in a study of children's coping responses to
stressful dental procedures, found that as children
mature they utilize greater number and variety of
cognitive responses to cope.

Hyson (1983) specifically analyzed the
developmental differences in emotional responses and
coping behaviors of children during a visit to the
doctor. Forty-eight children, eight girls and eight
boys in each of three age groups, 6 to 12 months, 18 to
36 months, and 42 to 60 months, were observed during a
well-child checkup using a behavioral coding system.
Results indicated that the pattern of coping depended on
age. Hyson concluded that as children develop, coping
behavior becomes increasingly realistic, anticipatory,
and goal directed. Memory development was important in
developing responses to potentially stressful events.

However, some studies show that age per se does not
constitute a significant explanation for age-related
differences (Burnstein & Meichenbaum, 1979; Goggin,
Lansky, & Hassanein, 1976; Zeltzer, Ellenberg, & Rigler,
1980). No associations between the age of the child and
outcome variables were found.

It is thus unlikely that there is any linear

30

increase or decrease with age in vulnerability to stress
(Maccoby, 1983), although a curvilinear relationship may
exist (Vernon et al., 1966). Children evidence age
progressive growth of self-appraisal and other cognitive
strategies. School aged children begin to develop
skills at monitoring their own thought processes and
performances. In addition, there is increasing
avoidance of premature closure (Maccoby, 1983). The
increasing use of metacognitive processes and problem-
solving skills (Maccoby, 1983: Shure, 1981) in children
fosters increasingly enduring rather than temporary
problem solutions. Yet, metacognitive processes might
also foster greater anxieties in children about events
which they can now forsee but feel unable to protect
themselves against (Maccoby, 1983). The issue of age,
as related to the stress of hospitalization, is an area
not yet fully addressed in the pediatric literature.
Conclusion

In conclusion, hospitalization and surgery are very
stressful experiences for children. Many behavioral
disturbances, both short and long-term, are noted in the
literature. There are numerous reasons why
hospitalization and surgery are stressful for children,
including fears related to separation, unfamiliarity,
and pain. The child's age, gender, and length of
hospitalization are seen to affect recovery from

surgery. In addition, there is research demonstrating

31

that psychological factors affect children's recovery
from surgery such that preparation for surgery and
medical procedures has demonstrable results. Data
derived from studying how children cope with
hospitalization and surgery may provide information that
is relevant to many other situations in which children

must cope with life stress.

TheStructureofCQQingW

The following major section reviews studies that
investigated the structure of coping responses,
emphasizing cognitive processes. Included are two
specific sections: a) common coping responses, and b)
the relationships between coping responses and
adaptational outcomes.

WWW

There are a number of recently completed
descriptive studies (Ilfeld, 1980; Pearlin & Schooler,
1978; Taylor, 1983) that lay a foundation for research
on cognitive processes as mediators of stress in
children, as they describe three common coping responses
and strategies people use in stressful situations. One,
action strategies are responses that change the
situation and help people gain a sense of mastery.
Acquiring information is a common behavioral effort at
gaining a sense of mastery. Two, some responses control
the meaning of an experience after it occurs, e.g.,

“count your blessings“ and “we're all in the same boat."

32

Such responses are analogous to rationalization and/or
avoidance. Three, other responses control stress after
it emerges and help people maintain their self-esteem.
“Time solves all,“ “it was meant to be,“ “everything
works out for the best,“ and downward comparisons, in
which the self is compared to those less fortunate, help
with self-protection against threat.

Various coping strategies used by school-age
children have been described. Tesler and Savedra (1981)
observed 33 children, ages 6-12 years, at specific
stress points during hospitalization. The following
coping strategies were identified: inactive, precoping
or orienting, and active coping, which included attempts
to control, cooperation, and resistance. Orienting,
seeking support from others, expression of feelings, and
intellectualization have also been forwarded as coping
techniques children undergoing hospitalization and
surgery use (Knight, Atkins, Eagle, Evans, Finkelstein,
Fukushima, Ratz, & Weiner, 1979; Youssef, 1981).

Curry and Russ (1985) identified adaptive coping
strategies employed by children undergoing stressful
dental procedures. Eighteen children, 8 through 10
years of age, were observed during dental treatment and
interviewed thereafter. Nine functional classifications
of coping were derived: Information-Seeking: Support-
Seeking: Direct Efforts to Maintain Control: Reality-

Oriented Working Through: Positive Cognitive

33

Restructuring: Defensive Reappraisal; Emotion-Regulating
Coping Cognitions; Behavior-Regulating Coping
Cognitions: and Diversionary Thinking. Two coping
measures were then developed, based on the above
classificatins, using behavioral observations during
dental treatment and an interview immediately following
treatment. Thirty children, ages 8 through 10,
participated in this second phase. Results indicated
that children used a variety of coping responses, and
there was a relationship between age and type of coping
strategy used. Both situational and person variables
played an important role in determining coping patterns.
Limitations included a small sample size and
retrospective and self-report data from children.

Active cognitions play an essential role in the
appraisal of and subsequent coping with stressful
situations. When individuals experience stressful
situations they respond with cognitively adaptive
efforts that enable them to achieve a level of
adaptation that is equal to or exceeds a previous level
of psychological functioning (Taylor, 1983). These
cognitions help individuals form and maintain a set of
illusions by looking at the known facts in a particular
light in order to maintain the most positive picture
possible (Curry 5 Russ, 1985). Avoidance and illusion
may be cognitive processes that serve essential adaptive

functions (Alloy & Abramson, 1979: Taylor, 1983).

34

Breznitz (Turkington, 1984) maintains that a sense of
hope is essential for successful adaptation to stressful
situations. Hope always involves hard, active work and
consists of selecting the positive aspects of a
situation and developing them, as opposed to keeping out
the negatives. Active, cognitive processes in stressful
situations may lead to positive adaptational outcomes.
The coping responses described above fit into the
general categories appraisal-focused coping, problem-
focused coping, and emotion-focused coping outlined in
Chapter 1.
Adaptational Qutsomes

The efficacy of coping responses for both children
and adults depends both upon the demands of the
situation and the personality characteristics of the
person. For example, Shapiro (1973) and Kalb (1977)
studied the effects of the cognitive control of
leveling-sharpening on the response of children to
stress. Shapiro proposed that there was a
reorganization of the cognitive control of leveling-
sharpening under the stress situation of surgery that
would return to prestress levels of functioning
following the surgery. Results supported the
hypothesis. Children used cognitive strategies of
leveling during stressful situations but demonstrated an

increased ability to sharpen immediately after surgey

35

and three weeks postsurgery.

Kalb (1977) also studied the adaptive value of
cognitive shifts in leveling-sharpening of pediatric
surgery patients. Coping effectiveness was measured by
physiological distress, psychological distress, and
recovery rate. Results indicated that children
undergoing stressful situations tended to shift toward
leveling cognitive strategies. Both authors concluded
that there was a great deal of individual variation in
the cognitive control of leveling-sharpening both within
and between children.

Cohen and Lazarus (1973) studied the relationship
between coping styles and recovery from surgery.
Surgical patients, 21 through 60 years of age, both male
and female, completed interviews, dispositional
measures, and a life events inventory. Their recovery
to surgery was measured by the number of days in the
hospital, number of pain medications, number of minor
complications, and number of negative psychological
reactions. Results indicated that patients using an
avoidant coping style recovered faster from their
operations than did vigilant patients on two of the four
recovery measures. They concluded that knowledge of
threatening aspects of surgery, if uninterrupted by
denial, could result in a more complicated postoperative
recovery.

The most adaptive response to stress may be a task

36

orientation that directs the individual's attention to
the task at hand rather than emotional reactions '
(Sarason & Sarason, 1981). Vaillant (1977) presented
evidence suggesting that pervasive personal
preoccupations are maladaptive in various areas and that
successful adaptation is associated with a task
orientation and suppression of other cognitions. A
growing set of studies suggest that passive acceptance,
helplessness, and depression result in higher mortality
rates, as opposed to anger, complaining, or fighting to
control one's circumstances (Lazarus & Folkman, 1984).

Ray and Fitzgibbon (1981) found that high levels of
cognitive arousal, rather than high levels of emotional
arousal were related to successful postsurgical
adaptation. Cholecystectomy patients were given
measures of psychological adjustment and physical
recovery indices over repeated measures. Patients with
high cognitive arousal scores reported less pain at the
postoperative interview, received fewer medications for
pain and sleeplessness, and were most quickly
discharged.

There is also support for the hypothesis that a
varied repetoire of coping responses is more effective
than a more limited one. Pearlin and Schooler (1978)
found that a variety of coping responses were more
effective in ameliorating the effects of stress than any

single response. Effective coping depended not only on

37

what subjects did, but also on how much they did. Curry
and Russ (1985) found that the greater the stressful
demands, the more cognitive coping responses were
elicited in children. Rutter (1983) states that
successful coping depends on flexibility, adaptability,
and an adequate range of strategies and tactics in
children undergoing hospitalization. Lazarus and
Folkman (1984) suggest that there is a curvilinear
relationship between the range of coping strategies used
and adaptational outcome and that further serious
investigation is warranted.

Simultaneous consideration of both extrinsic and
intrinsic factors is essential in order to adequately
investigate the relationships between surgical coping
responses and postsurgical adaptation. According to an
interactional stress model, variables external to the
person and internal characteristics interact in an
ongoing fashion. There is much research to support the
interactive effects of various types of individual
differences and particular environmental situations in
affecting adaptation to stress (e.g., Cohen & Larzarus,
1973: Fluger, 1981: Seal, 1973; Shapiro, 1973).

' Extrinsig fastgrs. Stress accumulation is an
important extrinsic factor that affects adaptation. The
simple accumulation of stressful events determines, in
part, the extent of stress and subsequent psychological

adjustment. For example, Bellotti (1983) investigated

38

the effects of stress accumulation on the psychological
adjustment of 405 adolescents ages 12 through 15 years.
Coddington's Life Events Scale for Adolescents was used.
The data supported the conclusion that the number of
stressful events experienced by the individual was
related to psychological adjustment. Adolescents who
experienced a greater number of stressful life events
had significantly lower levels of psychological
adjustment, as measured by a personality test. In
addition, there were significantly higher levels of
psychological adjustment for adolescents whose stress
events occured in the more distant past. There appeared
to be a time factor involved in stress accumulation and
psychological adjustment.

The length of the child's hospitalization has been
addressed in the majority of studies reviewed. For
example, Vernon et al. (1966) found that children
hospitalized for longer periods of time demonstrated
poorer adaptation than children hospitalized for shorter
periods. However, only one study focused specifically
on long term hospitalization (Rie, Broverman, Grossman,
& Olga, 1968). Although it is implied that there is a
relationship between length of hospitalization and
severity of the child's reaction, it has not yet been
adequately addressed empirically.

There is also continued debate whether previous

hospitalization positively or negatively affects the

39

degree of emotional upset during or following subsequent
hospitalizations (Lambert, 1984). Rutter (1983),
commenting on his own epidemiological studies, found
that the effect of repeated hospital admissions in
provoking emotional disturbance was significant and
concluded that there was a potentiating intearactive
effect of a combination of chronic stressors.

Intrinsis fsstgrs. In addition to extrinsic
factors, instrinsic variables affect cognitive appraisal
and hence coping responses. Relevant variables reviewed
are: a) age, b) gender, and c) personality and
intellectual functioning, including mastery, competency,
and problem-solving skills.

The effects of age have already been discussed with
respect to the effects of hospitalization. Age factors
were seen as significantly although not unequivocally
related to the stress of hospitalization. Children
between 6 months and 4 years appeared to be particularly
vulnerable to distress during hospitalization; younger
infants and older children appeared less vulnerable
(Rutter, 1983: Vernon et al., 1965). The growth of
cognitive strategies such as self-appraisal, problem-
solving skills, and avoidance of premature closure
(Maccoby, 1983) are developmentally related and affect
the impact of stress on children. As children mature,
they utilize a greater number and variety of cognitive

responses to cape (Curry & Russ, 1985).

40

There appears to be gender differences in response
to most kinds of stress events, as boys are more
vulnerable (Rutter, 1983). Rutter also notes a tendency
for males to show more adverse effects with respect to
the effects of hospital admission, although the results
are not as dramatic as in other stress events such as
the birth of a sibling, divorce, day care, and parental
discord.

Lambert (1984) reviewed studies that investigated
whether gender affects children's responses
hospitalization and surgery. Results suggested that
boys used physical aggression and controlling behaviors
and girls used verbal aggression and precoping or
orienting behaviors.

Many reasons have been forwarded for gender
differences in children's reactions to stress events,
e.g., parents are less supportive of boys or respond
negatively to their distress reactions, there are
tempermental differences associated with sex, the
salience of stress events is greater for boys, and there
may be biologically determined increased male
vulnerability to stress (Rutter, 1983).

Researchers using case studies have suggested that
children with preexisting psychological problems will
experience more severe reactions to hospitalization and
surgery (Barnes, Kenny, Call, & Reinhart, 1972).

However, there is no research in which the reactions of

41

children with and without preexisting psychological
problems are compared, with respect to adaptational
outcomes (Lambert, 1984).

Rutter (1983) and Lambert (1984) raise the
possibility that intellectual functioning is important
with respect to children's responses to hospitalization
and surgery. There is a consistent tendency for
children of above average intelligence to have lower
rates of psychiatric disorder in general. More
specifically, there is evidence that good scholastic
achievement helps protect against chronic psychosocial
adversity.

Mastery, competence, and problem-solving skills in
children are important coping resources and may affect
adaptation. Competence is defined as a “set of
hierarchical attributes including a sense of self-
efficacy, degree of optimistic trust in interpersonal
relationships and the ability to cope actively with
life's events“ (Otero, 1983). The area of social
competence has received a good deal of research
attention. Social competence refers to the effective
participation of the person in the activities of his or
her society (Wrubel, Benner, & Lazarus, 1981). The
competent individual actively defines what he or she
wants in a social situation, and furthermore, possesses
the skills to actualize the individually defined goals

in the context of specific social situations (Wrubel,

42

Benner, & Lazarus, 1981).

Masten (1983) studied the relationships of humor,
divergent thinking, intelligence and competence in
normal urban children with varying levels of life
stress. It was hypothesized that creative thinking was
associated with resistance to stress. Ninety three
children, grades 5-8, were assessed for humor, divergent
thinking, social competence, intelligence, and stress.
Results indicated that the advantages of divergent
thinking ability depended on the intelligence level of
the child.

Pellegrini (1980) investigated the social-cognitive
qualities of stress resistant children. Competence was
defined from a multi-dimensional perspective, including
social, behavioral, and academic competence. Subjects
included a community cohort of families with children in
grades 3-6. Stress was measured through a parental
response to a checklist of life events of children and
families. Children were assessed with regard to two
aspects of social cognitive functioning: interpersonal
awareness and social problem-solving abilities.
Intellectual functioning was also assessed with
individually administered intelligence tests. Results
indicated that social-cognitive ability was related to
competence in children.

Otero (1983) investigated the handling of stressful

psychosocial life events as a function of a heirarchical

43

configural pattern of competence. It was hypothesized
that a higher level of competent behavior enabled
individuals to deal more effectively with stressful life
events. Results indicated that competent subjects were
less involved with past stressful events. Less
competent subjects evidenced an increase of and focusing
on negative feelings, increased cognitive activity with
past events, and increased worry.

Shure (1983) has investigated how children think
through and solve typical everyday problems that come up
and concluded that good problem-solvers are better
adjusted and more socially competent than poor ones. An
individual who plans his or her actions, can weigh the
pros and cons, suffers less frustration. “Means-ends“
thinking, i.e., a process of thought involving the
ability to plan, step-by-step, ways to reach a goal,
distinguishes normal children from those diagnostically
disturbed. Alternate solution thinking relates very
strongly to social adjustment in children (Spivack,
Platt, & Shure, 1976).

Garmezy (1976; 1983) has conducted and reviewed
much research regarding vulnerable and invulnerable
children and has identified several factors found to
relate to risk of psychopathology, including attentional
dysfunction, birth complications, communication
disorders within the family, and genetic factors which

interact with environmental conditions in the

44

development of schizophrenia. He repeatedly refers to a
triad of factors that are instrumental in protecting
children who are exposed to high levels of stress: a)

a positive personality disposition, b) a supportive
family milieu, and c) an external societal agency, such
as a school figure, that functions as a support system
for strengthening and reinforcing a child's coping

efforts (Garmezy, 1983).

SummefStrsssRessmh

Research in the area of stress and coping is
extremely broad. There is yet no agreed upon definition
of stress. Instead, many definitions are offered, some
of which are very general or even contradictory.
Researchers continue to devote great amounts of time and
energy investigating various aspects of human stress: it
is an impelling concept, for virtually all people
experience stress on a regular basis.

As a result of the broad array of issues
encompassed by the concept of stress, there is still
basic disagreement concerning the most useful research
paradigms and measurement tools. Much of the theory and
model building in the field of stress research today are
in fact attempts to delineate the breadth and depth of
the concept of stress and propose research paradigms
that will assist researchers in asking the questions

most likely to be fruitful. Initially, researchers used

45

paradigms that reflected the current practices in
personality research, i.e., they looked strictly at
personality factors in causal relationships. Today
however, due to the limited usefulness of exploring a
very complex and multifaceted concept such as stress
with a narrow research methodology, most stress
researchers are grounding investigations in
interactional models that recognize both personality and
situational factors.

In addition, the site for research most likely to
be fruitful in the areas of stress and coping has come
under question. Originally, most of the research
occured in laboratory settings, as it was very desirable
to isolate variables of interest and posit cause and
effect relationships. Today, however, many researchers
state that investigations in naturalistic settings are
necessary in order to observe and describe the many
factors operating in any given stressful interaction.
Although researchers recognize the value of naturalistic
settings, there is a dearth of research that both occurs
in a naturalistic setting and uses measures that have
demonstrable psychometric properties. Leading stress
researchers, such as Lazarus (Lazarus & Folkman, 1984),
are recommending microanalytic process-oriented
approaches to understanding and explaining coping and
adaptational outcomes.

The role of cognitions in stress and coping is the

46

subject of a great deal of research activity. Cognitive
processes mediate the impact of stressful events. It is
also suggested that cognitive processes affect
adaptational outcomes. Early researchers (e.g., Haan,
1977; Vaillant, 1977) claimed that the use of strategies
such as logical analysis, cognitive redefinition,
information seeking, reliance on self, and problem-
solving were positively related to indexes of
adaptation. There is limited research specifically
describing and measuring the link between cognitive
processes and adaptational outcomes in children
undergoing surgery.

The vast majority of stress related research has
focused on adults. However, there is increased interest
in how children cope with stress, spearheaded by
Garmezy's work (Garmezy, 1976) on “invulnerable“
children, i.e., children who experience high degrees of
stress yet evidence very satisfactory adaptational
outcomes. As a result, there are new lines of
longitudinal research investigating those children who
are at risk for but fail to exhibit psychiatric

disorders (e.g., Garmezy, 1981; Rutter, 1979).

Conclusions
The conclusions which can be tentatively drawn from
a review of the literature are as follows:
1) The effects of stress on children are well

documented and must be viewed within a developmental
context.

2)

3)

4)

a)

b)

47

There is a link between stressful life events
and the perceived ratings of well-being by
children.

Both internal and external factors determine
whether an event is stressful for a child.

Hospitalization and surgery are stressful events for
children.

a)

b)

C)

6)

Psychological factors such as trait anxiety,
expectations, and locus of control influence
children's recovery from surgery.

Separation is an important source of stress both
during and immediately following hospitalization
and is distinguishable from the affects of
illness.

Unfamiliarity as a source of stress is well
supported by the literature. The stress
ameliorating role of preparation for
hospitalization and surgery has received
considerable support.

Age factors are significantly related to the
stress of hospitalization. The relationship of
age to stress and hospitalization appears to be
curvilinear; children between the ages of 6
months to 4 years are most vulnerable.

Cognitive processes such as problem and emotion-
focused coping mediate the impact of stressful
events.

a)

b)

C)

Action strategies, controlling the meaning of a
situation, and self-enhancement are common
coping responses used by adults during stressful
times. All imply active, information processing
and have adaptational value.

It appears that the most adaptive response to
stress is a task orientation that directs the
individual's attention to the task at hand
rather than emotional reactions.

There is some support for the hypothesis that a
varied repetoire of coping responses is more
effective than a more limited one.

Both extrinsic and intrinsic factors afffect
children's adaptational outcomes to hospitalization
and surgery.

a)

b)

C)

d)

48

The efficacy of coping responses for both
children and adults depends both upon the
demands of the situation and the personality
characteristics of the person. There is much
research in general to support the interactive
effects of various types of individual
differences and particular environmental
situations in describing successful adaptation.

The simple accumulation of stressful events
partly determines the extent of stress and
subsequent psychological adjustment. Both the
length of the child's hospitalization and number
of previous admissions are believed to affect
their adaptation.

There may be gender differences in children's
adaptation to hospitalization and surgery, as
boys in general appear to be more vulnerable to
the effects of stress. Boys may use more
problem-focused coping, while girls may use more
emotion-focused coping.

Personality and intellectual functioning may be
important with respect to children's adaptation
to hospitalization and surgery. There is
growing evidence that children's sense of
mastery, competence and problem-solving skills
are positively related to their ability to
effectively cope with stressful life

events. The effect of children's previous
psychological adjustment on their adaptation to
hospitalization and surgery has not yet been
empirically investigated.

CHAPTER III

DESIGN OF THE STUDY

The purpose of this chapter is to present the plan
of operation for the study. The following sections are
included: selection and description of the sample,
measures, procedures for collecting data, design,

research hypotheses, and procedures for quantitative

data analysis.

wmmmamm

The sample for this study consisted of children
undergoing elective orthopedic surgery on an inpatient
basis. In addition, the child's parent served as the
respondent for two of the three measures. Mothers
served as respondants whenever possible in order to
standardize the assessment procedure. Subjects were
recruited from a listing of all children scheduled for
elective orthopedic surgery at a 300-bed urban
children's hospital between March and August, 1985 that
met the following criteria: a) English speaking, b) no
brain injury involvement, c) free from obvious
psychological disorders and d) minimum of two days
hospitalization.

Recruitment of subjects occured as follows. The

49

50

parent(s) of all pediatric patients consecutively
scheduled for orthopedic surgery at the hospital during
the winter, spring, and summer of 1985 who met the above
criteria following a review of their medical charts and
consultation with the Department of Orthopedic Surgery,
were mailed a packet of materials. Both private
patients of the surgeons and orthopedic clinic patients
were included. Included in the packet was a consent
form that met all guidelines for research with human
subjects and described the purpose of the proposed
study, duration of participation, and length of time
involved to fill out questionnaires (Appendix A). A
stamped envelope addressed to the researcher was
provided to allow parents to return the consent form.
The researcher followed—up with a phone call to the home
in the interim between orthopedic consultation and
hospital admission in order to fully explain the study
and subjects' participation. In some cases signed
consent forms were obtained from the parents and
patients following admission to the hospital.

To insure strict confidentiality of all subjects,
no identifying names were used on any of the research
instruments. Instead, a coding system only was used,
whereby the four research protocols could be linked
together for purposes of data analysis. The code only
appeared on the research instruments. The letter of

consent was separated from all data collection such that

51

no identification of subjects by name was possible.
Subjects were thus recruited on a “rolling“ admissions
basis.

The subject pool consisted of 27 pediatric
orthopedic surgery patients and their respective parent.
Of the 33 subjects eligible and asked to participate in
the study, 28, or 85% gave informed consent. Of the 28
subjects, 27, or 96%, completed the study.

The 27 children ranged in age from 6 to 17 years.
Their mean age was 12.6 years. The sample consisted of
18 males (66%) and 9 females (33%). Because the
hospital was located in the inner city of a large urban
center, a favorable racial mix was represented, as 21
subjects (78%) were Caucasion and 6 subjects (22%) were
Black. Complete age x sex x race information is found
in Table 3.1.

The subjects' length of hospitalization ranged from
2 days to over 10 days, with a mean length of stay of
5 days. However, over half of the subjects stayed only
2 days. Over 75% of the children had previous overnight
hospital admissions, and the mean number of previous
admissions, including this most recent admission, was
2.6. Table 3.2 presents their hospital histories in

greater detail.

52

Table 3.1
Description of Subject Sample
Age x Sex x Race

(N=27)
Age Sex Total
Male Female
White Black White Blank
8-6 to 11-5 11.1 0 0 3.7 14.8
11-6 to 14-5 18.5 14.8 14.8 0 48.1
14-6 to 17—5 11.1 3.7 11.1 0 25.9
Total 48 1 18.5 29.6 3.7 99.9
Table 3.2

Description of Subject Sample By
Hospital History

(N=27)
11.2mm of Heapitalization lin dam
Two Days 51.9%
2) Four Days 14. 8
3) Six Days 18.5
4) Eight Days 3.7

5) Ten or More Days 11.1

NumberszotalesmishtHQsitalA'
1) One Admission 25.9%

2) Two Admissions 22.2

3) Three Admissions 11.1

4) Four or More Admissions 40.7
Measures

Three measures were used in the study: a) The
Roberts Apperception Test for Children (RATC) (McArthur
& Roberts, 1982), b) The Personality Inventory for
Children (PIC) (Wirt, Lachar, Klinedinst, a Seat, 1977),
and c) The Revised Behavior Problem Checklist (RBPC)
(Quay & Peterson, 1983). The Adaptive Scales of the

RATC were used to measure surgical coping responses;

53

the Adjustment and Cognitive Triad Scales of the PIC
were used to measure personality and cognitive
functioning, respectively, of children undergoing
hospitalization and surgery; the RBPC was used to
measure post and long-term surgical adaptation of
children. Postsurgical adaptation refers to child's
behavior directly following orthopedic surgery but prior
to discharge from the hospital. Long-term surgical
adaptation refers to the child's behavior in the period
between discharge from the hospital and follow-up visit
to the orthopedic clinic, typically four weeks in
length.
Th9 Babfixlfi Apssrsestion 125; £91 Children

Batisnsls. The Adaptive Scales of the Roberts
Apperception Test for Children (RATC) was used to
measure surgical coping responses of children
hospitalized for orthopedic surgery. The test requires
children to verbalize responses to situations and
problems of an interpersonal nature and assesses their
adaptive capacity to cope with stressful or potentially
stressful situations. Children will project their
characteristic thoughts, concerns, conflicts, and coping
styles into the stories they create. There is a good
deal of support for the use of story telling techniques
in the assessment of coping responses to stress (Moos,

1974).
Esngral Dssgriptign. The Roberts Apperception Test

S4

for Children (RATC) (McArthur & Roberts, 1982) is a
picture thematic apperception technique designed to
assess children's perceptions of common interpersonal
situations. It consists of a standard set of 16
stimulus cards which depict common situations,
conflicts, and stresses in children's lives. Eleven of
the cards have parallel male and female versions. I

The RATC is intended for use with children ages 6
to 15. All 16 stimulus cards are presented to the child
in their exact numerical order. The children's
responses are recorded verbatim and later scored on a
number of quantitative rating categories. Raw scores
are obtained for all rating categories and converted to
normalized T scores (x=50, SD=10) on the appropriate
Profile Form based on the child's age.

Tbs Adsptiys Ssslss. The eight adaptive scales
used in the study as measures of surgical coping are
fully described in Appendix B. They included the
following (the parentheses indicate the name of the
scale for purposes of the study):

a) Reliance on Others.

b) Support-Others.

c) Support-Child. (Self-Sufficiency)

d) Problem Identification

e) Limit Setting

f) Resolution 1. (Unrealistic Solution)

g) Resolution 2. (Constructive Solution)

h) Resolution 3. (Insightful Solution)
Standardization Of the BATS. The RATC was

standardized on a sample of 200 “well-adjusted“ school

55

children, ages 6 to 15. An equal number of children of
both sexes was represented, resulting in 20 males and 20
females in each of four age groups: 6-7, 8-9, 10-12,
and 13-15. An effort was made to select children from
lower, middle, and upper socio-economic family
backgrounds, although the sample was not formally
stratified. The standardization sample was drawn from
three school districts in California, chosen because
they provided a representative cross-section of lower,
middle, and upper socio-economic families based on
census data (McArthur & Roberts, 1982).

Rslisbility. Interrater agreement indicates that
the average agreement across all 16 profile scales was
84% to 89%. The authors suggest that the profile scales
meet the standards for interrater agreement.

Split-half reliability estimates were calculated
using the formula for nominally parallel tests of Lord
and Novick. In addition, the Spearman-Brown correction
estimate was also used. Coefficients for the 8 adaptive
scales ranged from .44 to .86 for the Lord and Novick
estimate and from .48 to .86 for the Spearman-Brown
estimate.

Validity. The validity of the RATC has been
explored by the authors (McArthur & Roberts, 1982) in
three ways: a) intercorrelations among the RATC
measures, b) investigating the thematic content elicited

by the individual stimulus cards, and c) comparing the

56

responses of clinic-referred and well-adjusted children
and families. In addition, there have been several
studies performed by other investigators that are
further described in Appendix B.

Intercorrelations among the profile scales were
calculated using a combined sample of 200 clinic-
referred and 200 well-adjusted children. A high degree
of interrelatedness of scales within the adaptive and
clinical subgroups and a relative independence of
certain scales was observed.

The underlying relationships amongst the profile
scales were investigated by factor analysis. Three
factors were identified: Adaptive, Clinical, and
Developmental. The authors concluded that the three
factors help confirm the validity of the RATC profile
scales for differentiating adaptive and maladptive
functioning.

McArthur and Roberts (1982) state that the
reliability and validity studies lay the foundation in
establishing the psychometric properties of the RATC.
More investigation is needed in areas such as
socioeconomic background, homogeneous diagnostic
subgroups, and cross-cultural trends in children's

responses to the stimulus cards.

The Personality Imaentery fer Children
Ratignale. The Adjustment Scale (ADJ) and the

Cognitive Triad Scales (IS, ACH, DVL) of the Personality

57

Inventory for Children (PIC) (Wirt, Lachar, Klinedinst,
& Seat, 1977) were used to measure premorbid adjustment
and cognitive functioning of children undergoing
hospitalization and surgery. The PIC provided response
set indicators, or validity scales, thus giving the
researcher an indicator of the validity of the
personality profile obtained.

Dessriptign. The PIC is an objective,
multidimensional measure of behavior, affect, ability,
and family function for children ages 3 to 16. It
consists of 280 questions answered by the child's mother
as “True“ or “False.“ Raw scores on each of the scales
are plotted on profiles modeled after the MMPI profiles,
for which 1 scores can be read. For each scale, higher
I—score elevations represent a reduced probability of
occurence among nonreferred children and the increased
probability of psychopathology or deficit. The
dimensions represented by scales selected for the PIC
profile do not reflect a specific theoretical
perspective. Factor analysis, empirical-keying, and
rational/content methodologies were applied to scale
item selection. All profile scales successfully predict
non-PIC measures of child adjustment and ability
(Lachar, Kline, & Boersma, in press).

Tbs PIC Prefile Ssales (Lachar, Kline, & Boersma,
in press). The PIC scales to be used in the proposed

research are fully described in Appendix C. They

58

included the following:
Informant Response Style:

a) Lie Scale (L).

b) Frequency Scale (F).

c) Defensiveness Scale (DEF).

General Adjustment:

d) Adjustment Scale (ADJ).
The Cognitive Triad:

e) Achievement Scale (ACH).

f) Intellectual Screening Scale (IS).

g) Development Scale (DVL).

Standsrdizatign: The PIC was normed on 2,390
children between the ages of 6 and 16 collected between
1962 and 1985. Both males and females were roughly
equally represented in all age categories. Although no
data is presented in the Manual regarding the race of
the standardization sample, the authors (Wirt et al.,
1977) studied the effects of both race and sex on PIC
scale elevations. The analyses did not result in any
significant sex main effects or sex by race interactions
for the profile scales. Only the F scale resulted in a
significant race effect.

Beiisbiiisy. The authors report three studies
examining test-retest reliability. The PIC was
completed on two separate occassions by 34 mothers of
children being evaluated at a large, urban clinic. The
interval between test administrations was randomized,
between 4 and 72 days, the average interval being 15
days. The sample consisted of 22 boys and 12 girls aged

5 to 14. The average reliability coefficient obtained

was .86.

59

A second study extended the test-retest interval to
an average of 51 days. Forty-six mothers in the Detroit
area completed PIC protocols for 25 normal boys and 21
normal girls. The average test-retest coefficient
obtained was .71.

A third study of normal children was also completed
using a wider sample. Fifty-five test-retest pairs were
obtained from parents in Indiana and Pennsylvania. The
interval was 14 days. The sample contained 34 boys and
21 girls between 5 and 11 years. The mean correlation
coefficient for the sample was .89.

Validisy. The PIC Manual (Wirt et al., 1977)
documents effective normative-criterion group separation
for scales ADJ, ACH, and IS, amongst others. These
scales demonstrated predictive ability to independent,
clinically meaningful external criteria. Factor
analysis revealed meaningful patterns of correlations
among the 33 PIC scales, and within the items of the 16
profile scales (Wirt & Lachar, 1981). PIC scales have
been found to predict meaningful external criteria for
various target groups. Additional evidence of PIC
profile scale validity was obtained in the ability of
these scales to separate homogenous groups of
behaviorally disturbed children and adolescents (Wirt &
Lachar, 1981).

There are currently 77 data-based studies

investigating the validity of the PIC scales. The

6O

majority of the studies are presented in the Manual
(Wirt et al., 1977). In addition, there are 25 reviews
of the PIC published. These studies have helped
establish the validity of the PIC for use in clinical,
research, and school settings. The reader is urged to
refer to the Manual, as it presents the numerous
validity studies as they relate to each scale. In
addition, Appendix C further describes the validity of
the PIC. It is suffice to note that the PIC is
establishing a well-respected empirical base with
demonstrable psychometric qualities and is being used

internationally.

The Bexififid Behaxier BIleem ChBQKliEL (RBPC)

Ratignals. The Revised Behavior Problem Checklist
(RBPC) (Quay and Peterson, 1983) was used to measure
post and long-term surgical adaptation. The RBPC is a
behavior rating scale and is widely used in research,
clinical, and school settings. As it samples a broad
range of behaviors exhibited by children and adolescents
and is sensitive to change in behaviors, it is an
appropriate measure of post and long-term surgical
adaptation.

General Dasgripgign. The RBPC is an individually
administered 89 item checklist focusing on the
identification of specific behavior problems occurring
in childhood and adolescence. The items are rated by an

adult familiar with the child's behavior. Each item is

61

rated on a 3-point scale ranging from “no problem“ (0)
to “severe problem“ (2).

Research involving factor analysis of the items has
yielded four broad behavior syndromes, which have been
found to effectively differentiate between children with
emotional or specific learning difficulties and “normal“
children. These behavioral dimensions make up the four
primary subscales of the RBPC and are labeled: Conduct
Disorder (CD) (22 items), Socialized Aggression (SA) (17
items), Attention Problems-Immaturity (AP) (16 items),
and Anxiety-Withdrawal (AW) (11 items). The two minor
scales are Psychotic Behavior (PB) (6 items) and Motor
Tension-Excess (ME) (5 items). The reader is referred
to Appendix D for a more complete description of the
subscales.

The RBPC requires approximately 10 minutes to
administer and can be used across a wide range of
children. It is not limited to use with a specific
population. It has been used in a large number of
studies involving unselected as well as clinical samples
and is seen to effectively differentiate between many
clinic subtypes.

Standardizatign. There were four separate clinical
samples used for the standardization sample,
representing a broad range of behaviors and an age range
from 5 to 23. The samples include 760 cases, including

private psychiatric residential, outpatient and

62

inpatient, a private school for children with learning
disabilities, and a community sponsored school for
children with developmental disabities. Males were more
highly represented than females by a margain of two-to-
one. Whites and blacks were proportionally represented.
All socio-economic groups were equally represented.

Both average and below average intelligence was
included. There is no indication of geographical
location in the Manual.

Reliability. Estimates of internal consistency for
the samples across all six subscales range from .95 (CD)
to .68 (PB). The range of alpha coefficients for each
subscale across five samples are: CD .92 - .95, SA .85
-.93, AP .87 -.94, AW .74 - .89, PB .68 - .80, and ME
.70 -.83.

Interrater reliability estimates were obtained from
a sample of 172 children with developmental
disabilities, 39 of which were girls and 133 were boys.
All SES groups were represented. Ten teachers rated the
children. The average intercorrrelations among the
raters ranged from .85 (CD) to .28 (PB).

In order to estimate test-retest reliability, 149
children in grades one through six were rated by their
teachers in October and again two months later. The
rate-rerate correlations were .63 for CD, .49 for SA,
.83 for AP, .79 for AW, .61 for PB, and .68 for ME (Quay

& Peterson, 1983).

63

Validiey. In order to establish the ability of the
RBPC to successfully discriminate between clinical and
normal children, 293 males and 273 female normal
children in grades one through six were contrasted with
three clinical samples of children. Results indicated
that for both sexes the difference between the means
were substantial and significant. Seventy-seven percent
of the clinical group were correctly classified as were
87% of the normals.

The authors (Quay & Peterson, 1983) state that the
correlations of the RBPC with a number of relevant
variables and scales have already been obtained,
supporting the construct validity of the instrument.
Studies documenting comparisons of the categories of
DSM-III to the empirically derived dimensions of the
RBPC, correlations of subscales with behavioral
observations and peer nominations, and correlations of
subscales with intelligence and academic achievement are
reported in the Manual. These studies increasingly
support the validity of the RBPC.

ProeeduresferCelleCtinsData
Data was collected from child and parent subjects
as follows. Upon admission and room assignment and
after consent, the child-subject was administered the
Roberts Apperception Test for Children (RATC) by the

researcher. The RATC was administered in a standardized

64

fashion in the period after admission but prior to
surgery. The RATC took approximately 30 minutes to
administer. The child's responses were audio recorded
and then transcribed in order to permit reliable scoring
of the protocols.

Immediately prior to or during surgery, the child's
parent (mother) completed by herself the 280-item
version of the Personality Inventory for Children (PIC).
The PIC took approximately 45 minutes to complete. Upon
completion, she placed the Answer Sheet in the envelope
provided. All envelopes were collected by the
researcher within 12 hours of completion.

Following surgery but immediately prior to
discharge, the parent-subject was given the Revised
Behavior Problem Checklist (RBPC) to complete. The
directions were modified to instruct the mother to rate
her child's behavior enly following surgery. The RBPC
took approximately 10 minutes to administer. Upon
completion, she placed the RBPC in an envelope provided.
The researcher picked up the envelope within 12 hours.

The parent-subject was mailed and asked to complete
the RBPC again one month following discharge. A thank-
you note and stamped envelope addressed to the
researcher were included. The instructions for the RBPC
were modified to instruct the mother to rate her child's
behavior enly following discharge from the hospital. In

addition, the parent completed an attached face sheet

65

requesting the following information: a) child's age,
b) child's gender, c) prior hospitalizations, and d)
length of current hospitalization. If the parent failed
to return the RBPC within a week, the researcher
telephoned the parent, and an identical packet was again
sent. Of the 27 parentsmailed copies of the RBPC for
follow-up, 22, or 81.5%, returned the completed
checklist. Figure 2 temporally depicts data collection
points and measures.

The RATC tapes were transcribed for purposes of
scoring. Two experienced doctoral level candidates in
psychology, blind to the hypotheses of the study, scored
the protocols. Practice scoring RATC protocols was
provided by the researcher prior to scoring the research
protocols. Inter-rater reliability was calculated using
the following formula:

the number of scales/card in which both raters agree

the number of agreement + disagreements
Interrater reliability was calculated for each of the 16
RATC cards for three sample protocals. These
coefficients were then summed and divided by 16 to
obtain the overall reliability coefficient. An
interrater reliability coefficient of .81 was obtained
following the above procedures after two trial
calibrations. The Adjustment and Cognitive Triad Scales
of the PIC were scored by hand using templates provided

by the test publisher. The RBPC was scored by hand

66

using templates provided by the test authors.

Figure 2
Data Collection Points and Measures
Brewery -------- > Pastemerx ------- >Eellenzun
RATC-l RATC-2
PIC RBPC-1 RBPC-2
Design

The overall design of this study was descriptive,
the purpose being to explore the relationships between
coping responses and other instrinsic and extrinsic
factors and adaptational outcomes in children undergoing
orthopedic surgery. It was apparent from a review of
the literature that an interactional theoretical
framework encompassing both individual and situational
variables was necessary in order to more fully
understand the complexities inherent in the constructs
of stress, coping, and adaptation. One of the major
problems with research in the area of coping and
adaptation has been the causal and overly restricting
experimental approaches to research used in lieu of more
exploratory approaches with solid theoretical
foundations. A microanalytic process-oriented approach
to coping was necessary to more fully understand coping
processes and explain adaptational outcomes (Lazarus &
Folkman, 1984).

A correlational approach was chosen for three

reasons: a) The variables necessarily under

investigation were very complex and did not lend
themselves to the experimental method and controlled I
manipulation. b) Correlational research permitted the
simultaneous measurement of several variables and their
interrelationships within a naturalistic setting. c)
Correlational research permitted an analysis of the
degrees of relationship between variables rather than
all-or-nothing questions (Isaac & Michael, 1971).

A correlational research design in the form of a
naturalistic field investigation was used in this study
because of the flexibility involved in this approach.
Such flexibility facilitated the inclusion of a variety
of carefully selected variables and the study of a
complex area. This type of research design did not
directly address issues of causality. Rather, it was
hoped that the results from the study would provide
direction for intervention with children undergoing
potentially stressful hospital events such as orthopedic
surgery, generate further questions regarding the
affects of hospitalization and surgery on children, and
broaden the knowledge base concerned with the definition
and measurement of stress and coping in children as

applied to hospitalization and surgery.

Researehflxnetheses
This study investigated the relationships between

coping responses and adaptational outcomes of children

undergoing elective orthopedic surgery. Factors

intrinsic and extrinsic to the child were studied.

HmthesesRelatedtenpinsBesnenses
The first two hypotheses were developed to study
the relationships between coping responses and

adaptational outcomes.

Hypethesis 1: Children who obtain higher T-scores
on each of the surgical coping response scales a)
Reliance on Others, b) Support Others, c) Self-
Sufficiency, d) Problem-Identification, e) Limit
Setting, f) Unrealistic Solution, 9) Constructive
Solution, and h) Insightful Solution, as measured by the
Roberts Apperception Test for Children (RATC), will
exhibit better post and long-term surgical adaptation,
as measured by the Revised Behavior Problem Checklist
(RBPC), than will children who obtain lower T-scores.

is II: There will be significant
differences between T-scores on each of the surgical
coping response scales, as measured by the RATC,
administered preceeding surgery and following surgery.

Hymtheseshelatedtelntrinsiefitressfaeters
The second set of hypotheses were developed to
investigate how factors intrinsic to the child were

related to surgical adaptation.

EXPQ£h£§i§ 111: Children who obtain lower T-scores
on the cognitive functioning scales Intellectual
Screening (IS), Achievement (ACH), and Development
(DVL), as measured by the Personality Inventory for
Children (PIC), will exhibit better post and long-term
surgical adaptation, as measured by the RBPC, than
children who obtain higher T-scores.

Hypothesis 11: Children who obtain lower T-scores
on the premorbid adjustment scale Adjustment (ADJ), as
measured by the PIC, will exhibit better post and long-
term surgical adaptation, as measured by the RBPC, than
children who obtain higher T-scores.

Hypetnesis 2: There will be a significant
correlation between post and long-term surgical
adaptation, as measured by the RBPC, and age of the

69

child.
Hypethesis yl: Girls will exhibit better post and

long-term surgical adaptation, as measured by lower
scores on the RBPC, than will boys.

HmihesesRelatedteExtrinsieStressEaeters
The final set of hypotheses were developed to

investigate how factors extrinsic to the child were
related to surgical adaptation.

y11: Children hospitalized for fewer
days will exhibit better post and long-term surgical
adaptation, as measured by lower scores on the RBPC,
than will children hospitalized for more days.

VIII: Children with more prior hospital
admissions will exhibit poorer post and long-term
surgical adaptation, as measured by higher scores on the

RBPC, than will children with fewer prior hospital
admissions.

Analysis

Statistical procedures were used to test the eight
hypotheses. The statistics used included: the t-test
statistic, Pearson product-moment correlations, and
multiple regression analysis. The form in which the
variables were expressed and the nature of their
relationship determined which of the correlational
statistics was used (Borg & Gall, 1979). The analytic
procedures used are discussed below for each hypothesis.
Significance level was set at .05.

Prior to any statistical analysis, scattergrams and
histograms were generated for each variable. If the
histograms indicated a markedly skewed distribution or

if the scattergrams indicated a curvilinear

7O

relationship, a log transformation of the original
variable was undertaken in order to restate the
relationship in a linear form. Log data was then used
in all subsequent analysis.

A three step analytic strategy was employed to test
the hypotheses. The first level, or provisional
analysis, consisted of bivariate correlations generated
according to the specific hypotheses under
investigation. These correlations were then examined in
terms of statistical significance.

A second intermediate step involved computing a
correlational matrix of all of the variables studied.
The purpose of the correlational matrix was to examine
whether confounding existed, i.e., whether the
correlations between two variables obtained through the
provisonal analysis might be spurious because of the
effects of a third independent variable.

If in fact the independent variable was confounded
or correlated with one or more independent variables, a
multiple regression analysis was computed between the
two correlated independent variables and the dependent
variable in order to partial out the effects of the
confounding. Multiple regression is a statistical
technique through which one can analyze the relationship
between a dependent variable and a set of independent
variables. The multiple regression analysis permitted

examination of the relationship between the independent

71

and dependent variables, while holding constant the
effects of the second independent variable. This three
step strategy was undertaken in order to empirically
demonstrate whether the correlational effects obtained
were in fact valid. In order for the null hypothesis to
be rejected, significant correlations had to be obtained
at this third level of analysis.

Hypethesis 1 refers to the possible relationship
between children's coping responses and post and long-
term adaptation to orthopedic surgery. The surgical
coping variables (RATC) and the post and long-term
adaptation variables (RBPC) are expressed as T-scores,
which are continuous scores.

The Pearson product-moment correlation (r) was
used, as the variables were continuously expressed.
Correlation analysis summarizes the relationship between
two variables, i.e., the degree to which variation in
one variable is related to variation in another. It
measures the goodness of fit of a linear regression line
to the data (Nie, Hull, Jenkins, Steinbrenner, & Bent,
1975). The product-moment corrrelation is the most
stable correlation, with the smallest standard error of
the correlation techniques. One tailed t-test
statistics were then computed in order to determine
whether the correlation coefficients obtained were
statistically significant.

HXPQEhfifiifi 11 tests whether the number of

72

children's coping responses differs significantly before
orthopedic surgery as opposed to following orthopedic
surgery. Two-tailed matched-pairs or dependent t-tests
were computed between pre and postsurgery coping scores
(RATC) in order to test this hypothesis. The t-test
statistic is used to determine whether two means,
proportions or correlation coefficients, differ
significantly from one another. The hypothesis does not
predict direction, but rather tests whether there are
significant differences, either positive or negative, in
the magnitude of children's coping responses.

EXPchefiifi 111 is concerned with whether there is a
significant linear relationship between children's
cognitive functioning and their post and long-term
surgical adaptation. Both the PIC Cognitive Triad
Scales and the RBPC scales are constructed using T-
scores. Thus, both variables were expressed
continuously and the Pearson product-moment correlation
was computed in order to obtain the strength and
direction of their linear relationship.

Hypethesis l! is concerned with whether there is a
significant linear relationship between children's
premorbid adjustment and their post and long-term
surgical adaptation. Both the PIC Adjustment scale and
the RBPC scales are constructed using T-scores and are
thus continuously expressed. The Pearson product-moment

correlation was computed in order to obtain the strength

73

and direction of the relationship.

Hypethesis 1 refers to the relationship between age
and children's post and long-term surgical adaptation.
Both age and surgical adaptation are continuously
expressed. In order to measure the linear relationship
between the two variables, the Pearson product-moment
correlation was computed.

Hypethesis yl tests whether girls or boys
demonstrate better post and long-term adaptation to
orthopedic surgery. A one-tailed independent t-test was
performed between the mean scores of males and females
on the RBPC.

HXEQIhfifiifi 211 is concerned with the linear
relationship between length of hospitalization and post
and long-term adaptation to orthopedic surgery. Once
again, both variables, i.e., days and RBPC, were
continous. Thus, the Pearson product—moment correlation
was computed in order to determine the degree to which
variation in the number of days hospitalized was related
to variation in post and long-term surgical adaptation.

HXPQLhfifiifi 2111 is concerned with the relationship
between number of overnight hospital admissions and
children's short and long term adaptation to orthopedic
surgery. Both variables, i.e., number of admissions and
surgical adaptation, as measured by the RBPC, are
continuous. Thus the Pearson product-moment correlation

was computed.

74

Supplementary Descriptixe Data Analysis

Certain aspects of the present study did not lend
themselves to quantitative analysis and the rigor of
testing for statistical significance. The intensive
data collection used and the difficulties associated
with obtaining sufficiently large numbers of pediatric
patients undergoing stressful orthopedic surgeries
restricted the study to a relatively small sample. In
an attempt to capture the richness of the data obtained,
a qualitative case-study approach was used to describe
two children's coping with their operations. Additional
clinical material was obtained from these children,
including interviews, scores on test variables not
included in the hypotheses, and review of their medical

charts. These case studies are reported in Chapter IV.

Summarx

The primary purpose of the present study was to
study the relationships between children's coping
responses and adaptational outcomes to orthopedic
surgery. A descriptive research design in the form of
naturalistic field investigation was used in conjunction
with correlational analytic techniques to address the
questions posed.

A sample of 27 children undergoing orthopedic
surgery participated in the study. Mothers of the
patients completed the Personality Inventory for

Children, used to measure premorbid adjustment and

75

cognitive functioning of their children, prior to the
surgery. They also completed the Revised Behavior
Problem Checklist, used to measure surgical adaptation,
immediately before discharge and again one month later.
The children completed the Roberts Apperception Test for
Children, used to measure surgical coping responses,
less than one day prior to their operations and again
before their discharge.

Hypotheses related to both intrinsic and extrinsic
factors related to surgical adaptation were developed
and procedures to test these hyotheses were outlined.
Pearson's product-moment correlations were used to
summarize the degree to which variation in the
independent variables were related to variation in the
dependent variables. A correlation matrix was also
computed in order to more fully examine the possibility
of confounding of the independent variables. Multiple
regression analyses were then performed in order to
partial out or hold constant the effects of one
independent variable while examining the relationship
between a second independent variable and the outcome
measure.

In addition to coping responses, the relationships
between other independent variables and surgical
adaptation were examined, including age, sex, length of
hospitalization, and number of overnight hospital

admissions.

76

The procedures used for data analysis included:
one and two-tailed t-tests and correlational models.
Supplementary descriptive case analysis was also used to
aid in description of children's experiences in the
hospital. Descriptive research such as this, while not
addressing cause and effect, has heuristic value. The
results from the present study will begin to build
theory and broaden the knowledge base concerned with how
children cope with stressful events such as
hospitalization and surgery and how to help prepare high

risk children for orthopedic surgery.

CHAPTER IV
RESULTS

This chapter presents summary statistics of the
major variables and the test results of the hypotheses
under investigation. Each hypothesis is restated in
statistical form and the statistical procedures
described. The results of the analysis are then

presented.

SunnarxStatistiesefsngiealmningandAdantatien

The Roberts Apperception Test for Children (RATC)
was used to measure coping responses of children to
orthopedic surgery. The RATC was twice administered:
once 24 hours or less preceeding surgery and again
immediately preceeding discharge from the hospital. The
total scale RATC T-scores, which are composed of mean T-
scores of the eight subscales, ranged from 39 to 64 for
the first RATC administration (RATC-l) and from 39 to 63
for the second RATC administration (RATC-2). The
overall mean T-score for RATC-1 was 51.76 (SD = 7.74).
The overall mean T-score for RATC-2 was 52.43 (SD =
6.49)

The Revised Behavior Problem Checklist (RBPC) was

used to measure post- and long-term surgical adaptation.

77

78

The RBPC was twice administered: once immediately prior
to discharge from the hospital, and again one month
later. The total scale RBPC T-scores, which are
composed of mean T-scores of the six subscales, ranged
from 39 to 63 for the first RBPC administration (RBPC-1)
and from 42 to 63 for the second RBPC administration
(RBPC-2). The overall mean T-score for RBPC-1 was 52.43
(SD = 6.49). The overall mean T-score for RBPC-2 was
50.14 (SD = 7.77). Table 4.1 presents descriptive
statistics for all coping response and adaptational

outcome scales.

Snmmaufitatistieeeflntrineieandfixtrinsiefitreas
tasters

Four intrinsic factors, hypothesized to affect
adaptational outcomes to orthopedic surgery, were
investigated: cognitive functioning, premorbid
adjustment, age, and gender.

Cognitive functioning was measured by the Cognitive
Triad scales of the Personality Inventory for Children
(PIC), administered immediately prior to or during
surgery. Higher scores on the PIC indicate the
increased possibility of psychopathology or deficit.
Three scales compose the Cognitive Triad: Achievement,
Intellectual Screening, and Development. T-scores for
each subject were obtained on the three scales, added
together, and divided by three in order to obtain a

measure of cognitive functioning. Cognitive functioning

79

Table 4.1

Descriptive Statistics for Surgical Coping and
Adaptational Outcome Scales

 

Standard Standard
Scale N Mean Deviation Error

Presursieal Casing lBATC:ll

Total 25 51.76 7.74 1.55
Reliance on Others 25 56.4 12.59 2.52
Support Others 25 47.12 15.47 3.09
Self-Sufficiency 25 50.44 9.24 1.85
Limit Setting 25 59.8 14.50 2.90
Problem Ident. 25 51.08 11.47 2.29
Unrealistic Solut. 25 49.92 9.52 1.90
Constructive Solut. 25 51.44 13.66 2.73
Insightful Solut. 15 50.27 6.13 1.58
Restaursieal Canine lRATC:21
Total 21 52.43 6.50 1.42
Reliance on Others 21 53 9.46 2.06
Support Others 21 51.86 13.14 2.87
Self-Sufficiency 21 50.52 9.37 2.05
Limit Setting 21 60.10 15.70 3.42
Problem Ident. 21 51.71 10.34 2.26
Unrealistic Solut. 21 49.52 9.20 2.00
Constructive Solut. 21 52.10 10.76 2.35
Insightful Solut. 12 51.92 8.20 2.37
Restaursieal Adaptatien 18829211
Total 27 49.93 6.72 1.29
Conduct Disorder 27 46.26 7.40 1.42
Socialized Aggress. 27 48.78 7.26 1.40
Attention Problems 27 51.19 11.53 2.22
Anxiety-Withdrawal 27 50.93 11.82 2.27
Psychotic Behavior 27 49.70 6.06 1.17
Motor Excess 27 51.74 9.82 1.89
Lenszterm Surgical Adaptatien 18822221
Total 22 50.14 7.77 1.66
Conduct Disorder 22 49.60 10.42 2.22
Socialized Aggress. 22 - 48.18 6.30 1.34
Attention Problems 22 49.90 9.30 1.98
Anxiety-Withdrawal 22 49.77 9.66 2.06
Psychotic Behavior 22 51 8.71 1.86

'Motor Excess 22 52.14 10.60 2.26

80

ranged from T-scores of 43 to 78. The mean T-score was
54.80 (SD = 9.06).

Premorbid adjustment was measured by the Adjustment
scale of the PIC. T-scores ranged from 40 to 85. The
mean T-score was 54.58 (SD = 11.69).

The age of the child was documented from the
birthdate on the medical chart. Children's ages ranged
from 6 to 17 years. The mean age was 12.6 (SD 8 2.86).
There were 18 boys (67%) and 9 girls (33%) in the study.
Table 4.2 presents the descriptive statistics for the
instrinic variables.

Two extrinsic variables, hypothesized to affect
chidren's adaptation to orthopedic surgery, were
included in the study: length of hospitalization in
days, and total number of overnight hospital admissions.
This data was obtained both through a review of the
child's medical charts and questions answered by the
parent. The length of stay ranged from a minimum of two
days to over 10 days. The mean length of stay was 4.60
(SD= 2.65) The total number of hospital admissions
ranged from one to over four. The mean total number of
admissions was 2.67 (SD = 1.28). Table 4.3 presents the

descriptive statistics for the extrinsic factors.

81

Table 4.2

Descriptive Statistics for the Intrinsic Variables

Standard

Variable N Mean Deviation
Cognitive Funct. 26 54.80 9.06
Premorbid Adjust. 26 54.58 11.69
Age 27 12.56 2.86
Sex

Males 18 12.44 2.90

Females 9 12.78 3.0

Table 4.3

Descriptive Statistics for the Extrinsic Variables

 

 

Standard
Variable N Mean Deviation
Length of Hosp. 27 4.60 2.65
Total Admissions 27 2.67 1.27

Testeftheflxnetheses

firmneses Related te Seeing Beanenses
andSurgiealmantatien

Hypethesis 1: Children who obtain higher T-scores
on the surgical coping scales, as measured by the
Roberts Apperception Test for Children, will
exhibit better total post and long-term surgical
adaptation, as measured by the Revised Behavior
Problem Checklist, than will children who obtain
lower T-scores.

He: rho = 0 (Total RATC-1 and Total RBPC-l)
Hl: rho < 0 (Total RATC-l and Total RBPC-1)

The bivariate relationships between the surgical
coping scales and the surgical adaptation scales were
determined by computing Pearson product-moment

correlations. One-tail t-tests were used to determine

82

whether the correlations obtained were significant.
The correlation between Total Presurgical Coping

and Total Postsurgical Adaptation was not significant

(r = -.18, p >.05). The null hypothesis is retained.

HQ
HZ

The correlation between Total Postsurgical Coping

rho = 0 (Total RATC-2 and RBPC-l)
rho < 0 (Total RATC-2 and RBPC-1)

and Total Postsurgical Adaptation was not significant
(r = -.17, p >.05). The null hypothesis is retained.

He: rho = 0 (Total RATC-1 and RBPC-2)
El: rho < 0 (Total RATC-1 and RBPC-2)

The correlation between Total Presurgical Coping
and Long-term Surgical Adaptation was not significant
(r = .31, p >.05). The null hypothesis is retained.

He: rho = 0 (Total RATC-2 and RBPC-2)
HA: rho < 0 (Total RATC-2 and RBPC-2)

The correlation between Total Postsurgical Coping
and Total Long-term Surgical Adaptation was not
significant (r s .36, p >.05). The null hypothesis is
retained.

He: rho = 0 (Subscales RATC—l/RATC-Z and RBPC-l/

RBPC-2)
Hi: rho < 0 (Subscales RATC-l/RATC-Z and RBPC-l/
RBPC-2)

The correlations ranged from -.03 to .47 between the
Surgical Coping Subscale Scores and the Total Surgical
Adaptation scores. Three correlations were
significant: (a) Presurgical Self-Sufficiency and Long-

term Surgical Adaptation (r = .44, p (.05), (b)

Presurgical Problem Identification and Long-Term

83

Surgical Adaptation (r = .47, p (.05), and (c)
Postsurgical Self-Sufficiency and Long-Term Surgical .
Adaptation (r = .47, p (.05).

The correlations ranged from -.03 to .41 between the
Total Surgical Coping Scores and the Surgical Adaptation
Subscale Scores. Two correlations were significant:

(a) Total Presurgical Coping and Postsurgical Adaptation
Anxiety-Withdrawal (r = -.39, p (.05), and (b) Total
Postsurgical Coping and Long-Term Surgical Adaptation
Anxiety-Withdrawal (r = .41, p (.05).

Following the three-step strategy outlined in
Chapter III, a correlational matrix of all independent
and dependent variables was generated. Multiple
regression equations were computed after identifying all
possible sources of confounding in the independent
variables in order to isolate the effects of the
confounding independent variable. Multiple regression
analysis revealed two significant linear relationships,
both in the hypothesized directions: (a) Presurgical
Limit Setting and Long-term Surgical Adaptation (t -
-2.16, p (.025) and (b) Total Presurgical Coping and
Postsurgical Anxiety-Withdrawal (t = -2.01, p (.05).

Although there are two significant correlations
between subscale scores, the correlations between the
total scores are not significant, and the null
hypothesis is thus retained. The results of these

analysis are presented in Table 4.4.

84

Table 4.4

Correlation Coefficients Between the
Total Surgical Coping Scores (RATC) and the
Total Surgical Adaptation Scores (RBPC)

RBPC’l RBPC’Z

 

Correlation Coefficients Between the
Surgical Coping Subscale Scores and the
Total Surgical Adaptation Scores

RBPC-l RBPC-2
RATC-1
Reliance On Others —.16 .33
Support Others -.12 .22
Self-Sufficiency .12 .44*(a)
Limit Setting -.18 .16**
Problem Identification .14 .47*(b)
Unrealistic Solution -.32 -.12
Constructive Solution -.13 -.03
Insightful Solution -.09 .36
RATC-2
Reliance On Others -.35 -.09
Support Others -.07 .26
Self-Sufficiency .15 .47*(c)
Limit Setting -.09 ~ .25
Problem Identification .04 .29
Unrealistic Solution -.19 -.04
Constructive Solution -.04 .37
Insightful Solution -.16 .30
Correlation Coefficients Between the
Total Surgical Coping Scores and the
Surgical Adaptation Subscale Scores
RATC-1 RATC-2
RBPC-1
Conduct Disorder -.08 -.09
Socialized Aggression -.03 -.07
Attentional Problems -.18 -.12
Anxiety-Withdrawal -.39* -.34
Psychotic Behavior -.08 -.03
Motor Excess -.07 -.06
RBPC-2
Conduct Disorder .25 .34
Socialized Aggression .22 .29
Attentional Problems .32 .38
Anxiety-Withdrawal .15 .41*(d)

Psychotic Behavior .29 .23

85

Table 4.4 (cont'd.)

. Motor Excess .31 .23

(a)
(b)
(C)
(d)

(.05 bivariate correlation only.
(.025 when effects of Adjustment held constant.
>.05 when effects of Adjustment held constant.

>.05 when effects of Adjustment held constant.
>.05 when effects of Age held constant.

P
P
p >.05 when effects of Adjustment held constant.
P
P

Hypethesis ll: There will be significant
differences between T-scores on each of the

surgical coping response scales (a) Reliance on
Others, (b) Support Others, (c) Self-Sufficiency,
(d) Limit Setting, (e) Problem Identification, (f)
Unrealistic Solution, (9) Constructive Solution,
and (h) Insightful Solution, as measured by the
Roberts Apperception Test for Children administered
preceeding surgery versus following surgery.

u a 0
u # 0

HQ
Hl

Two tail t-tests for paired or dependent samples

were computed. None of the t-values were significant at

p (.05. These results appear in Table 4.5. There were

no significant differences in the number of surgical

coping responses used presurgery as opposed to

postsurgery. The null hypothesis is retained.

Hinethesesaelatedtelnstrinsieatressaaeters

Hypethesis lll: Children who obtain lower T—scores
on the cognitive functioning scales, as measured by
the Personality Inventory for Children (PIC) will
exhibit better post and long-term surgical
adaptation, as measured by the RBPC, than children
who obtain higher T-scores.

: rho = 0 (Cognitive Functioning and
Postsurgical Adaptation

: rho > 0 (Cognitive Functioning and
Postsurgical Adaptation)

rho = 0 (Cognitive Functioning and Long-term
Surgical Adaptation)

rho > 0 (Cognitive Functioning and Long-term
Surgical Adaptation)

SEES

86

Table 4.5

Paired Difference t-test Results for
Presurgical (RATC-l) and Postsurgical (RATC-2)
Coping Response Scales

 

Scale N i1 X2 t-value
Total 20 51.76 52.43 -.79 us
Reliance on Others 20 56.40 53.00 1.35 NS
Support Others 20 47.12 51.86 1.92 NS
Self-Sufficiency 20 50.44 50.52 .03 NS

Limit Setting 20 59.80 60.10 .08 NS
Problem Identification 20 51.08 51.71 .15 NS
Unrealistic Solution 20 49.92 49.52 .37 NS
Constructive Solution 20 51.44 52.10 -.37 NS
Insightful Solution 12 50.27 51.92 1.34 NS

The bivariate relationship between cognitive
functioning and surgical adaptation was determined by
the Pearson product-moment correlation. Correlations
between cognitive functioning and post and long-term
surgical adaptation were not significant (r = .06,

p >.05, and r = .21, p >0.5, respectively).

Further multiple regression analysis with cognitive

functioning did not reveal any significant correlations.

The null hypothesis is retained.

Hypethesis 111 Children who obtain lower T-scores
on the premorbid adjustment scale Adjustment, as
measured by the PIC, will exhibit better post and
long-term surgical adaptation, as measured by the
RBPC, than will children who obtain higher T-
scores.

He: rho = 0 (Premorbid Adjustment and Postsurgical
Adaptation)

Hl: rho ( 0 (Premorbid Adjustment and Postsurgical
Adaptation)

87

E

: rho = 0 (Premorbid Adjustment and Long-term
Surgical Adaptation)

H2: rho ( 0 (Premorbid Adjustment and Long-term
Surgical Adaptation)

The Pearson product-moment correlation was computed
in order to investigate Hypothesis IV. Both the
correlations between premorbid adjustment and
postsurgical adaptation (r s .39, p (.05) and long-term
surgical adaptation (r c .70, p (.0005) were
significant.

Multiple regression analysis revealed that the
relationship between premorbid adjustment and
postsurgical adaptation was confounded by the
independent variable “days hospitalized“ and was not
significant with the effect of days hospitalized held
constant (t = .99, p >.05). However, the relationship
between premorbid adjustment and long-term surgical
adaptation was significant despite partialing of all
possible confounding variables (t = 2.88, p (.005).

The null hypothesis is rejected in favor of the

alternative hypothesis H2.

Hypeenesis 1: Different age children will show
different post and long—term surgical adaptation.

He: rho = 0 (Age and Postsurgical Adaptation)

Hl: rho f 0 (Age and Postsurgical Adaptation)

He: rho = 0 (Age and Long-term Surgical
Adaptation)

H2: rho f 0 (Age and Long-term Surgical
Adaptation)

The relationship between age and surgical
adaptation was investigated using the Pearson product-

moment correlation. Provisional analysis indicated that

88

age was significantly correlated with postsurgical
adaptation (r = -.38, p (.05), but not with long-term
surgical adaptation (r = -.025, p >.05).

Further analysis using multiple regression
indicated that age was confounded with total
postsurgical coping. The standardized beta value for
age was -.35. The correlation between age and
postsurgical adaptation with postsurgical coping held
constant was not significant (t = -1.5, p >.05).
However, the correlation between age and postsurgical
adaptation with presurgical coping held constant
remained significant (t - -2.07, p (.025). Nonetheless,
the null hypothesis is retained.

Expethesis 21: Girls will show better post and
long- term surgical adaptation than will boys.

He: u a 0 (Postsurgical Adaptation)
Hl: u £ 0 (Postsurgical Adaptation)
He: u = 0 (Long-term Surgical Adaptation)
H2: u £ 0 (Long-term Surgical Adaptation)

This hypothesis was tested by t-test comparisons
of the RBPC-l and the RBPC-2 means for the male and
female groups. There were no significant differences in
postsurgical adaptation (t = -0.59, p >.05) and long-
term surgical adaptation (t = -0.443, p >.05) between
males and females. Table 4.6 describes the scores for
males and females. The null hypothesis is retained.

Table 4.7 is a summary table and presents the
bivariate correlations for Hypothesis III-VI, hypotheses

related to instrinsic stress factors.

89

Table 4.6

T-test Results for
Postsurgical Adaptation (RATC-l) and
Long-term Surgical Adaptation (RATC-2)
Mean Scores for Males (M) and Females (F)

 

 

Surgical Adaptation Mean (M) Mean (F) t-value

Postsurgical Adap. 49.67 51.38 -0.60 NS

Long-term Surgical Adap. 49.57 51.13 -0.44 NS
Table 4.7

Summary of Bivariate Correlation Coefficients for
Hypotheses Related to Intrinsic Stress Factors

 

_ Long-term
Postsurgical Surgical
Adaptation Adaptation
III Cognitive Functioning .06 .21
IV Premorbid Adjustment .39*(a) .70**
V Age -038*(b) -002

 

* p (.05
** p (.0005
(a) p >.05 when effects of Days Hospitalized held
constant.
(b) p >.05 when effects of total Presurgical Coping held
constant

amethesisaelatedteExtrinsieStressEaaters

Hypethesis yll: Children with longer periods of
hospitalization will exhibit less successful post
and long-term surgical adaptation than will
children with shorter periods of hospitalization.

: rho = 0 (days hospitalized and postsurgical
adaptation)

: rho > 0 (days hospitalized and postsurgical
adaptation)

rho = 0 (days hospitalized and long-term
surgical adaptation)

rho > 0 (days hospitalized and long-term
surgical adaptation)

EEEE

90

The correrlations between days hospitalized and
surgical adaptation were determined by computing Pearson
product-moment correlations.

The correlation between days hospitalized and
postsurgical adaptation was not significant (r = .32,

p >.05). The correlation between days hospitalized and
long-term surgical adaptation was significant (r = .41,
p (.05).

Multiple regression analysis indicated that the
variable “days hospitalized“ was confounded with the
variable “premorbid adjustment.“ The relationship
between days hospitalized and long-term surgical
adaptation was not significant with the effects of
premorbid adjustment held constant (t - .83, p >.05).

The null hypothesis is retained.

Hypethesis ylll: Children with more prior hospital
admissions will exhibit less successful post and

long-term surgical adaptation than will children
with fewer hospital admissions.

He: rho = 0 (Admissions and Postsurgical
Adaptation)

Hl: rho > 0 (Admissions and Postsurgical
Adaptation)

He: rho = 0 (Admissions and Long-term Surgical
Adaptation)

H2: rho > 0 (Admissions and Long-term Surgical
Adaptation)

The correlations between hospital admissions and
surgical adaptation were determined by computing Pearson
product-moment correlations.

The correlation between admissions and postsurgical

adaptation was not significant (r s .17, p >.05). The

91

correlation between admissions and long-term surgical
adaptation was also not significant (r = .04, p >.05).
Futher analysis using multiple regression did not reveal
any significant effects. The null hypotheses are
retained.

The results of the correlations for hypotheses

related to extrinsic stress factors are presented in

Table 4.8

Table 4.8

Bivariate Correlation Coefficients for
Hypotheses Related to Extrinsic Stress Factors

 

 

Long-term
Postsurgical Surgical
Adaptation Adaptation
VII Days Hospitalized .32 .41*(a)
VIII Hospital Admissions .17 .04

 

* p (.05
(a) p >.05 when effects of Adjustment held constant

D . l' C E J .

Two case studies are presented in an attempt to
capture the richness of the data obtained. Gary was a
nine year old male, undergoing operations on both of his
legs due to bone growth deformities, who demonstrated a
problematic surgical adaptation. Alex was a 17 year old
male with severe scoliosis who, despite a demanding
operative procedure and several postoperative
complications, exhibited satisfactory surgical

adaptation.

92

Casemfiau

Gary was a 9-8 year old white male with an
admitting diagnosis of Perkins Disease. The surgical
procedure involved orthopedic surgery on both legs in
order to correct bone growth deformities. Gary remained
in the hospital for 10 days. He had a significant
history of prior hospitalizations involving surgery.

Two weeks prior to the surgery, his mother indicated
that he was experiencing many behavioral difficulties
related to his upcoming hospitalization and surgery,
including difficulties following directions, poor
frustration tolerance, overdemanding, and defiance.
His mother was a single parent and expressed
exasperation with Gary's behaviors.

Test Results: Gary's mother completed the
Personality Inventory for Children (PIC) while Gary was
undergoing surgery. Gary's profile was valid and had
clinically significant elevations on scales indicative
of poor scholastic achievement, sadness, fearfulness,
poor self-control and defiance, and overactivity,
restlesssness, and distractability. Mothers of children
obtaining similar profiles are frequently seen as overly
permissive and have difficulties setting limits on child
demands. Gary clearly presented many behavioral
concerns prior to his hospitalization and surgery.

Sequential analysis of Gary's scores on the Roberts

Apperception Test for Children (RATC), administered

93

one day prior to his surgery, indicated significant
elevations (T > 60) on the following scales: Reliance
on Others, Self-Sufficiency, Limit Setting, Anxiety,
Depression, Rejection, and Unresolved Conflict. There
were no significantly low scores (T ( 40).

Gary's presurgical coping responses were
characterized by high rates of limit setting, self-
sufficiency, and reliance on others. Gary's high scores
on Limit Setting suggest excessive concerns about
pleasing his parents and authority figures, as others
were frequently required to correct his wrong doings,
e.g., “They did something bad and got grounded for three
days,“ and “A gang tried picking her up. Her mother and
dad said do not walk by the street again.“ His
reliance on others was extremely high, indicating Gary's
preoccupation with going to the hospital and getting
help from others. In addition, he tended to use
unrealistic solutions to problematic situations or left
problems unresolved, e.g., “They're talking to their son
about going into the hospital. They're sad. After that
they were happy,“ and “He's getting into bed and he's
nervous about tomorrow. That's all.“ Gary's high
scores on Self-Sufficiency as a coping strategy, on the
other hand, suggests that he was able to be self-reliant
and displayed much affection for others. His self-
sufficient coping responses were an important

compensatory resource to the anxiety, depression, and

94

rejection he experienced, e.g., “He's glad to be back
home from the hospital,“ and “He's got the answer done
and he was happy.“

Examination of Gary's clinical scale scores suggest
much sadness, worry, and rejection. The high rejection
score reflects Gary's concern that parental conflict,
accidents, or death might leave him feeling rejected and
abandoned. In combination with his high rejection
score, Gary's anxiety and depression suggest that his
hospital admission and surgery had an overwhelming
affect on his behavior and feelings.

The RATC was readministered 10 days following
Gary's surgery, prior to his discharge from the
hospital. Sequential analysis indicated significant
elevations on the following scales: Self-Sufficiency,
Limit Setting, Constructive Resolution, Anxiety,
Aggression, and Depression. There were no significantly
low scores.

Although several of Gary's coping strategies were
the same preceeding and following surgery, e.g., self-
sufficiency and limit setting, his reliance on others
significantly decreased. In addition, Gary verbalized
more constructive solutions to interpersonal problems,
e.g., “If anyone pushes him, walk away, don't fight. He
never fights again in school“ and “The father is trying
to think how he can get them home safe. So he figured

out to pick them up after school in the car.“ Gary also

95

expressed fewer feelings of rejection.

Examination of his clinical scale scores indicates
that Gary's level of aggression and depression were
significantly higher following surgery than preceeding
surgery. The wide scatter of Gary's scores suggests
that being in the hospital was quite demanding.
Physical restriction imposed by having full-length casts
on both legs might have increased Gary's postsurgery
levels of aggression and depression.

Gary's postsurgical adaptation, measured 10 days
following surgery, was very problematic. He exhibited
significant behavioral concerns on all subscales of the
Revised Behavior Problem Checklist (T > 73).
Particularly noteworthy were his scores on the
Attentional Problems and Anxiety/Withdrawal scales
(greater than two standard deviations above the mean).

Gary's long-term surgical adaptation, measured one
month following discharge, continued to be problematic.
There was an increase in aggressive behaviors, although
he did demonstrate a decrease in anxious, fearful and
depressed behaviors.

Cenclusien: Gary's case illustrates two important
points relative to this study. One, his level of
premorbid adjustment was predictive of his surgical
adaptation, both 10 days after surgery and 30 days
following discharge. Problematic behaviors, both

internalizing and externalizing, exhibited prior to

96

hospitalization, placed Gary at increased risk for
experiencing problematic surgical adaptation.

Two, although Gary used a wide variety of coping
responses, including high levels of self-sufficiency and
increased constructive resolution skills, the demands of
the situation exceeded his ability or resources. He
clearly experienced much anxiety about being in the
hospital and having an operation. For example, his
first response on the RATC was: “They're talking to
their son about going to the hospital. They're sad.“
Rather than appraising the situation merely as a
challenge to his resources, it was perhaps appraised as
a threat to his well-being because of the compromised
resources he had prior to the surgery. The situation
was stressful for Gary and he demonstrated significant

post and long-term surgical adaptation as a result.

Case 121 Alex

Alex was a 17-3 year old white male with a history
of congenital scoliosis. Alex's scoliosis was diagnosed
within the past year when an x-ray was taken following a
football injury he sustained. A myelogram confirmed
scoliosis of the thorasic region.

Congential scoliosis is often caused by a defective
embryologic development.o Alex suffered from the
presence of a hemivertebra, or the asymmetric fusion of

two vertebrae, eventually involving a 62 degree

97

curvature of the spine. The operation involved the
insertion of rods along the spine and a fusion of the
vertebrae involved, called a spinal fusion with
Harrington rod instrumentation. Following the
operation, Alex was placed in a circle bed to increase
his movement, circulation, and skin integrity. A body
cast was placed five days later. Alex remained in this
cast for approximately six months.

Alex developed several complications during and
postsurgery. He lost over 90 cc of blood and was placed
in the Intensive Care Unit for two days as a result. In
addition, he developed an immunologic problem as a
result of the operation. Postsurgery he was unable to
urinate, necessitating that he be cathaterized.

Test Results, Alex's mother completed the
Personality Inventory for Children (PIC) while Alex was
in the ICU. There was a tendency to minimize Alex's
problem behaviors. There were no clinically significant
elevations on the PIC. Overall, Alex's premorbid
adjustment, as evidenced by the PIC, was excellent.

Sequential analysis of Alex's scores on the Roberts
Apperception Test for Children, administered one day
prior to his surgery, indicated clinically significant
elevations (T > 60) on the following scales:
Constructive Resolution, Aggression, and Depression.
There were no significantly low scores.

Alex's presurgical coping responses were

98

characterized by high rates of constructive and
insightful resolutions to problem situations.
Frequently, new insights or problem solving abilities
which generalized to new situations were expressed:

“The son feels left out. The mother realizes this and
tells him that she loves him just as much and the kid
realizes it and learns to like his brother,“ and “He
finally realizes that if he doesn't do it, he'll get bad
grades and fail.“

Recognition of support by others was another coping
strategy: “They'll talk about their problem,“ “She
wakes up and her friend tells her to go home to sleep in
bed,“ and “The dad asks him how much he needs, gives it
to him, and lets him go to the show.“ However, low
levels of problem identification were evident,
suggesting much denial of conflict. Alex's anxiety
about his operation was evident by significantly high
levels of aggression and depression on the clinical
scales. The wide variation in Alex's scores suggested
that being in the hospital was an acutely disturbing
situation.

Sequential analysis of Alex's postsurgical coping
responses indicated signficant scores on Self-
Sufficiency and Insightful Resolution. Other clinically
significant scales were Anxiety and Depression.

Alex's postsurgical coping responses were

characterized by high rates of self-sufficiency,

99

perception of appropriate limits, ability to recognize
problem situations, and insightful solutions to problem
situations. Self-sufficiency included responses such as:
“He realizes that the quicker he does it, the sooner he
can do what he wants,“ and “He thinks fighting is stupid
and doesn't solve anything.“ Alex also used
significantly more coping responses postsurgery in which
problem situations were recognized: “He lost his job,“
and “A couple of guys are giving the black boy a hard
time.“ Increased problem identification following
surgery suggests that denial and avoidance served
adaptive functions; it was necessary to deny the
stressful aspects of the surgery in order to
successfully adapt to a situation in which he had little
control. Ten days following the surgery, however, Alex
no longer needed to use high levels of denial and
avoidance, as he had overcome a difficult postoperative
recovery, including loss of blood, pain, traction, and
inability to urinate, and could exhibit more control
over his body and the environment.

Alex also used more age appropriate and
sophisticated resolution skills following surgery, e.g.,
“He realized that the quicker he does his homework, the
sooner he can do what he wants. He does it and then
goes outside,“ “They realized that just because he's
black, he has feelings too. Eventually they became

friends and play together,“ and “He helps the parents

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and realizes that the parents love him as much as the
baby.“

Alex's scores on the measure of postsurgical
adaptation, administered 10 days following his surgery,
indicated a significant elevation only on Motor Excess.
All other scales were below the mean, suggesting no
other significant behavioral reactions to the
hospitalization and surgery. Follow-up assessment one
month later indicated no problem areas.

Qenelusien: This case study illustrates two
important conclusions relevant to the present study.
One, Alex's level of premorbid adjustment predicted his
post and long-term surgical adaptation. He demonstrated
no significant adjustment difficulties prior to his
hospitalization and scoliosis operation. Alex's surgery
and postoperative recovery were particularly demanding:
he lost much blood, necessitating a stay in the ICU; he
developed a serious immunologic problem postoperatively:
and was unable to freely urinate. In spite of these
obstacles, however, he demonstrated very positive
adaptation using coping strategies such as support from
others, self-sufficiency, and adequate problem-
resolution skills.

Two, a coping strategy characterized by denial and
avoidance presurgy may have helped Alex more
successfully adapt to the anxiety, aggression, and

depression he experienced while in the hospital. Once

101

he overcame the immediate challenges imposed by the
surgery, however, Alex returned to prestress levels of
recognizing differences and difficulties. Denial and
avoidance might have served an adaptive function for
Alex in a stressful situation in which he had little

control.

Summarxeffindings

Research questions about children's coping
responses and adaptation to orthopedic surgery have been
investigated by the testing of eight hypotheses and
qualitative case analyses.

The first two hypotheses investigated the main
research question, which concerned the linear
relationship between coping responses and surgical
adaptation. The statistical hypothesis that there was a
significant linear relationship between the magnitude of
coping responses used and post and long-term surgical
adaptation was not accepted for the total scales.
However, there were two significant relationships
amongst the subscales: (a) presurgical limit setting
and long-term surgical adaptation, and (b) total
presurgical coping and postsurgical anxiety-withdrawal.
The second hypothesis that the magnitude of children's
coping responses significantly differs preceeding
surgery versus following surgery was not supported.

The next four hypotheses investigated the linear

102

relationship between intrinsic stress factors and
surgical adaptation. Hypothesis III, which investigated
whether cognitive functioning was related to surgical
adaptation, was not supported.

Hypothesis IV, indicating that children with better
premorbid adjustment will show better surgical
adaptation, was supported for long-term surgical
adaptation.

The hypothesis (V) that age is related to surgical
adaptation was equivocal. Although age was
significantly correlated with postsurgical adaptation,
it was confounded with postsurgical coping.

Hypothesis VI investigated whether girls would show
better surgical adaptation than would boys. The
hypothesis was not supported.

The last two hypotheses were related to the
relationship between extrinsic stress factors and
surgical adaptation. Hypothesis VII, which indicated
that length of hospitalization was related to surgical
adaptation, was supported using bivariate correlations.
However, multiple regression analysis indicated that
days hospitalized was confounded with the variable
premorbid adjustment. The null hypothesis was thus not
rejected.

The last hypothesis, that children with more
hospital admissions would exhibit less successful

surgical adaptation, was not supported by any analysis.

103

Qualitative analyses of the data suggested that the
relationships between surgical coping responses and
adaptational outcomes were complex and affected by many
idiopathic intrinsic and extrinsic factors.

A discussion of the meaning and significance of

these results is found in the next chapter, Chapter V.

CHAPTER V

DISCUSSION AND CONCLUSION

Snmmaxx

This study was undertaken in an effort to
understand the relationships between coping responses
and adaptational outcomes of children undergoing
elective orthopedic surgery. Knowledge of these
relationships is needed in order to prevent possible
negative reactions due to hospitalization and surgery.

The reactions and psychological adjustment of
children to hospitalization and surgery can be
hypothesized from a stress and coping model. This model
is based on a theory of interactionism, whereby stress
is defined as the interaction between the individual,
his or her resources and capabilities, and the demands
of the situation. Accordingly, factors both within the
person and situational or extrinsic factors are
important in understanding coping and adaptation.
Psychological stress is thus defined as a relationship
between the person and the environment that is thought
to be a threat to one's well-being. Theorists
advocating interactional models of stress and coping
include: Lazarus and Folkman (1984), Sarason and Sarason

(1981), Moos and Billings (1982), and Rutter (1983).

104

105

A descriptive research design in the form of a
naturalistic field investigation was used, in
conjunction with quantitative and descriptive analysis
of the data. A sample of 27 children, ages 6 through
17, undergoing orthopedic surgery at a large, urban,
children's hospital participated in the study. They
completed the Roberts Apperception Test for Children,
used to measure their coping reponses, at two points:
once immediately preceeding surgery and again prior to
discharge from the hospital. In addition, the child's
parent completed the Revised Behavior Problem Checklist,
used to measure surgical adaptation, at two points:
once prior to discharge from the hospital and again one
month post-discharge. Premorbid adjustment and
cognitive functioning of the child were measured prior
to the surgery, using the Personality Inventory for
Children. Length of stay number of hospital admissions,
age and gender were obtained from the parent and the
medical chart.

Eight hypotheses related to children's responses to
hospitalization and surgery were developed and tested.
The main hypothesis that children who score higher on
measures of surgical coping will exhibit better surgical
adaptation than those who score lower was not accepted
for the total scores using statistical hypothesis
testing. However, presurgical limit setting and long-

term surgical adaptation were significantly correlated

106

in the predicted direction, such that children who
perceived appropriate and constructive limits placed on
their behaviors, as assessed prior to their surgery,
also exhibited better surgical adaptation upon one month
follow-up. In addition, total presurgical coping and
postsurgical anxiety/withdrawal were significantly
related: children who used greater numbers of total
coping responses, as assessed prior to their surgery,
also exhibited less anxiety and withdrawal after
surgery.

Children's coping responses did not significantly
differ preceeding surgery versus following surgery.
Furthermore, the hypotheses that children with higher
intellectual functioning, shorter periods of
hospitalization, or fewer hospital admissions will show
better surgical adaptation were not supported. Girls
did not show better surgical adaptation than did boys.

The hypothesis that younger children will
experience poorer short-term adjustments to
hospitalization and surgery was supported using
bivariate correlations but was not supported with the
effects of postsurgical coping held constant. There was
no significant correlation between age and long-term
surgical adaptation. Finally, the hypothesis that
premorbid adjustment would predict surgical adaptation
at 30-day follow-up was supported.

Qualitative data analysis, using case studies,

107

suggested that the relationships between coping
responses and adaptational outcomes did exist, although
they were complex and not easily demonstrated
empirically. The following sections discuss the
significance and meaning of the results of the research
questions. Implications for children entering the
hospital for orthopedic surgery and future research

questions are also discussed.

Discussieneftheflxnetheeee
WWMWW

Children's overall surgical coping responses
were not significantly linearly related to their
surgical adaptation using statistical hypotheses
testing techniques. However, there were two exceptions:
presurgical limit setting was related to long-term
surgical adaptation, and total presurgical coping was
related to postsurgical anxiety and withdrawal.

A possible explanation for the results of
Hypothesis I is that hospitalization and orthopedic
surgery were not appraised as taxing or exceeding the
child's resources or endangering his or her well-being.

An interactional model of stress and coping states
that an individual's cognitive appraisal of a stressful
event is crucial to understanding how that person may
respond to the stress or whether stress is perceived at
all (Magnusson, 1982). An essential question is thus

whether the children appraised the orthopedic surgery as

108

exceeding their resources and endangering their well-
being? If so, at what point might they have appraised
it as stressful--prior to the surgery, during anesthesia
induction, or while in traction postsurgery?

Were there factors that helped protect these
children against the possible threat of hospitalization
and surgery to their resources or well-being? There is
general agreement in the literature that the presence
and use of a wide variety of social resources
facilitates children's adjustment to stressful life
events. It has further been demonstrated that parent-
child contacts during hospitalization are helpful in
reducing the level of stress experienced by the child
(Peterson, Mori, & Carter, 1985).

Although there is solid evidence that even minor
surgery is stressful for children (Burstein &
Meichenbaum, 1979; Lambert, 1984: Skipper 5 Leonard,
1968), interviews with the children prior to and
following the surgery indicated that the majority felt
well-prepared and cared for while in the hospital.
Although sometimes expressing anxiety about the surgical
procedures, the older children frequently expressed
confidence in their own ability to cope with the
experience, particularly if they had successfully been
through a similar procedure in the past. Younger
children frequently expressed confidence in the ability

of their parents or the nursing staff to care for them.

109

In fact, many of the parents functioned as paranurses,
staying by their children's bedside and comforting and
supporting them throughout their stay. It is possible
that these children thus did not appraise the situation
as a threat to their resources or well-being because of
the support they received from parents and staff.
Examples of coping responses used by children
demonstrating support by others included: “the doctor is
talking with the girl“, “mother is trying to make her
feel better,“ “they are talking about going to the
hospital and the parents are asking him how he feels,“
“the lady is hugging her child because he might be
getting out of the hospital,“ and “he's explaining to
the boy how its gonna be at the hospital.“

There is a notable exception, however. Qualitative
observations indicated that children whose parent(s) did
not remain in the hospital throughout the entire stay
frequently exhibited much anxiety related to separation.
This anxiety became particularly exacerbated when
undergoing stressful procedures such as blood work or
physical examinations by the orthopedic resident. At
these times the child either cried and could not be
easily comforted or, in the case of several adolescents,
remained silent and withdrawn.

A second possible explanation for the above results
is that the children's expectations about the surgery

influenced their postoperative adaptation (Burstein &

110

Meichenbaum, 1979; Cohen & Lazarus, 1973). Melamed and
her associates concluded that appropriate psychological
treatments prove effective for preparing children for
hospitalization and medical procedures (Melamed et al.,
1982). The children in the present study did not all
participate in a preparation program. The hospital
offered an optional Saturday morning program consisting
of a film and discussion with the nursing staff,
parents, and children in an effort to prepare children
and their families for surgery. In addition, ward staff
again helped prepare children and their families once
the child was admitted. The child's doll was frequently
used to demonstrate and model to the child the medical
procedures necessary. Children thus were prepared on
different levels; such preparation was not controlled
for in the present study. Examples of children's coping
responses indicative of the effects of preparation
include: “the doctor is explaining to the girl what
will be done,“ “they say it is just like going to
sleep,“ and “he has been there before and knows what to
expect.“

Another explanation for the nonsignificant
correlations between total surgical coping and total
surgical adaptation is measurement related, involving
the choice of a multi-band outcome measure. The Revised
Behavior Problem Checklist measures four broad behavior

syndromes, in addition to two minor scales. Although

111

both externalizing and internalizing behaviors are noted
in the literature in conjunction with hospitalization,
interview data with the subjects and their parents
suggest that attention and anxiety/withdrawal behaviors
are predominant while in the hospital, while aggressive
behaviors surface at home following discharge from the
hospital. The restriction to a single broad band
measurement instrument might be more effective in
assessing children's behaviors following surgery.

One overriding limitation effecting the results
obtained is methodological. Although Table 4.4 presents
many correlations in the .30 to .38 range, these were
not statistically significant because of the relatively
small sample size. Frequently, an increase of less than
five subjects would have significantly added to the
power of the statistic.

The presence of statistically non-significant
results in a correlational study employing a small “N“
does not mean that these relationships do not exist,
however. A question is thus raised over meaningful
versus statistical significance, suggesting that a more
qualified conclusion be drawn about the relationship
between children's surgical coping responses and
adaptation; this relationship cannot be adequately
described by the presence or absence of statistically
significant correlations alone. A more qualified

conclusion, based on both empirical and qualitative data

112

analysis, is that relationships between surgical coping
responses and adaptational outcomes exist. However, the
inherent complexities in these relationships do not
easily lend themselves to the rigor of hypothesis
testing. Both intrinsic and extrinsic factors, such as
the presence of social supports, may affect the
relationship between children's coping responses and
adaptation to surgery. Further study, using more
restrictive measures but greater sample size, is
warranted.

While the major aspects of Hypothesis I were not
supported, two correlations involving subscales of
coping and adaptation were significant in the predicted
direction using regression analysis: (a) presurgical
limit setting and long-term surgical adaptation and (b)
total presurgical coping and postsurgical anxiety and
withdrawal. Presurgical limit setting reflects the
child's perception of reasonable and appropriate limits
placed by adults in response to a violation of rules or
expectation, as assessed one day or less prior to
surgery. Long-term surgical adaptation refers to
observable behaviors one month following discharge from
the hospital.

While significant correlations might be expected
merely out of chance occurance, the magnitude and
direction of these correlations are notable. The

results suggest that children who perceived appropriate

113

limits placed on their behaviors by adults, as assessed
one day or less prior to their surgery, exhibited better
long-term surgical adaptation than those who perceived
fewer limits in their environment. One possible
explanation for this result is once again the role that
social supports, particularly intra-familial, play in
children's adaptation to orthopedic surgery. Children
whose coping responses include firm limits and
guidelines on their behavior, i.e., support from their
environment, demonstrate better long-term surgical
adaptation. Appropriate and firm limit setting is
associated with better child adjustment in the
develomental literature (Baumrind, 1968). Such limits
provide the child with a sense of stability, security,
and trust. It is the presence of a caring,
authoritative adult that is important.

In addition, the correlation is between limit
setting and lengztetm surgical adaptation. It is
probable that limit setting does not occur only when a
child is in the hospital, but rather prior to and after
the surgery as well. Examples of coping responses used
by subjects included: appropriate punishments for doing
something wrong, telling the child what not to do,
limiting or restricting the child's behavior, having to
take medicine, and getting grounded for bad school
grades.

The correlation between total presurgical coping

114

and postsurgical anxiety and withdrawal was also
significant. A possible explanation for this
correlation is the role that action strategies play in
reducing the impact of a stressful event. It has been
hypothesized that active cognitions play an essential
role in coping with stressful situations. Action
strategies help form and maintain a set of illusions by
looking at the known facts in a particular light in
order to maintain the most positive picture possible
(Curry & Russ, 1985; Taylor, 1983).

Children who used greater numbers of coping
responses prior to their surgery thus demonstrated less
anxiety and withdrawal while in the hospital. Rather
than passive acceptance of the situation, these children
used active strategies to gain a sense of mastery and
control the meaning of the experience. Passive
acceptance, helplessness, and depression have been
linked to higher morbidity and mortality rates in a
number of investigations (Lazarus & Folkman, 1984). On
the other hand, high levels of cognitive arousal are
related to successful surgical adaptation (Ray 8
Fitzgibbon, 1981). Effective coping might have depended
not only on what the subjects did, but also on how much
they did (Curry & Russ, 1985).

Active cognitions might thus have functioned to
help the subjects form and maintain a set of illusions

by looking at the known facts in a particular light in

115

order to maintain the most positive picture possible.
Other researchers (Alloy & Abramson, 1979; Cohen &
Lazarus, 1973: Taylor, 1983) have concluded that
avoidance and illusion may be cognitive processes that
serve essential adaptive functions. If one is to
maintain hope, the opposite of depression, then one must
select the positive aspects of the situation and believe
that one's actions make a difference. Breznitz
(Turkington, 1984) maintains that a sense of hope is
essential for successful adaptation to stressful
situations. Hope involves active work, as opposed to
passive acceptance. Coping responses indicative of
children's efforts to maintain hope included: “He went
to the hospital and found out it wasn't a bad place
after all,“ “his surgery wasn't bad because he didn't
even know,“ “when the person gets out of surgery, then
he'll be alright,“ and “maybe her mom and dad might be
separated and they might be getting together again.“
Hypothesis II predicted that the number of coping
responses would significantly differ preceeding surgery
versus following surgery. The hypothesis was not
supported. The results obtained suggest that coping
efforts, in a quantitative sense, remained relatively
stable throughout the child's hospital stay.
Qualitative examination of the subject's coping
responses on the RATC administrations again suggest

stability. The children's stories demonstrated quite

116

similar thematic content one day prior to their surgery
and before their discharge from the hospital.

One further way to investigate the stability of
children's coping reSponses to orthopedic surgery is to
examine the test-retest reliability coefficients
obtained for the sample. Overall test-retest
reliability for the sample is remarkably high (r 8 .86),
given the nature of stimulus bound thematic apperception
tests such as the RATC to be influenced by state factors
of the child. More weight can thus be given to the
conclusion that coping responses are stable over time,
as opposed to predictions from an interactional model of

stress to the contrary.

Whelatedtelntrinsiefiressfaetm

Four hypotheses related to intrinsic stress factors
were developed and tested. Intrinsic factors
hypothesized to affect adaptational outcomes to
orthopedic surgery were: cognitive functioning,
premorbid adjustment, age, and gender.

Hypothesis III predicted that the child's cognitive
functioning would be significantly related to post and
long-term surgical adaptation. Correlations were not
significant at the p (.05 level: further regression
analysis did not reveal significant correlations. The
hypothesis was not supported. Not only was cognitive
functioning not significantly related to surgical

adaptation, but examination of the correlation matrix

117

indicates that cognitive functioning was not related to
measures of surgical coping.

One possible explanation for this result is that
the advantages of good scholastic achievement and '
intellectual functioning do not protect children from
the adversities imposed by hospitalization and surgery.
Although this finding seems to contradict the work of
Rutter (1983), it should be noted that his finding
referred to long-term functioning. On the other hand,
the present study focused on adaptation to a specific
stressor over a relatively short period of time (three
to thirty days). The value of superior cognitive
functioning might be evident over the long haul, across
many stressors, as opposed to discrete episodes of
stress measured in days.

Hypothesis IV predicted that children's premorbid
adjustment, i.e., the variety and frequency of problem
behaviors prior to admission to the hospital for
orthopedic surgery, was related to their surgical
adaptation. Initial results indicated that premorbid
adjustment was significantly correlated with both post
and long-term surgical adaptation at the p (.05 level.
Further regression analysis indicated that the
relationship between premorbid adjustment and
postsurgical adaptation (short-term) was confounded by
the number of days the child was hospitalized. However,

the relationship between premorbid adjustment and long-

118

term surgical adaptation was significant at the p (.005
level.

These results raise several important issues. The
most important is that children's overall psychological
adjustment was the most powerful predictor, investigated
in the present study, of their behavioral responses to
hospitalization and orthopedic surgery. Children with
poorer premorbid adjustment were more likey to develop
behavioral concerns at home one month following their
operations. Premorbid adjustment was an important
individual difference that mediated the impact of
hospitalization and surgery over the first month
following discharge.

One possible explanation for the finding that
premorbid adjustment predicted long—term surgical
adaptation is the role that a child's psychological
resources play in his or her adaptation to stressful
events. Reseachers, most notably Garmezy (1976; 1983)
consistently refer to the role that a positive
personality disposition plays in protecting children who
are exposed to stressful events. The ability of these
children to meet and conquer the adversities imposed by
the rigors of hositalization and painful orthopedic
surgery, including traction, forced dependency, and loss
of privacy might depend, in large part, upon the
psychological resources they bring into the stressful

encounter.

119

Why was “premorbid adjustment“ confounded with the
variable “days hospitalized? The importance of
psychological resources in protecting children from the
effects of hospitalization and surgery might also depend
upon the severity of the stress they encounter while in
the hospital. There is much research to support the
hypothesis that the simple accumulation of stressful
events is significant; the more stressors encountered,
the more severe the reactions. The severity of the
children's orthopedic surgery could roughly be measured
by the number of days they remained in the hospital.
Children undergoing spinal fusions for scoliosis
generally remained in the hospital for 10 days and
remained in body casts for up to six months following
discharge from the hospital. Removal of excess bone
growth or heel cord lengthening, on the other hand,
necessitated a hospital stay of two to three days.
Because the relationship between premorbid adjustment
and postsurgical adaptation was confounded by the number
of days the child was hospitalized, the results suggest
that in the short run, the affects of premorbid
adjustment are not signficant when adjusted for the
severity of the stressor. However, it is in the long
run that the importance of a child's psychological
resources is more evident.

Although researchers using case studies have

suggested that children with preexisting psycholgical

120

problems will experience more severe reactions to
hospitalization and surgery (Barnes, Kenny, Call, &
Reinhart, 1972), there has been no research to date in
which the reactions of children with and without
preexisiting psychological problems are compared
(Lambert, 1984). The results of the present study thus
represent an important first step in studying the
correlations between premorbid adjustment and
adaptational outcomes to orthopedic surgery.

Hypothesis V predicted that different age children
will show different post and long-term surgical
adaptation. The literature states that the age period
of greatest risk is about 6 months to 4 years. On the
other hand, the advanced metacognitive processes of
older children could also foster greater anxieties in
children (Maccoby, 1983), as they might forsee the
possible threats to their well-being associated with
hospitalization and surgery but are unable to protect
themselves.

The results of Hypothesis V were equivocal. Age
was significantly correlated with postsurgical
adaptation (p (.05), such that younger children
experienced greater postsurgical difficulties than older
children. However, age was confounded with total
postsurgical coping, but not with presurgical coping.

One explanation for this result is that

hospitalization and orthopedic surgery are stressful for

121

younger children with deficient coping responses. Young
school-aged children who utilize fewer numbers of
cognitive responses exhibit poorer adadptation while in
the hospital. Younger children who are more active in
using coping responses, on the other hand, may be at
less risk for developing adjustment difficulties
postsurgery. In addition, older children as a group
have developed cognitive processes that allow them to
actively respond to being in the hospital. The results
suggest that older children utilized greater numbers of
cognitive responses.

Once the child returned home, however, his or her
age was not signficiantly associated with surgical
adaptation. It is perhaps only during the intense
stress associated with being in a hospital that age
plays a role in surgical adaptation. At home the
surroundings are no longer unfamiliar, as the child is
reunited with his or her family.

Hypothesis VI predicted that girls would show
better post and long-term surgical adaptation than would
boys. The hypothesis was not supported. There were no
significant differences between males and females on any
of the total surgical adaptation measures.

Researchers such as Rutter (1983) state that boys
tend to be more vulnerable to the effects of stress and,
in particular, hospital admissions. However, the boys

in this sample did not quantitatively exhibit poorer

122

surgical adaptation, as compared with the girls. In
retrospect, a more pertinent line of investigation with
regard to gender is whether boys and girls use different
coping responses. For example, do boys use physical
aggression and controlling behaviors and girls use
verbal aggression and orienting behaviors as Lambert
(1984) suggests? Further research is needed to
determine if the quality of girls and boys coping
responses to orthopedic surgery differ, regardless of

their surgical adaptation.

Wfielatedteflznineiefitreeefaetere

Hypothesis VII predicted that length of
hospitalization was a significant factor in children's
surgical adaptation, such that children with longer
periods of hospitalization would exhibit less successful
post and long-term surgical adaptation than would
children with shorter periods of hospitalization.
Although the correlation between days hospitalized and
long-term surgical adaptation was significant in the
predicted direction, it was not significant with the
effects of premorbid adjustment held constant. The
hypothesis was not supported.

One possible explanation for the results is that
the children hospitalized for longer periods of time had
serious orthopedic conditions that affected their level

of premorid adjustment. The long-term cases in the

123

sample consisted of children undergoing spinal fusions
for correction of scoliosis. There is a large body of
literature describing the affects of chronic physical
illness or disability on children's adjustment (Moos &
Tsu, 1977). Scoliosis is a deformity involving lateral
curvature of the spine and is often progressive through
childhood. Many nonsurgical and conservative treatments
are available such as exercises to improve posture, bed
rest, traction, and plaster cast or brace. Surgical
treatment is indicated when curvatures cannot be
stisfactorily improved, or their improvement
satisfactorily maintained, by nonsurgical measures
(Raney, Brashear, & Shands, 1971). The scoliosis
patients in this sample had been in and out of the
orthopedic clinic many times. Scoliosis is a
disfiguring deformity for children and adolescents that
would have psychosocial consequences. In addition, the
scoliosis was frequently associated with other physical
conditions, including muscular dystrophy. The variable
days hospitalized was very much linked to the severity
of the orthopedic condition. It is thus not surprising
that the variable days hospitalized was signficantly
confounded with the variable premorbid adjustment.
Together, these two independent variables accounted for
19% of the variance in postsurgical adaptation (p >.05)
and 51% of the variance in long-term adaptation

(p (.001).

124

Hypothesis VIII predicted that children with more
prior hospital admissions would exhibit less successful
post and long-term surgical adaptation than would
children with fewer hospital admissions. The hypothesis
was not supported.

There is continued debate in the literature whether
previous hospitalization positively or negatively
affects the degree of emotional upset during or
following subsequent hospitalizations (Lambert, 1984).
The children in this sample with many prior
hospitalizations did not experience more difficulties
postsurgery or in the month following discharge from the
hospital.

Qualitative analysis indicates that in general the
benefits of orthopedic surgery outweight the drawbacks.
Conversations with parents and children prior to the
surgery indicated much variation in children's reactions
to coming again to the hospital for surgery. Many
parents stated that their child expressed great
displeasure about the upcoming hospital admission and
exhibited increasingly irritable and argumentative
behaviors. Still other parents, usually of adolescents,
stated that their child was ready and eager to get their
body “fixed,“ although apprehension was nonetheless
expressed by the child. There are thus likely many
other variables not directly addressed in the present

study, such as the child's and parent's view of the

125

orthopedic difficulty and orthopedic surgery, that
affected whether prior admissions was related to the

child's surgical adaptation.

Limitatiens Qt the Study

The most significant limitation of the study
concerns the size of the sample. A sample of 27
children affects both the empirical results and the
generalizations that can be made, or the external
validity. Quite frequently, relatively large
correlations were obtained in the predicted direction in
the testing of the hypotheses, but because of the small
sample size, these correlations were not statistically
significant at the p (.05 level. The conclusions based
on the empirical results are thus limited by
methodological constraints.

In addition, the generalizability of the results is
limited. With a sample of 27 subjects, it is more
difficult to generalize the results beyond the sample

itself.
Generalization to a larger patient population is

often made using the Tukey-Cornfield Bridge argument
(Glass & Stanley, 1970). This is a logical argument
allowing for inferrences to be made from non-randomized
samples to populations of interest, provided that the
characteristics of the sample are described in detail.
Of the 33 subjects eligible and asked to participate in
the study, 27, or 82%, completed the study. This

126

participation rate is quite high and compares favorably
with other published studies in the field (Curry & Russ,
1985). The subject pool consisted of adequate numbers
of minority children. However, boys outnumbered girls
three-to-one. Socioeconomic status was varied, as both
private and orthopedic clinic patients participated.

Use of the Tukey-Cornfield Bridge argument allows for
the cautious generalization of these results to the
larger pediatric orthopedic population undergoing
similar operations.

Another limitation of the study was the use of a
projective test to measure surgical coping responses.
Although the Roberts Apperception Test for Children has
adequate psychometric properties, projective tests in
general have certain limitations in terms of construct
validity. Other methods of assessing children's coping
responses, such as structured interviews, were
considered in the present study, but also have
limitations associated with using retrospective self-
report measures. However, the use of projective
measures is well-supported by stress researchers
(Moos, 1974), and is one viable method of exploring
coping processes, particularly when such processes
cannot be readily observed.

In addition to the above limitations, naturalistic
field investigations are unable to control for many

confounding variables. Although an effort was made to

127

control for confounding among the independent variables
under investigation by using multiple regression
analysis, other variables were not controlled for and
might be confounders. Confounding variables might
include expectations regarding the surgery, and the
amount of social support and preparation the child

received prior, during, and following surgery.

mnlieatienseftheaeseareh

The results of this research have implications for
hospital staff and parents of children entering the
hospital for orthopedic surgery. The clearest finding
of the study is that children's premorbid adjustment
functions as a powerful predictor of surgical
adaptation. Children experiencing various and frequent
problem behaviors prior to their surgery exhibit higher
rates of both internalizing and externalizing behaviors
one month after they are discharged from the hospital.
It is thus important to adequately screen for children
at risk for problematic postsurgical adaptation prior to
orthopedic surgery. Appropriate secondary prevention
strategies can then be used. Intervention programs
specifically aimed at this population of children can be
implemented. Such interventions might include increased
parental and hospital staff support, behavioral
programs, modeling procedures, systematic
desensitization, and exposure therapy (Melamed et al.,

1982; Peterson, Mori, & Carter, 1985). This implication

128

is important to nursing staff, pediatric and orthopedic
residents, and pediatric psychologists involved with
providing care for children undergoing orthopedic
surgery.

It is also important that children are encouraged
by hospital staff and parents to use action-oriented
cognitive strategies prior to orthopedic surgery in
order to limit behaviors indicative of anxiety and
withdrawal following the surgery. The use of coping
strategies such as reliance on others, self-sufficiency,
problem-identification, and problem resolution should be
encouraged so that the child may maintain a sense of
hope. Traditional puppet therapy, modeling procedures,
and exposure therapy can be used, depending on the age
of the child, to help encourage active use of
strategies, as opposed to passive acceptance of the
situation. In this context, the defiance sometimes
noted of children by hospital staff can be viewed as a
positive attempt of children to cope with a situation
that is not totally under their control.

Finally, the results suggest that it is important
that parents and hospital staff continue to impose
appropriate but firm limits on the children's behavior
prior to the orthopedic surgery. Children's perceptions
of such limits are important in terms of their
adaptation one month following discharge from the

hospital.

129

Directiensfertntnreaeseareh

The present study, while directly assessing the
relationships between coping responses and adaptational
outcomes of children undergoing elective orthopedic
surgery, merely begins the process of describing the
relationships. The results of the study indicate the
need for further investigation of children's responses
to various surgeries and medical procedures, pose new
questions for researchers in the stress and coping
field, and provide directions for future research.

More information is needed regarding how children
appraise the stress associated with hospitalization and
major surgical procedures. Are there particular points
that they appraise as stressful, e.g., admission, first
night in the hospital, transport to the operating room,
anesthesia induction, postoperative pain and
restriction, or discharge? Interviews with the child as
the stress occurs is advantageous. However, assessment
of cognitive appraisal during the actual coping episode
is not always possible or appropriate in terms of the
treatment process. A coping interview, based on
prospective and retrospective self report, can be used
(Curry and Russ 1985).

A second needed line of inquiry is whether
children's expectations about their surgeries influence

their surgical adaptation. For example, if children

130

believe that the positive results of the surgery

will outweigh the negatives, do they demonstrate more’
positive adaptational outcomes than those who do not
expect good results? Use of elective orthopedic surgery
patients would allow the researcher to interview
children at various points prior to the surgery and
compare their expectations to their surgical adaptation.

The role of social supports in helping children
cope with the adversities of hospitalization and surgery
is powerful and requires future research. What are the
essential aspects of social supports that help children
cope with surgery? Are children of single parent,
foster care, or institutionalized families at increased
risk for developing emotional difficulties? Social
support might be measured in a number of ways, including
number of visitors, time spent visiting, hospital staff
time, and time on the telephone.

In order to explore gender issues in relation to
adaptation to orthopedic surgery, comparisons of the
coping responses used by girls and boys is necessary.

Do boys use more physical agression and controlling
responses, while girls use more verbal aggression and
orienting responses? Implications from this line of
inquiry could assist with predicting and explaining
differential reactions to surgery and help prepare boys
and girls for surgery based on their coping strengths.

Use of more narrow band outcome measures is

131

necessary in order to more fully describe surgical
adaptation. Internalizing symptomatology is more
prevalent while the child is in the hospital, while
externalizing symptomatology becomes more prevalent
after the child returns home.

Although research on stress and coping is
exploratory in nature, use of larger sample sizes is
necessary, once the variables of interest have been
narrowed. Further research is necessary in order to
increase the statistical power of the analyses while not

prematurely narrowing the scope of the inquiry.

Cenelusien

The results of this research highlight the
resiliance in children under stress. Most children
exposed to a stressor of marked gravity, associated with
a heightened probability of maladaptive outcomes,
demonstrated behavior marked by adapation and
competence. The “stress resistance“ of these children
is noteworthy and is a starting point for research on
protective factors and the processes they activate.

However, those children demonstrating poorer
premorbid adjustment are at risk for developing adverse
reactions to orthopedic surgery. This subgroup of
children requires special attention as they prepare to

enter the hospital; their stress resistance is

132

lower as they are less apt to have available effective
protective factors. This minority poses a special
challenge to parents and hospital staff to insure the
most advantageous physical and psychological adaptation

possible.

APPENDICES

APPENDIX A

CONSENT FORM

 

 
      

i133
l‘ ‘

Children’s

HOSPITAL OF M|CH|GAN

DETROIT MEDICAL CENTER - 3901 Boaubion Boulevard/Detroit. Michigan 48201

Dear Parent(s):

Your child will soon be undergoing orthopedic surgery at
Children’s Hospital of Michigan. Children and their parents
often find hospitalization and surgery to be stressful. I am
a Psychologist in the Department of Psychiatry/Psychology and
am studying how children cope with their surgery. I would
like to have you and your child participate in a research
study I am conducting.

This work may improve our understanding of surgical
stress in order to develop new ways of helping children
facing similar operations. It is sponsored by your child’s
surgeon, Dr. LaMont, the Department of Psychiatry/Psychology,
and Michigan State University.

You will be asked to complete two questionnaires about
your child, both while s/he is at the hospital and when you
see Dr. Lauont for a follow-up visit. Altogether these
questionnaires require about one hour of time. Your child
will be asked to make up stories for 16 pictures for which
there are no right or wrong answers, requiring about one hour
of time. The questionnaires are currently used by the
Department of Psychiatry/Psychology.

Your participation is completely voluntary. Enclosed is
a consent form that more fully describes your participation
in the study. If you are willing to participate, please sign
the form and leave it with the receptionist, or mail it to me
in the stamped envelope provided. I will call you at home in
order to more fully explain the study and answer any
questions you might have.

Thank you for your consideration.

Sincerely,

aJLRdm'a/ H4-

aul Robins, H.A.
Psychiatry/Psychology

133

A Priuxc. Voluntary. Non-prom Hospital Orgamzcd an 1886

13A

Consent Form
No. 1985-03

Children and their parents often find
hospitalization and surgery to be stressful. Paul
Robins, M.A. is a psychologist, and is trying to learn
more about the stresses of pediatric surgery for
children. This work will help improve the understanding
of surgical stress in order to develop new ways of
helping children. The work is sponsored by Children's
Hospital of Michigan and Michigan State University. He
would like us to help him learn about how children cope
with surgery by taking part in a study. We will be
asked to complete some questions which ask about:

a) background information (child's age, gender,
days hospitalized, etc.);

b) child's personality (likes, dislikes, skills,
etc.);

c) child's behavior (attention seeking, shy,
etc.).

Your child will be asked to make up stories for 16
pictures for which there are no right or wrong answers,
both prior to and following his or her surgery.

We understand that it will take approximately one
hour of our time and one hour of our child's time to
participate in this study. The investigator will give
us the questionnaires both in the hospital and when we
bring our child to the doctor for a follow-up visit.

All information obtained will be kept confidential.
No names will be placed on any of the questionnaires,
nor will our names be used in any reports of the study.
When the study is completed, we will be mailed a written
summary of the results if we so desire.

This is a research study, and it does not involve
any psychological treatment. However, it may be of
benefit to us in that we may learn how children cope
with hospitalization and surgery. We may withdraw from
this study at any time. If we do withdraw from this
study, the hospital and the doctors will still give us
the best care that they can, both currently and if we
are treated there in the future.

Information about what we learned from this study
may be published, or given to other people doing
research, but our names will not be used.

135

Participation in this study does not entail any
known risks. However, in the unusual event of emotional
upset resulting from completing the questionnaires or
stories, no compensation and no free psychological
treatment or reimbursement is offered.

Any questions we have asked about this study have
been answered. If we have other questions later on,
Paul Robins, M.A. will answer them for us. He can be
reached at 494-4878 weekdays from 8:00 a.m. to 5:00 p.m.
We also may call Dr. Flossie Cohen, who can be reached
at 494-5566. She is Chairman of the Children's Hospital
of Michigan Research Grants and Investigation Committee
and will answer any questions we have about our rights
as part of a research study.

By signing this paper we are saying that we have
read and understood it and that we agreed to take part
in this study.

 

 

Name of Participant Signature of Child
(if over age of 13)

 

 

CHM # (PDB #) Signature of Participant
or Parent or Legal Guardian

 

 

Date Physician's Signature

 

Witness

The child assented to participate in this project.

 

Investigator

APPENDIX B

THE ROBERTS APPERCEPTION TEST FOR CHILDREN

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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136

137

Summary Score Sheet - '
Protile Scales

Supplementary

Clinical Indicators

Identification
Resolution 2
Aggression
Depression
Unresolved
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Refusal

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Resolution 1

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'For ages 13-15 only. Resolution 3 should be plotted as a prolile scale.

138

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139

The RATC differs from other apperception tests
commonly used with children, e.g., the CAT and TAT, in
five major respects: a) it is specificially designed
for children and thus depicts children in all 16
stimulus cards, b) it emphasizes everyday interpersonal
events, as opposed to psychosexual or adult concerns, c)
the stimuli show realistic drawings of children and
adults executed in a uniform style by the same artist,
d) it employs easily scored, objective measures which
yield high interrater agreement, and e) it provides
normative data for a sample of 200 well-adjusted
children ages 6 through 15.

The More Scales

The eight adaptive scales used in the study as
measures of surgical coping are each described below
(McAruthur & Roberts, 1982). The parentheses indicate
the name of the scale for purposes of the study.

Reliance on chete. The Reliance on Others scale
assesses a child's tendency to make up stories in which
the character reaches out to others for help in solving
a problem, either external or intrapsychic. The scale
measures the adaptive capacity to use outside help to
overcome a problem. Examples include: “he went to tell
his parents,“ “he talked it over with his mom,“ and
“please can't I hold him.“

- . The Support-Other scale reflects a
tendency to support others by giving assistance,
emotional support, or material objects. Common examples
of thematic content include granting a request, buying a
present, or giving professional help: “he reads him the
story,“ and “I love you.“

uppottzchild. (Self-Sufficiency) The Support-
Child scale measures self-sufficiency and maturity as
indicated by assertiveness or the experience of positive
emotions. Common examples of thematic content include
curiosity, positive feelings about self, pride in work,
joy, expectation, affection, and a good dream: “he's
excited,“ and “he's thinking hard about all the
answers.“

Problem Identification. The Problem
Identification scale indicates the child's ability to
formulate concepts beyond the nature of the card. The
ability to engage in and articulate problem situations
is considered adaptive. It requires a lack of
defensiveness, verbal ability, and the capacity to view«
others in complex, dynamic ineractions. Common examples
include marital separation, not knowing what to do,
inability to handle school work, getting lost, lying,
environmental disaster, and having problems: “he's
wondering what's going on,“ and “they want to go surfing
and they don't have a ride.“

Limit Setting. The Limit Setting scale reflects
the child's perception of reasonable and appropriate

1&0

limits placed in response to a violation of rules or
expectations. Low scores may reflect a lack of parental
involvement or concern. Common examples include
scolding, punishment, explaining what the child did
wrong, making the child do something over, or showing
the child how to do something the right way: “the
father took him to his room and he went to bed without
his supper,“ “his dad's telling him not to do that any
more,“ and “he had to clean up the paint on the walls.“

Reeeiutien i. (Unrealistic Solutions) The
Resolution 1 scale reflects a child's tendency to seek
easy or unrealistic solutions to problem solutions that
have magical, wish-fulfilling, or unrealistic quality.
Common themes include living happily ever after, and
suddenly not having a problem.

Resolutign 2. (Constructive Solution) The
Resolution 2 scale indicates a constructive resolution
of a problem either external or intrapsychic. The
resolution is limited to the present situation. It is
not accompianed by any new insights or approaches which
may be applied to new problem situations. This scale
involves resolution without explanation of the process
or “working through“ of the problem, e.g., “he figures
out it was just a dream and he goes back to sleep,“ and
“she'll go get help and make sure she's 0K.“

Beselutien 3. (Insightful Solution) The
Resolution 3 scale indicates a constructive resolution
which goes beyond the immediate problem or conflict
situation. The character in a story acquires new
insight or develops problem-solving abilities which
generalize to new situations. It occurs developmentally
for older children.

The authors investigated the relationship among the
stimulus cards, i.e., which cards evoked similar
responses in children and what were the underlying
dimensions. A factor analysis was performed and yielded
four factors, which accounted for 89% of the common
variance.

Roid (1983) explored two kinds of factor structure
using more complex factors methods: a) the structure of
the 13 basic profile scales, and b) a hierarchical
analysis of the structure of individual cards in the
context of selected profile indicators. The findings
replicated the three-factor structure of profile scales
described by McArthur and Roberts (1982), i.e.,
Adaptive, Clinical, and Developmental. In addition,
specific combinations of cards elicited a structure of
profile indicators that suggested the presence of four
higher-order factors: a) internalization, b)
externalization, c) aggressive—destructive, and d)
degree of maturity in the child's resolution of stories.

An initial test of criterion-related validity was

1141

conducted by the authors (Zachary, 1983). In order to
affirm the ability of the RATC to discriminate between
clinic and nonclinic groups, the RATC was administered
to a heterogeneous sample of 200 clinic chidren. A
multiple regression was calculated and resulted in a
multiple R of .79, which was highly significant, P(12,
387)=48.53; p<.001. 62% of the variance in group
membership was accounted for by the 13 profile scales.
In addition, clinic and nonclinic children differed
significantly on 12/15 rating variables at the .01 level
or better, providing further evidence of the RATC's
validity.

Muha (1977) assessed the ability of the RATC to
discriminate successfully between clinic and nonclinic
families. 10 cards were administered to clinic and
nonclinic families. Family functioning was also
observed and rated, using a standardized evaluation
scale. The RATC protocals were scored on 13 RATC
measures. Results indicated that the two groups
differed significantly on 8 of the 13 measures. All
significant differences were in the expected directions.

McArthur (1976) compared the clinical effectiveness
of three projective tests, i.e., the RATC, CAT, and TAT.
Stimulus cards from each test were selected and
administered to 98 white males ages 8 and 11, who were
judged by their teachers to be well-adjusted. Results
indicated that the RATC elicited a significantly lower
percentage of stereotyped responses than either the CAT
or TAT. The author maintained that projective stimuli
should elicit a minimum of stereotyped responses and
hence the RATC is useful in a manner for which it is
intended.

Hersh (1978) investigated the predictive validity
of the RATC and obtained mixed results. Subjects
included 25 children, ages 6 to 13, referred for
psychiatric evaluation. A wide range of presenting
complaints were included. Therapeutic change was
assessed by comparing children's scores on the RATC and
four additional measures pre and post treatment. The
four outcome measures were published and unpublished
rating scales, filled out by the child's parents or
teachers, thus functioning as independent criterion
scores against which to measure the validity of the
RATC. Results indicated that the children improved over
the course of theraPY: as assessed both by changes in
the children's average scores of the RATC, and by the
independent criteria of parent and teachers' ratings.
However, the RATC scales did not correlate significantly
with the independent ratings of the severity of the
children's presenting problems at intake, or the
direction and magnitude of changes in individual
children as the result of therapy.

APPENDIX C

THE PERSONALITY INVENTORY FOR CHILDREN

PERSONALITY INVENTORY
FOR CHILDREN

REVISED FORMAT "
ADMINISTRATION BOOKLET

by ROBERT D. WIRT. Ph.D.

PHILIP D. SEAT. Ph.D.

WILLIAM E. BROEN. Jr.. Ph.D.
Revision by DAVID LACHAR. Ph.D.

Why

*-
VEST!!! minimum
- habitation one Dim
w ”031m. w
us Armies. Cal-torn. sous

_—

 

 

This inventory consists oI statements about children and tamily rela-
tionships. The inventory items are presented in tour parts.

DIRECTIONS: First Iill in the information requested on the answer
sheet; then read each ol the statements in this booklet and decide

 

whether it is true or Ialse as applied to your child. Swim 0, ans“,
sheet correctly
Look at the example at the answer sheet shown mm“,
at the right. In the example the parent decided
that statement 25 was true as applied to the child I F
and statement 26 was Ialse as applied to the child. 25 O G)
26 o o

 

 

 

II a statement is TRUE or MOSTLY TRUE. as applied to your child.
use a pencil to blacken the circle labeled T (See 25 in the example). It a
statement is FALSE or NOT USUALLY TRUE. as applied to your child.
blacken the circle labeled F (See 26 in the example). .

In marking your answers on the answer sheet. be sure that the
number of the statement agrees with the number on the answer sheet.
Make your marks heavy and black. Erase completely any answer you
wish to change. 00 not make any marks on this booklet.

Continue to answer the inventory items unless instructed to stop
at the end oI Part I. II. or III.

 

Copyrth . l9". l98l by WESTERN PSYCHOLOGICAL SERVICES
Not to be reproduced in whole or in part withOut written permssion at Western Psychological Services

All rights reserved 2 3 4 5 6 7 0 9 Primed in U SA
“RH?!

142

143

DO NOT MAKE ANY MARKS ON THIS BOOKLET

v

PART]

 

|2.
l3.
l4.
l5.
|6.

|7.

2|.
22.
23.
24.

23.

. My child often plays with a group of children.

. My child hardly ever smiles.
. Other children often get mad at my child.

. My child worries about things that usually only

adqu worry about.

. My child has many friends.

. My child seems avenge or above avenge in

intelligence.

. My child's manners sometimes embarrass me.

. My child has a good sense of humor.

. My child sometimes secs things that aren't there.
. My child is worried about sin.

. Other children don‘t seem to listen to or notice my

child much.

My child sonretirncs undresses outside.

My child has little self-confidence.

I often wish my child would be more friendly.
My child can comb his (her) own hair.

My child is usually rejected by other children.

My child seems to enjoy destroying things.

. Now and then my child writes letters to friends.
. Thunder and lightning bother my child.

. The school says my child needs help in getting along

with other children.

My child often asks if I love him (her).

Other children look up to my child as a loader.
My child could ride a tricycle by age five years.
My child sometimes gets angry.

My child frequently complains of being hot even
on cold days.

27.

3|.

32.

33.

35.

37.

39.

4|.

42.

43.

45.

47.

49.

. My child's behavior often makes others angry.

Recently my child has complained of eye trouble.

. Others think my child is talented.

. My child frequently has gas' on the stomach (sour

stomach). .

. My child is good at lying his (her) way out of

trouble.
My child often cheats other children in deals.
My child is good at leading games and things.

A: 3... time my child had speech difficulties.

. Pestcring others is a problem with my child.

My child can out things with scissors as well as can
others of his (her) age.

. My child doesn‘t seem to care to be with others.

My child has difficulty doing things with his (her)
hands.

. Others think my child is mean.

My child seems to know everyone in the
neighborhood. ‘

. My child would never take advantage of others.

My child can be left home alone without danger.
My child jumps from one thing to another.

My child has been in trouble for attacking others.

. My child seems too serious minded.

My child hasmore friends than most children.

. When my child gets mad. watch out.

My child really has no real friend.

. My child is as happy as ever.

My child often complains that others don‘t
understand him (her).

GO ON TO THE NEXT PAGE

5|.

52.

53.

55.

57.
58.

59.

6|.
62.

63.

65.

67.

69.

70.

7|.

72.
73.

74.

7'3.

144

. My child has very few friends.

My child likes to play active games and spans.

Sometimes I worry about my child‘s lack of concern
for others‘ feelings.

Often my child is afraid of little things.

. My child tends to see how much he (she) can get

away with.

My child almost never argues.

. My child often disobeys me.

My child likes to show off.
Others have said my child hasa lot of ”personality."

My child goes to bed on time without complaining.

. My child likes to “boss” others around.

Reading has been a problem for my child.
A scolding is enough to make my child behave.

My child sometimes disobeys his (her) parents.

. My child is in a special class in school (for slow

learners).

My child usually plays alone.

. My child sometimes eats too many sweets.

My child often brings friends home.

. My child learned to count things by age six years.

My child could print his (her) first name by age six
years.

My child doesn't seem to learn from mistakes.

My child can‘t seem to wait for things like other
children do.

My child always does his (her) homework on time.
My child is usually a leader in groups.

Sometimes my child lies to avoid embarrassment
or punishment.

Other children make fun of my child’s different
ideas.

76.
77.

78.

79.

82.
83.

84,

' 85.

87.

89.

9|.
92.

93.

95.

97.

98.

I00.

Sometimes my child‘s muscles twitch.
My child worries about talking to others.

My child first talked before he (she) was two years
old.

School teachers complain that my child can‘t sit
still.

. My child has some bad habits.

Several times my child has spoken of a lump in his
(her) throat. ‘

My child frequently has nightmares.
My child almost never acts selfishly.
My child is usually in good spirits.

My child seems fearful of blood.

. My child seems more clumsy than other children

his (her) age.

My child will do anything on a dare.

. My child sometimes becomes envious of the

Wnions or good fortune of others.

Shyness is my child's biggest trouble.

. Usually my child gets along well with others.

My child gets lost easily.
My child often has headaches.

My child seems to get along with everyone.

. My child is easily embarrassed.

My child is very popular with other children.

. My child gets confused easily.

My child is almost always smiling.

My child loses most friends because of his (or her)
temper.

. My child is shy with children his (her) own age.

My child was difficult to toilet train.

My child wants a lot of attention when sick.
GO ON TO THE NEXT PAGE

|02.

|03.

|08.

I09.

110.
m.
”2.
”3.
m.
us.
“6.
iii.

“8.
“9.

I20.

I2l.

I22.
l23.
I24.
l25.

l27.

145

My child can count change when buying something.

My child can tell the time fairly well.

. Many times my child has become violent.
. My child can take a bath by him (her) self.
. Recently my child has complained of chest pains.

. There is seldom a need to correct or criticize my

child.

My child has as much pep and energy as most
children.

Recently the school has sent home notes about my
child's bad behavior.

Sometimes my child will put off doing a chore.
My child often talks about death.

My child has been difficult to manage.
Sometimes my child‘s room is messy.

My child is usually afraid to meet new people.
My child almost never needs punishing or scolding.
My child could eat with a fork before age four years.

Often my child complains of blurring (blurred
vision).

My child needs protection from everyday dangers.
My child respects the property of others.

Frequently my child will put his (her) hands over
his (her) ears.

Everything has to be perfect or my child isn’t
satisfied.

Spanking doesn‘t seem to affect my child.
My child talks a lot about his (her) size or weight.

My child often will cry for no apparent reason.

My child will worry a lot before starting something
new.

. My child usually looks at the bright side of things.

My child often has crying spells.

l28.

l29.

|3|.

Sometimes my child gets hot all over without
reason.

My child seems tired most of the time.

. Others have remarked how smart my child is.

My child takes illness harder than most children.

60 ON TO THE NEXT PAGE
(unless instructed to stop at the end of Part |)

146

 

 

PARTII
l32. My child tends to pity him (her) self. I58. Most of my child‘s friends are younger than he
(she) is.
I33. Others always listen when my child speaks.
I59. There is a lot of swearing at our house.
l34. Several times my child had complaints. but the
doctor could find nothing wrong. I60. My child never takes the lead in things.
I35. I often wonder if my child is lonely. I6I. My child takes criticism easily.
I36. Usually my child takes things in stride. I62. My child sometimes swears at me.
I37. My child is likely to take remarks the wrong way. I63. My child is not worried about disease.
l38. Little things upset my child. I64. My child seems bored with school.
I39. My child keeps thoughts to him (her) self. I65. The child's parents are now separated or divorced.
I40. It has been a long time since our family has gone I66. My child gets exhausted so easily.
out together.
I67. I can‘t get my child to do his (her) school lessons.
|4I. My child has never mentioned his (her) heart racing
or pounding. I68. My child stays close to me when we go out.
I42. My child has usually been a quiet child. I69. Often my child goes about wringing his(her) hands.
I43. At times my child has seriously hurt others. I70. The child‘s parents have broken up their marriage
‘ several times.
I44. My child has never had cramps in the legs.
”I. Sometimes my child runs errands for me.
I45. At times my child yells out for no reason. -
I72. It is not too unlikely that my child will stay in the
I46. My child is liable to scream if disturbed. house for days at a time.
I47. My child has no special talents. I73. My child has had brief periods of time when he (she)
seems unaware of everything that is going on.
I48. Our family seems to enjoy each other more than
- most families. I74. My child has never had face twitchings.
I49. My child broods some. I75. My child usually runs rather than walks.
I50. My child could do better in school if he (she) tried. I76. My child is different from most children.
I5l. M h'ld liked to be cuddled.
’ c ' m" 117. My child is afraid of dying.
I52. ' has bee table hak .
0‘" "mm“ " my m (‘ y) us. My child believes in: God.
l53. T h'ld' f t ' lo of the h'ld.
he c ' . ‘ h" seems j“ us c . I79. My child doesn‘t seem to care for fun.
I.I fid h'ld'htbe " .
5‘ am ‘ ra my c ‘ m“ '0." insane I80. Often my child will sleep most of the day on a
I55. My child seldom talks about sickness. holiday.
I56. My child has had convulsions. I8I. My child often stays in his (her) room for hours.
l57. My child often gets up at night. I82. My child has never had any paralysis.

GO ON TO THE NEXT PAGE

I83.

I84..
I85.

I86.
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I88.

I89.

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I92.

I93.

I94.

I95.
I96.
I97.

I98.

I99.

20l.

202.

203.

205.

207.

147

My child seldom breaks rules.

How to raise the child has never been a problem
at our house.

Several times my child has threatened to kill him
(her) self.

My child usually doesn‘t trust others.
My child has many friends of the opposite sex.
My child seems unhappy about our home life.

Others often remark how moody my child is.

. The trouble with my child is a “chip on the shoulder.“

Nothing seems to scare my child.

My child doesn‘t wem to be interested in practical
things.

My child can‘t seem to keep attention on anything.

The child‘s parents are not active in community
affairs.

My child tends to swallow food without chewing it.
My child loves to stay overnight at a f riend‘s house.
School has been easy for my child.

My child can‘t sit still in school because of
nervousness.

I do not approve of most of my child‘s friends.

. Constipation has never been a problem for my child.

My child is often restless.

Several times my child has been in trouble for
stealing.

My child seldom complains of stomachaches.

. My child has never failed a grade in school.

My child is afraid of strangers.

. The child's parents can't seem to live within their

income.

My child loves to work with numbers.

. My child has never been in trouble with the police.

2|0.

2| I.
2|2.
2|3.
2|4.

2|5.

2|6.
2|7.
2|8.
2|9.

22I.

222.

223.
224.
225.

226.

227.

228.

230.

23I.

232.

233.

. My child seldom visits a doctor.

My child's favorite stories are fairy tales or nursery
rhymes.

The child's father doesn‘t,understand the child.
Dizzy spells are no problem with my child.
The child's father drinks too much.

My child tends to brag.

’

My child would rather be with adults than with
children his (her) own age.

My child tends to be pretty stubborn.
My child seldom talks.
Our whole family seldom gets to eat together.

Reading is my child's favorite pastime.

. The child‘s father usually makes the important

decisions at our house.
“Bad days” are frequent with my child.

My child insists on keeping the light on while
sleeping.

My child seems to prefer adults to children.
My child is dependent on others.

My child gets common colds more often than most
children.

The child's parents disagree a lot about rearing the
child.

Often my child locks himself (herself) in the
bedroom.

Often my child will laugh for no apparent reason.

. My child sometimes skips school.

My child is not as strong as most children.

Others have remarked how self-confident my child
is in a group. ‘

Others often remark how sensible my child is.

My child seems to understand everything that
is said.

00 ON TO THE NEXT PAGE

 

234.

235.
236.
237.
238.

239.

240.
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242.

243.

244.
245.
246.

247.

248.

249.

25I.
252.
253.

255.

256.

257.

258.
259.

260.

148

Sometimes the child's father will go away for days
after an argument.

Money seems to be my child's biggest interest.

I have often found my child playing in the toilet.
The child‘s father sometimes gets drunk and mean.
My child is a healthy child.

My child thinks others are plotting against him
(or her).

Usually my child plays inside.
The child's father seldom misses work.
Often my child takes walks alone.

The child‘s parents have set firm rules that must
be obeyed.

Often my child will wander about aimlessly.
Several times my child has threatened to run away.
At times my child has difficulty breathing.

There is always a lot of argument at our dinner
table. -

My child plays with friends who are often in trouble.

My child seldom has nose bleeds.

. My child has never been expelled from school.

My child whines a lot.
My child has never run away from home.

My child shows unusual talent.

. Speaking up is no problem for my child.

I had an especially difficult time with temper
tantrums in my child at an early age.

Sharing things has been no problem for my child.

The child‘s parents always discuss important
matters before making a decision.

My child smokes at home.
The child's father frequently“blows up"at the child.

My child is shy with adults.

26I .
262.
263.

264.

265.
266.
267.

268.

270.
2‘” .
272.
273.
274.
275.
276.

277.

278.

279.

280.
go? Miami!

I have heard that my child drinks alcohol.
My child is rather absent-minded.
My child is afraid of the dark.

My child boasts about being sent to the principal
in school.

My child never has fainting spells.
The child‘s father is too strict with the child.
My child will never clean his (or her) room.

My child is able to keep out of everyday danprs.

. Most of my child‘s time is taken up watching

television.

'Frequently my child has a high fever.

The child's father is hardly ever home.
Sometimes I don't understand what my child means.
My child is exceptionally neat and clean.

My child speaks of him (her) self as stupid or dumb.
There is a lot of tension in our home.

Several times my child has threatened to kill others.

The child‘s father spends very little time with the
child.

My child seldom has back pains.

The child's father has very little patience with
the child.

The child‘s parents frequently quarrel.

GO ON TO THE NEXT PAGE
unless Instructed to stop at the end of Part II)

 

149.

Use of the mother as respondent has particular
advantages and helps overcome many of the limitations
associated with requesting the child to respond to
numerous self-report descriptions. Referred children
are often non-compliant and hence would not accept a
technique requesting them to read and respond to a large
number of questions. There are wide differences in
verbal comprehension abilities in children that restrict
the types and richness of items possible. In addition,
the PIC validity scales signal respondent defensiveness
or exaggeration. Rather than representing the mother's
intentional distortion or the mother's personality, the
PIC has established predictive accuracy (Lachar, Kline,
s Boersma, in press).

Informant Response Style

Lie agele,1Ll. This rationally developed scale was
constructed to identify a defensive response set in the
informant. L reflects the absence or denial of behavior
problems. L elevation increases when the respondent
intentionally attempts to portray the child as having
fewer problems than is actually the case.

Eregneney seele 121. This scale consists of seldom
ensorsed items. The F scale obtains extreme elevations
for profiles generated by All True, All False, and
Random Sort response sets. The F scale also reflects
the severity of symptoms.

Defensiceness Scale IDBEl. This empirically
constructed scale is composed of items that separated
mothers judged to be high-defensive from mothers judged
to be low-defensive. It reflects fake-good response
sets.

General Adjustment

Adjustment Scale iADll. This scale is a screening
measure to identify children in need of a psychological
evaluation and as a general measure of poor
psychological adjustment. It was empirically
constructed by comparing the items endorsement rates for
600 normal boys 7 to 12 years of age to the item
endorsement rates for 200 maladjusted boys 7 to 12 years
of age.

The Cognitive Triad

Aehieyement agele,LA§Hl. This empirically derived
scale identifies children with limited academic
abilities, poor achievement, and poor psychological
adjustment characterized by impulsivity, limited
concentration, over or under assertiveness with peers,
and disregard for parental expectations. These children
usually possess adequate intellectual capacity.

Intellectual Screening Scale IISl. This scale was
empirically constructed to identify children with
impaired intellectual functioning. Items were
identified by constrasting the protocols of retarded
children with normal, nonretarded disturbed, and
psychotic children.

 

150

(DyLl. This scale was rationally
derived and reflects retarded development in motor
coordination, poor school performance, and lack of any
special skill or abilities.

PIC scales were constructed using two methods. An
empirical approach involved comparing a group of people
without known psychopathology, i.e., 'normals,' with
groups of other persons believed to have certain
problems of living, i.e., "criterion'l groups. A second
approach was the rational method. Here the researchers
asked persons knowledgeable in the field to pick items
from the total pool which they believed could be related
to the disposition under question. Those items for
which there was high agreement among the judges made up
a scale which was tested using a criterion group to
determine if the scale in fact discriminated among
groups.

Due to the limitations posed by the task of
completion of a GOO-item inventory by a parent
informant, a Revised Format Manual Supplement and
Administratin Booklet were published (Lachar, 1982).
The Revised Format Administration Booklet retains all
600 original inventory items, but presents these items
in a different order. Completion of the first 280 items
of the Revised Format Administration Booklet allows the
scoring of the factor scales, validity and screening
scales, and the clinical scales.

The shortened profile scales have retained their
reliability properties. Both coefficient alpha
estimates of internal consistency and three test-retest
estimates of temporal consistency suggest that the
shortened versions have retained their reliability. In
addition, the equivalence of shortened and full-length
scales was evaluated (Lachar, 1982). The results again
suggest strong concordance between shortened and full
scales with a variety of populations. Lachar (1982)
concluded that all available evaluations of the
shortened profile scales suggest that they provide
reliable and valid data regarding child functioning.

 

APPENDIX D

THE REVISED BEHAVIOR PROBLEM CHECKLIST

Identification Number

53(3231F53IJIRCEIEIRXI IBEEIIJ§\IIECJI? (ZIIEZ(3!<1.3[£51P

Please rate your child’s behavior after surgery on the
following 89 items. If an item does not constitute a problem
or if you have had no opportunity to observe or have no
knowledge about the item, circle the zero. If an item
constitutes a mild problem, circle the one: if an item
constitutes a aevere problem, circle the two. Please
complete every item and remember to rate your child’-
behavior only following surgery.

Thank you for your cooperation.

151

 

 

152

Identification Number

I>C3£31rlit3£31?1[7r151.3E23111P3EC311
IBIEIIJK‘IJECJI? (ZIIEE(3!(I.JEES1T

Please complete the following two queetiona.

1. How many nights did your child remain in the hospital?
Circle One: 1 2 3 4 5 6 7 8 9 10+

2. How many times has your child been admitted overnight to
a hospital, including this past hospitalization?
Circle One: 1 2 3 4+

Please rate your child’s behavior since discharge from the
hospital on the following 89 itemm. If an item does not
constitute a problem or if you have had no Opportunity to
observe or have no knowledge about the item, circle the zero.
If an item constitutes a mild problem, circle the one: if an
item constitutes a mevere problem, circle the two. Please
complete every item and remember to rate your child’m
behavior only mince discharge from the hospital.

Thank you for your cooperation.

 

 

d
PP?N99‘§9.~:‘

.8;5.2.5.6awsssssswssszsswsss

0'
d

153

Restless; unable to sit still ......................................... O 1 2
Seeks attention; "shows-off" ....................................... 0 1 2
Stays out late at night ............................................ O 1 2
Self-conscious; easily embarrassed ................................. O 1 2
Disruptive; annoys and bothers others ............................... 0 1 2
Feels inferior .................................................... O 1 2
Steals in company with others ..................................... O 1 2
Preoccupied; “in a world of his own;" stares into space . . . . . . . . . . : ..... O 1 2
Shy. bashful .................................................... O 1 2
Withdraws; prefers solitary activities ................................. O 1 2
. Belongs to a gang ............................................... 0 1 2
. Repetitive speech; says same thing over and over ..................... 0 1 2
. Short attention span; poor concentration ............................. 0 1 2
. Lacks self-confidence ............................................. O 1 2
. lnattentive to what others say ...................................... O 1 2
. Incoherent speech. what is said doesn't make sense ................... 0 1 2
. Fights ......................................................... 0 1 2
. Loyal to delinquent friends ........................................ O 1 2
. l-las temper tantrums ............................................. 0 1 2
. Truant from school. usually in company with others .................... 0 1 2
. Hypersensitive; feelings are easily hurt .............................. 0 1 2
Generally fearlul; anxious ......................................... 0 1 2
Irresponsible, undependable ....................................... O 1 2
Has "bad" companions. ones who are always in some kind of trouble . . .. O 1 2
Tense. unable to relax ............................................ 0 1 2
Disobedient; difficult to control ..................................... O 1 2
Depressed; always sad ....... « .................................... O 1 2
Uncooperative in group situations ................................... 0 1 2
Passive. suggestible: easily led by others ............................ O 1 2
Hyperactive; "always on the go" ................................... O 1 2
Distractible; easily diverted from the task at hand ...................... 0 1 2
Destructive in regard to own and/or other's property ................... 0 1 2
Negative; tends to do the opposite of what is requested ................ O 1 2
lmpertinent; talks back ............................................ 0 1 2
Sluggish. slow moving. lethargic .................................... O 1 2
Drowsy; not ”wide awake" ........................................ 0 1 2
Nervous. jittery. jumpy; easily startled ............................... 0 1 2
Irritable. hot-tempered; easily angered ............................... O 1 2
Expresses strange. far-fetched ideas ................................ 0 1 2
Argues; quarrels ................................................. O 1 2
Sulks and pouts ................................................. 0 1 2
Persists and nags; can't take “no" for an answer ..................... O 1 2
Avoids looking others in the eye .................................... 0 1 2
Answers without stopping to think .................................. O ‘l 2
Unable to work independently; needs constant help and attention ........ O 1 2
Uses drugs in company with others ................................. 0 1 2
Impulsive; starts before understanding what to do; doesn't stop and think . . 0 1 2
Chews on inedible things .......................................... O 1 2
Tries to dominate others; bullies. threatens ........................... 0 1 2
Picks at other children as a way of getting their attention; seems to want to
relate but doesn't know how ..................................... 1 2
Steals from people outside the home ................................ 0 1 2

(please go on to next page)

 

151i

Expresses beliefs that are clearly untrue (delusions) ...................

Freely admits disrespect for moral values and laws ....................
Brags and boasts ................................................
Slow and not accurate in doing things ...............................
Shows little interest in things around him or her .......................
Does not finish things; gives up easily; lacks perseverance .............
is part of a group that rejects school activities such as team sports. clubs.
projects to help others ..........................................
Cheats .........................................................
Seeks company of older. “more experienced” companions ........... ,. .
Knows what's going on but is listless and uninterested .................
Resists leaving mother's (or other caretaker's) side ....................
Difficulty in making choices; can't make up mind ......................
Teases others ...................................................
Absentminded; forgets simple things easily ...........................
Acts like he or she were much younger; immature. “childish” ...........
Has trouble following directions ....................................
Will lie to protect his friends .......................................
Afraid to try new things for fear of failure ............................
Selfish; won’t share; always takes the biggest piece ...................
Uses alcohol in company with others ................................
School work is messy. sloppy ......................................
Does not respond to praise fromadults ..............................
Not liked by others; is a “loner" because of aggressive behavior .........
Does not use language to communicate .............................
Cannot stand to wait; wants everything right now ......................
Refuses to take directions. won’t do as told ..........................
Blames others; denies own mistakes ................................
Admires and seeks to associate with “rougher" peers ..................
Punishment doesn't affect his or her behavior ..... _. ..................
Squirms. fidgets .................................................
Deliberately cruel to others ........................................
Feels he or she can't succeed .....................................
Tells imaginary things as though true; unable to tell real from imagined . . .
Does not hug and kiss members of family; affectionless ................
Runs away; is truant from home ....................................
Openly admires people who operate outside the law ...................
Repeats what is said to him or her; "parrots" others' speech ............

88388383

38$8338§3833§3333§?38838838838

CD SA AP aw PB
Raw Score .........

Says nobody loves him or her ...................................... '

‘d‘ddd‘

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‘I'Score ...........

 

 

 

MNMNNNNNNNNNNNNNNMMNNNNNNNNNNNN NNMMNNN

155

3329 Subscales

. Disorder (CD). The CD subscale re resents
a dimen31on of aggress1ve, noncomplaint, quarre some,'

interpersonally aliented, acting-out behavior. It is
also linked with noncompliance with a medial regimen,
lower level of moral reasoning, and attribution of
hostility to others.

' ' Aggressive Diserder (SA). The SA
subscale also represents a dimension of acting—out,
externalizing behavior. However, unbridled
agressiveness and interpersonal alienation are not
present. There are strong bonds with others, socialized
delinquency, greater susceptibility to peer influence,
without cognitive deficits.

Attention arablems (AP). The subscale reflects
problems in concentration, perseverance, impulsivity,
and direction-following which leds to a deficient
ability to come to grips with the demands of both home
and school.

' - ' (AW). This subscale represents
the internalizing dimension of disorder which subsumes
such characteristics as anxiety, depression, fear of
failure, social inferiority, and self-concern,
reflecting subjective distress.

' Behaxigr (PB). The PB scale is comprised
both of items that are clearly related to overt
psychosis, and items related to language dysfunction.

notorziension Excess (ME). ME involes both gross
motor behaviors and apparent motoric tension.

 

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