palsy
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Résumé du premier article
Objectif. Examiner en quoi la déficience motrice cérébrale (DMC) et le score d’acceptation
sociale peuvent prédire les attributions d’intentions (AI).
Méthode. À 10 ans, le score d’acceptation sociale est obtenu par une entrevue
sociométrique réalisée dans la classe de l’enfant atteint de DMC. À 15 ans, les enfants complètent le Home Interview with Child (HIWC), un questionnaire mesurant les AI.
Résultats. Les enfants atteints de DMC, particulièrement les filles, sont plus rejetés et
moins populaires que leurs pairs à 10 ans. À 15 ans, les enfants rejetés et populaires font davantage d’AI hostiles que les enfants de statut social moyen.
Conclusions. Il n’y a pas d’effet combiné (interaction) du statut de naissance et du statut
social sur les AI. Toutefois, connaissant le risque de difficultés sociales associé à la DMC, les opportunités de participation sociale devraient être considérées pour comprendre le développement de la compétence sociale chez ces enfants.
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Sociometric status and the attribution of intentions in a sample of adolescents with cerebral palsy
ANNE-PIER VOYER 1 3, RÉJEAN TESSIER 1 3 & LINE NADEAU 2 3
1 School of Psychology, Université Laval, Quebec City, Canada and University Hospital
Research Center (UHRC), Quebec City, Canada, 2 Department of Readaptation, Université
Laval, Quebec City, Canada and 3 Center for Interdisciplinary Research in Rehabilitation
and Social Integration, Quebec Rehabilitation Institute, Quebec City, Canada.
Corresponding author
Anne-Pier Voyer, B.A., Ph. D. candidate 525, boul. Hamel, H-608 Quebec, Qc Canada G1M 2S8 001 418 529-9141, # 6072 anne-pier.voyer.1@ulaval.ca Keywords
26 Abstract
Purpose.To examine how cerebral palsy (CP) and sociometric status at age 10 explain the
development of a cognitive bias across two groups of adolescents aged 15.
Method. Children with CP (n = 60) and without CP (n = 57) are part of a follow-up study.
Three categories of sociometric status (popular, average, rejected) were obtained by conducting a class-wide interview in the class of the target children at age 10. At 15 years old, the same children (CP and non-CP) were asked to complete the Home Interview With
Child (HIWC) questionnaire measuring a cognitive bias (hostile attribution of intentions (AI)).
Results. Children with CP, especially girls, were significantly more rejected and less
popular than controls at age 10. At age 15, amongst all participants, sociometric rejected and popular children tended to have a higher percentage of hostile AI than sociometric
average children.
Conclusions. There were no significant results for the combined effect of CP and
sociometric status on the development of hostile AI at age 15. However, knowing the risk incurred by children with CP of being socially rejected, attention should be paid in the rehabilitation process to opportunities for social participation to facilitate the development of social competence.
27 Introduction
Cerebral palsy (CP) is a non-progressive motor disorder characterized by deficits in movement and posture. It affects 2 to 2.5 children per 1000 live births [1], half of whom were born prematurely [2]. Children with level I and II spastic hemiplegia or diplegia on the Gross Motor Function Classification System (GMFCS) scale are generally integrated in regular classrooms in the Québec education system [3]. However, some data indicate that a higher proportion of children with CP attending mainstream schools are rejected than their peers without disability [4]. They are often considered less popular in a group, have fewer friends, and are bullied more often than children without CP [5]. It has been suggested that the visibility of the disability only partly explains the variance in their social difficulties [6]. Other intrinsic components might be associated with the social competence difficulties observed in children and teenagers with CP.
According to the SOCIAL model [7], social competence results from the dynamic interactions of different components (brain development and integrity, internal and external individual factors) and the subsequent development of cognitive functions linked to social competence (i.e., attention-executive skills, communication skills and socio-emotional skills) (figure 1).
Insert figure 1 about here
The major brain components affected in CP are white matter and motor pathways [8], which have an influence on motor abilities (e.g., walking, fine motor skills) and cognitive functions [9]. Moreover, children with CP are known to be more susceptible to general cognitive problems than children without CP. According to various studies, children with CP have difficulty with short-term memory [10], information processing speed [11, 12], attention and executive functions [9, 13, 14], and visual-spatial and language impairments [9]. External environmental factors such as social acceptance from peers is also considered in the SOCIAL model for the understanding of social competence. Research has shown that acceptance scores as early as from the beginning of kindergarten could predict later adjustment outcomes such as emotional adjustment and achievement in later years [15] and, conversely, poor social acceptance induces a negative perception of
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self and others, resulting in an inaccurate perception of the social environment. Studies have also shown that children with CP were slower to interpret facial expressions and their interpretations were less accurate than those of children without motor problems [16]. It has been suggested that such social difficulties observed in children with CP could contribute to the bias observed in the development of their social competence [9, 12], which is better understood as “false attribution of intentions”.
Attribution of intention (AI) is related to empathy and theory of mind. It represents the ability to interpret basic and complex social information to infer causes or intent to the behaviour of others. AI is known to be a mediator between basic emotion perception and more complex cognitive activities modelled in the theory of mind [7]. Through social experiences and personality development, children with CP are at risk of developing cognitive biases such as a hostile AI bias, which is defined as the tendency to interpret others’ intention as being deliberately mean when it is not necessarily so. This bias makes them assume that peers could act with hostile intent towards them.
The questions arising from this state of knowledge include how to describe social acceptance from childhood to adolescence in the context of CP and how it could predict the attribution of others’ intentions. The main objective of this study was to describe the children with CP’s social competence (measured by sociometric status: popular, average or rejected) at 10 years old, and from a longitudinal perspective, to better understand how this social competence might be compared to that of normally developing children from childhood to adolescence. Therefore, the research question was: could a rejected sociometric status at elementary school combined with having CP hinder the development of AI, a socio-emotional cognitive function linked to social competence during adolescence, as described in the SOCIAL model? Based on the literature, the objective of this study was, first, to confirm the negative sociometric status of children with CP compared to children without CP at age 10, and second, to examine the longitudinal pattern that might explain the development of a cognitive bias (described as a percentage of hostile AI) at age 15. The compound effect of birth status (CP or non-CP) and sociometric status at age 10 was expected to be linked to the development of an AI bias during adolescence.
29 Methods Participants and procedures
This study is part of a two-phase longitudinal study [4]. In phase I, the sociometric status of children with a diagnosis of CP recruited from the records of seven rehabilitation centres across the Province of Quebec (N = 117) were identified. All participants had to attend a mainstream elementary school and be in grade 4, 5 or 6 (i.e., between age 9 and 12). Children with CP had to have been diagnosed with level I or II CP (hemiplegia or diplegia) on the GMFCS scale [17]. Children with level III to V CP (GMFCS) and children with moderate to severe visual, auditory or intellectual impairments were excluded. All recruited children with CP, whose parents had given their prior consent (N = 60), were visited in their respective school environments for the sociometric interview. This initial sample included 25 girls and 35 boys (mean age: 10.6 years) with a diagnosis of hemiplegia (73%) or diplegia (27%). They were matched on three variables (family income, child’s gender and mother’s education) to children without CP (N = 57: 22 girls and 35 boys) in their class. One matching was not possible due to a lack of parental consent and one group of triplets with CP was assigned to only one control in the classroom.
In phase II (this study), children from phase I were sent questionnaires by mail. Thirty-nine 15-year-old children with CP (19 girls and 20 boys) (65% of phase I) with hemiplegia (69%) or diplegia (31%) returned the questionnaires. Thirty-two controls (56% of phase I) did the same (14 girls and 18 boys) (figure 2). T-tests for independent samples were conducted to compare both groups on different variables (table 1). Levene’s test indicated unequal variances for the variable Age (F (54.24) = 7.55, p = .008), so degrees of freedom were adjusted from 69 to 54.24. There were no significant group differences except for intelligence quotient (IQ), which was significantly lower (7 points) in the group of children with CP.
30 Measure, phase I
Sociometric status: sociometric interview. The social acceptance measure was obtained by conducting a class-wide sociometric interview in the class of the target child (with CP) based on the sociometric status nomination method proposed by Coie, Dodge and Coppotelli [18], of which we only used the Social Preference axis. Every child was asked to name two classmates 1) with whom they liked doing activities the most (liked most score), and 2) with whom they liked doing activities the least (liked least score). These answers were standardized within each class using a z-score transformation for an easier inter-class comparison, with a higher score reflecting a more extreme level of each score. The social preference score was computed by subtracting the liked least score from the
liked most score (liked most - liked least). Following other studies stating that the one standard deviation (SD) cut-off is an arbitrary concept that does not necessarily apply to a clinical population [19, 20], a more lenient cut-off score of 0.75 was used in this study. The highest scores (> 0.75 SD) represent the sociometric status popular and the lowest scores (< 0.75 SD) represent the rejected sociometric status. In-between scores were grouped in the
average sociometric status. Measure, phase II
Socio-emotional cognitive functions. AI was measured with the Home Interview
with Child (HIWC: [21]), which has been frequently used to assess AI (e.g., [22-24]). The version used in this study was a French translation adapted for adolescents.
The HIWC is based on two types of ambiguous social situations. There are four situations described as “ambiguous minor harm” (e.g., being hit by a ball) and four as “unsuccessful peer entry” (e.g., being unable to sit with a group of peers at lunchtime). All adolescents, with and without CP, completed the HIWC at 15 years old. They were asked to interpret the intention of their peers by answering the question: “Why do you think the child reacted this way in this social situation?” The percentage of hostile attribution responses to the eight stories is calculated by dividing the hostile category count by the total number of responses (“Hostile” / (“Hostile” + “Non-Hostile” + “Don’t know”)). This score is called Hostile Attributions score. In this study, two judges coded the answers and
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obtained an acceptable reliability estimate (k = .805). When two or more responses were given to the same situation, only the first was recorded.
Statistical procedures
Data were analyzed using SPSS 20.0. For the first hypothesis, two-way between-groups analyses of covariance (ANCOVA) were conducted to compare social acceptance in children with CP and control children using a Bonferroni adjusted alpha level. Because of the significant difference in IQ scores between groups and the possible effect of gender on the social and socio-cognitive measures, those variables were covaried where applicable. Using the Coie, Dodge and Coppotelli method [18], children with CP and control children were classified according to three sociometric statuses: popular (liked most scores),
rejected (liked least scores) and average (in-between scores). For the second hypothesis, birth status (CP or non-CP) and sociometric status were regressed on the Hostile
Attributions score using two-way between-groups ANCOVA. Results
Sociometric status at 10 years old
A two-way between-groups ANCOVA (controlling for IQ and gender) with a Bonferroni adjusted alpha level of .012 showed that children with CP were significantly less likely to
be nominated in the liked most category (15.4% vs 40.6%) (F(1,66) = 7.92, p = .006, η2 =
.11) and more likely to be nominated in the liked least category (53.8% vs 12.5%) (F(1,66)
= 7.32, p = .009, η2 = .10). Since the Social Preference score was created by subtracting the
liked least from the liked most z-scores, a difference was also observed between children with CP and controls, with the former being less socially preferred (F(1,66) = 11.72, p =
.001, η2 = .15). Moreover, a significant interaction was observed between gender and birth
status, suggesting that girls with CP were significantly less socially preferred than control
girls (F(1,65) = 5.60, p = .021, η2 = .08), and this pattern was not observed for boys (table
2).
32 Attribution of intentions at 15 years old
For the second hypothesis, a two-way between-groups ANCOVA was conducted to examine the combined impact of birth status and sociometric status at age 10 on the Hostile
Attributions score measured by the HIWC at age 15. Variations of IQ and gender were introduced as covariates. Participants were divided into two groups according to their birth status (CP vs non-CP) and into three groups according to their sociometric status (group 1:
popular, group 2: average, group 3: rejected). There was a significant main effect for
sociometric status, F(2,62) = 3.61, p = .033, η2 = .10. Paired comparisons, considering both
birth statuses (CP and non-CP), indicated that the mean score of the average social group (M = 43.93, SD = 4.50) was significantly lower than both the rejected social group score (M = 61.35, SD = 6.32) and the popular social group score (M = 59.69, SD = 5.79) (figure 3). Moreover, there was no interaction effect between birth and sociometric status and neither birth status nor gender reached statistical significance.
Insert figure 3 about here
Discussion
The objectives of this study were 1) to compare the sociometric status of children with CP to that of children without CP at age 10, and 2) to investigate how this status was linked to the development of a socio-emotional cognitive function (attribution of intentions) at age 15, using the SOCIAL model [7]. First, as expected, results showed a clear difference between children with CP and controls on the sociometric dimensions: the former were less frequently nominated in the Liked most category and more often nominated in the Liked
least category, which indicates that they were less socially accepted than control children at age 10. The girls but not the boys were more rejected and less popular than their control counterparts. These results replicate previous results in the field, which found that a greater proportion of children with CP included in mainstream schools were rejected than their peers; they were often considered less popular in a group, had fewer friends and were bullied more often than children without CP [4, 5]. The presence of a motor disability seems to be an obstacle to positive sociometric status, which could foster social isolation particularly for girls. Similarly to Nangle and his colleagues [25] and Mrug, Hoza and
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Bukowski [26], we suggest that girls with CP are less popular because they are mainly assessed by girls and do not have enough similarities with them to be counted amongst their potential friends. Our results suggest that even after many years of school integration, girls with CP have poor social outcomes, which calls into question the government’s school integration policies and the rehabilitation programs already in place to address this problem.
Theoretically, as cognitive abilities develop through the teenage years, typical adolescents become more competent in interpreting social cues and the presence of a hostile AI bias in ambiguous contexts normally tends to decrease during adolescence [27, 28]. Based on this, we expected that children with CP would present a different type of pattern because of their prior cognitive characteristics and their earlier negative sociometric status. Significant differences were found not between birth statuses but unexpectedly between sociometric statuses: rejected and popular children (both children with and without CP) developed a higher level of hostile AI at 15 years old compared to the average sociometric group. In this context, it is suggested that there is a cost related to being at both ends of the sociometric status continuum during adolescence.
This result seems to be congruent with those of Buhs and Ladd [15], which demonstrated that peers’ acceptance (i.e., popular or rejected status) could predict children’s adjustment. For rejected children, a succession of negative social experiences could lead them to think that others probably have hostile intentions towards them. In fact,
rejected children more often experience negative social situations where peers’ behaviours are in fact hostile towards them. The development of a hostile AI bias thus seems to be related to their social context. Being in the rejected social position seems to affect the sensitivity to others, which might be mentalized as “I am different” or, even worse, “others don’t like me”. This might be specifically attributable to the girls with CP in this study as there were no control girls in the rejected subgroup. The other hypothesis to be considered is the often low level of social participation observed in children with CP in their classroom. Normally, adolescence is a period where more and more social experiences are possible and teenagers can foster their social competence. This is certainly not the case for adolescents experiencing chronic rejection.
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Results according to AI at 15 years old also suggest that popular children tend to have a higher level of AI hostility than average children. It is not clear in the literature why this kind of bias would develop in these adolescents since the majority of studies looked at the impact of rejection on later adjustment. We hypothesize that this response in popular children could result from the constant need to detect what might threaten their envied social position so they can maintain this position. However, we think that popular and
rejected children are differently motivated to react to hostile AI. Some studies found that
popular children are more competent in coordinating multiple perspectives in a social context and more prone to change their prior hostile cognitive bias when given information according to their peers’ emotional and personality traits [29-31]. In that sense, we suggest that popular adolescents compared to rejected ones could be more flexible in trying to find other explanations than prior hostile AI to understand peer behaviours. This would make them better adjusted in their social response to others and able to maintain their sociometric status.
Finally, our results indicate that children with CP are less socially accepted than their peers in a mainstream school environment at age 10. We also observed that sociometric status, namely rejection and popular statuses, appears to account for differences in hostile AI bias observed at 15 years old. In that sense, the elevated proportion of rejected sociometric status instances noted at age 10 in children with CP should be taken seriously. We think that their sociometric status makes them more likely to reduce their classroom participation and we assume that this is a mediator between rejection scores at age 10 and hostile AI bias observed at age 15 [15]. As the AI hostility percentage at age 10 was not available in our database, the following interpretations are based on normative data related to AI development during adolescence. Studies have shown that social information is normally better interpreted over time and that the AI hostility percentage tends to decrease [32]. However, these results should be interpreted with caution since we cannot know if the children’s percentage of AI hostility remained the same, increased or decreased from age 10 to 15.
35 Conclusion
This study provides some insights into the way mainstream school integration and rehabilitation services should be administered in the context of CP. It shows the importance of comprehensively evaluating children with CP who experience social difficulties, but who do not present major impairments (physically, psychiatrically or cognitively). We think that, from kindergarten on, the social skills of children with CP should be observed