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THE RELATIONSHIP OF SELF-CONCEPT AND

SOCIAL SUPPORT IN SCHOOL AGE
CHILDREN WITH LEUKEMIA
by
LISA DARLYNNE SOUTH
A DISSERTATION
Submitted in partial fulfillment of the requirements for

the degree of Doctor of Science in Nursing in the
School of Nursing in the Graduate S c h o o l ,
The University of Alabama at Birmingham
BIRMINGHAM, ALABAMA
1995
DMI Number:
9527022
Copyright 1995 by
South, Lisa Darlynne
All rights reserved.
OMI Microform 9527022

Copyright 1995, by UMI Company. All rights reserved.
This microform edition is protected against unauthorized
copying under Title 17, United States Code.
UMI
300 North Zeeb Road
Ann Arbor, MI 48103
Copyright by
Lisa Darlynne South
1995
ABSTRACT OF DISSERTATION
GRADUATE SCHOOL, UNIVERSITY OF ALABAMA AT BIRMINGHAM
Degree
D.S.N_______________ Major Subject
Name of Candidate
Title
Maternal Child Nursing
Lisa Darlynne South_____________________________
The Relationship of Self-Concept and Social Support___________

in School Age Children With Leukemia__________________________
Since 1960 there have been many advances in the treat
ment of pediatric cancers. With the focus of care shifting

from prolonging remission to the reality of cure, the p s y
chosocial well being of the pediatric oncology client must
be addressed.
The purpose of this study was to describe
perceived social support and self-concept of school age

children with leukemia,
and to ascertain if there is a
relationship between social support and self-concept of

school age children with leukemia.
The Neuman Systems model
served as the organizing framework for the research.

A convenience sample of 17 school age children with
leukemia was recruited from pediatric oncology treatment
centers in the southeast.
The Piers Harris Children's Self-
Concept Scale and the Personal Resource Questionnaire,

2 were utilized for data collection.
of descriptive statistics,
Part
Data analysis consisted
stepwise multiple regression,
and
one-way analysis of variance.

Results of the research show that school age children
with leukemia with lower levels of perceived social support
iii
are significantly more likely to have lower self-concept in

comparison to children with higher perceived social support.
Perceived social support of the sample was moderate to high.
Self-concept of the sample was average to high. There was a
strong positive relationship between social
self-concept of school
support and
age children with leukemia.
By c o n
trolling for race and sex, nearly one half of the variance
in self-concept was accounted for by social support.
Implications included teaching client and family s t r a t
egies for dealing with disease specific social situations.
Positive and effective coping strategies should be i de nti
fied and reinforced from the point of diagnosis and t rea t
ment initiation.
Crisis points,
and relapse of disease,
such as remission induction
can be anticipated,
and intervention
efforts can be intensified in preparation for these crisis

points.
Children at increased risk for psychosocial
should be identified,
problems
and more intense attention should be
focused on those children.

Further study of self-concept and social
support in
children should include children with solid tumors,

as hematogenous malignancies,
ic illnesses.
as well
and children with other chron
The Neuman Systems Model would be of benefit
as a guiding theoretical
framework.
)
Abstract Approved by:
Committee Chairman
Program Director _
Date
Dean of Graduate Si
iv
DEDICATION
I wish to thank the children with cancer who
participated in this research.
Clay.
I am especially thankful to
I would not be where I am today without these
children.
I am grateful
for having known them all.
dedicate this work, and its continuation,
to them.
ACKNOWLEDGMENTS
I am especially grateful
to committee members,
especially my chairperson, Dr. Kathy Jimmerson, who provided

me with support and encouragement at every step.
It is with
great appreciation that I acknowledge Dr. Penny Wright,

whose support,
expertise, and encouragement motivated me to
complete my work. Appreciation is also extended to Dr. Ann

Edgil, Dr. Rathi Iyer, Dr. Beth Stullenbarger,
Claypool
for their continued support,
and Dr. John
encouragement,
and
constant but gentle nudging to complete this work.

For their interest,
time, and cheerleading,
I thank the
faculty of 346 and the staff of 5SE. Their support and

encouragement are greatly appreciated.
Special thanks must go to Ann Douglas, who has shared
much of this experience with me and provided continuous
emotional support. Also,
for his computer expertise and for
always coming through in crisis,
I would like to thank Art
Drott.
I am grateful to God for His blessings of wisdom,
patience, and ability.
I am most grateful
to God for
allowing me to work with children with cancer.
vi
TABLE OF CONTENTS
Page
ABSTRACT
....................................................
iii
DEDICATION ...................................................
ACKNOWLEDGEMENTS
LIST OF TABLES
...........................................
vi
.............................................
ix
........................................
Chapter
I
Introduction
Purpose ............................................
Research Questions ...............................
Assumptions .......................................
Delimitations .....................................
Theoretical Framework ............................
Definition of Terms ..............................
Significance ......................................
S u m m a r y ............................................
II
III
IV
Review of R e s e a r c h ..................................
3
3
4
4
4
14
15
17
18
Self-Concept and Chronic Illness

...............
Psychosocial Responses to Childhood Cancer
...
Social Support and Health
......................
Self Concept and Childhood Cancer
.............
Summary ...........................................
18
22
29
37
39
M e t h o d o l o g y ...........................................
41
D e s i g n .............................................
Instrumentation ..................................
S u b j e c t s ...........................................
S e t t i n g ............................................
Procedure for Data C o l l e c t i o n ..................
A n a l y s i s ...........................................
L i m i t a t i o n s .......................................
S u m m a r y ............................................
41
41
46
46
47
48
49
50
F i n d i n g s ..............................................
vii
51
TABLE OF CONTENTS (Continued)

Chapter
Rqg
Description of Subjects .........................
Analysis of the D a t a .............................
Incidental Findings ..............................
S u m m a r y ............................................
51
52
56
59
Summary, Discussion, Conclusions, Implications

and Recommendations ..............................
61
S u m m a r y ............................................
D i s c u s s i o n .........................................
Limitations ......................................
C o n c l u s i o n s .......................................
Implications ......................................
Recommendations ...................................
References
....................................................
61
63
67
67
68
68
70
Appendices
A
Institutional R eview B o a r d Approval Forms
Program Director Approval
Guidelines for A d m i n ist ra tio n of Research Tools ...
85
Cover Letter ..........................................
89
Demographic Qu estionnaire/Consent
91
Form
........
....................
.................
viii
79
83
LIST OF TABLES
Table
1
Page
Frequency Distribution of Subjects by Age,
Race, and Sex
....................................
52
Descriptive Statistics for Self-Concept Scores.
53
Frequencies for Social Support Scores
55
Stepwise Multip le Regression Summary for

Self-Concept Total
Scores.......................
55
Stepwise Mu ltple Regression Summary for

Behavior Subscale
..........................
56
Stepwise Multiple Regression Summary for

............
Happiness and Satisfaction Subscale
56
Descriptive Statistics for the Mean Self-Concept

Score by Levels of Perceived Social Support ...
57
Self-Concept and
Stage of Therapy
Social Support by
................................
57
Self-Concept
and
Social Support by Race
......
58
10
Self-Concept
and
Social Support by Age
.......
58
11
Self-Concept
and
Social Support by Sex
.......
59
........
ix
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Chapter I
Introduction
Since 1960 there have been many advances in the treat
ment of pediatric cancers. Childhood cancers once viewed as
fatal can now be cured. Approximately 6,000 new diagnoses of
childhood malignancies are made each year. Of this number,
at least one half of these children will be cured of their
disease (Hockenberry, Coody,
S Falletta,
1986). Due to
prolonged survival and increased cure rates,
the child with
cancer requires nursing interventions that, in the past,

were not necessary (Hockenberry, Coody,
& Bennett,
1990).
Long-term psychological sequelae of cancer diagnosis and

treatment,
such as negative effects on the developing self-
concept, have only recently become topics of research.

Advances in therapy have prolonged the life expectan
cies of children with cancer.
In the 1940s, children with
acute lymphocytic leukemia died within a few months of

diagnosis. More than 50% of the children now diagnosed with
this disease will survive 5 or more years disease free
(Howell,
1981). By the year 2000 more than 1 in every 1,000
young adults will have survived childhood cancer

Kazak,
& Meadows,
(Greenberg,
1989). As the medical outlook for ch i l d
hood cancer continues to improve and childhood cancer b e

comes a chronic rather than fatal acute condition, many
2
psychosocial
responses are evolving (Van Dongen-Melman &
Sanders-Woudstra,
1986).
W i t h the focus of care shifting from prolonging remis

sion to the reality of cure, the psychosocial well being of
the pediatric oncology client must be addressed.
Normal
growth and development must be fostered despite the s t r e s s

ors of childhood cancer.
Frequent intensive drug therapy,
painful and invasive procedures,

hospitalizations,
social
influence personal
frequent clinic visits and
isolation,
and long-term adjustment
responses to cancer (Micheal
& Copeland,
1987). Quality of life for the child with cancer should be

evaluated by psychological
Body changes,
stomatitis,
cure as well
as biological
such as weight gain or loss,
amputation,
sterility,
and changes in intellectual
cure.
alopecia,
skeletal abnormalities,
functioning,
are common side
effects of cancer therapy. These changes are constant re

minders to children with cancer that they are different from
their peers.
It is assumed that the basic developmental
course proceeds despite the stressors of cancer;

course might be altered by the cancer experience.
yet, the
Research
is lacking regarding the emotional aspects of living with

childhood cancer
(Van Dongen-Melman & Sanders-Woudstra,
1986). There is little research dealing with self-concept of

children with cancer or with childhood cancer survivors.
Secondary to advances in the treatment of childhood
cancer,
children face psychological stressors previously
unidentified when children with cancer universally died
shortly after diagnosis.

include germ phobias,
related to therapy,
Lon g-t erm psychological sequelae
s el f-e ste em problems,
and depression
delayed puberty
(Koocher,
1986).
School
phobia is 10 times greater in children with cancer than that

in the general
population
Hockenberry
(Klopovich,
1983).
(1986) defines crisis points in pediatric
cancer as apparently unsolvable problems caused by stressful

events,
which lead to loss of individual
equilibrium.
lution of stress is possible only when the individual
Reso
is
able to re-establish equilibrium. Hockenberry identified

crisis points in pediatric cancer as diagnosis,
discontinuation of therapy,
However,
relapse,
treatment,
and end stage disease.
the degree of influence exerted by the stressors of
diagnosis,
treatment,
and living with cancer,
fects of these stressors on social

self-concept,
and the e f
support and the child's
are worthy issues for further study.
Purpose
The purpose of this research was to describe perceived
social support and self-concept of school
age children with
leukemia, and to ascertain if there is a relationship b e

tween social
support and self-concept in school
age children
with leukemia.
Research Questions
The research questions generated for this study i n c l u d
ed:
(a) What is the self-concept of school age children with
leukemia?
(b) What is the perceived social support of school
age children with leukemia?
(c)
Is there a relationship
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4
between social support and self-concept in school age chi l
dren with leukemia?
Assumptions
Assumptions inherent in this study include:
stressors of cancer diagnosis and its therapy,
self-concept of school age children,
(a) The
impact the
(b) the stressors of
cancer diagnosis and treatment effect the perceived social

support of school age children,
(c) accurate self-report
measures of self-concept can be obtained from school age

children
social
(d) accurate self-report measures of perceived
support can be obtained from school age children,
and
(e) responses to the items contained in the research tools

are an accurate reflection of the individual's self-concept
and social support.
Delimitations
This research was limited to school age children a t
tending pediatric oncology clinics of two major treatment
centers in the southeastern states. Uncontrollable extrane
ous variables,
which m a y influence alterations in self-
concept and social support,
include absence or death of a
family member, media presentation content, previous coping

strategies,
and mental
Theoretical
Framework
The theoretical
ability and education.
framework for this research was the
Neuman Systems model
(Neuman,
1989). The concept of concern
is the self-concept.
It is hypothesized that social support
may help to explain some of the variance in self-concept.
Neuman Systems M o d e l . The Neuman Systems model
focuses
on the person and the person's responses to stressors.

person is described as a multidimensional
composite of
biological,
spiritual,
psychological,
developmental variables.
sociocultural,
The
and
The interrelationships of these
variables and the lines of normal defense determine the

degree of resistance a person has to stressors
(Neuman,
1989).
Every person has a central core of basic survival
characteristics.
defense,
Lines of resistance,
the normal
line of
and flexible lines of defense form boundaries for
this core. Stressors vary in their potential to disrupt the

normal
line of defense.
In this holistic approach,
person is able to make specific,
the
unique choices in response
to the stressors of the environment
(Neuman,
1989).
The
person is in a constant state of dynamic equilibrium with

the environment. Neuman defines the environment as the
internal
and external forces surrounding the person.
Based
on N e u m a n s broad definition of the environment and the

focus on stress, Ross and Bourbannais
(1985) speculate that
the environment is composed of stress factors. According to

Neuman, stress is any stimulus producing tension.
Stress has
the potential to cause or intensify illness by disrupting

the person's equilibrium.
Health is a steady state of equilibrium determined by
the biological, psychological,
developmental variables.
sociocultural,
spiritual,
and
It is a process of becoming that
develops over time. H ealth is a reflection of the person's

level of wellness
(Neuman,
1989). This definition allows for
individual differences so that health is not a perfect

state, but the best possible state for the individual
given time
(Whall,
at any
1983). W i thi n the Neuman model, nursing
focuses on the total person and is concerned with all the

variables that stress the person.
Nursing's objective is to
assist the person in maintaining maxi mum health by stre ngt h

ening adaptation,
decreasing encounters with stressors,
and
reducing the effects of stressors that cannot be avoided

(Neuman,
1989).
Utilizing Neuman's model,
the nurse must focus on the
total client system and the system's reactions to stressors.

The client system may consist of an individual
clude significant others.
or may i n
The goals of pediatric nursing are
directed at assisting the client system in attaining optimal

wellness in order to progress through the stages of d e vel op
ment appropriately.
General
reactions to the stressors of cancer depend on
the developmental
capacity,
stage of the child, previous adaptive
the degree of pain and perceived mutilation,
meaning of the illness to the child and family,

child relationship,
in equilibrium.
the
the parent-
and the child's reactions to the change
The nurse must be cognizant of what the
individual is capable of accomplishing developmentally,

physically,
psychologically,
socioculturally,
and spi ritual
ly.
Children are in constant change and m o tio n resulting

from continuous interaction wit h the environment.
Stressors
associated wi th pe diatric cancer penetrate the normal and

flexible lines of defense,
through the lines of resistance,
to invade the core of the individual

ors may affect the biological,
spiritual,
and developmental
individual.
Stressors,
of both are most

individual,
and the family.
psychological,
Stres s
sociocultural,
variables that make up the
coping strategies,
and the appraisal
likely to be directly controlled by the
so they are the most amenable to change through
health promotion efforts
(Neuman,
S e l f - c o n c e p t . Shavelson,
1989).
Hubner,
and Stanton (1976)
broadly defined self-concept as perceptions of self inf lu

enced by environmental
ers.
reinforcements and significant oth
Self-concept is inferred from a person's physical
symbolic responses to situations.

influence actions.
perceptions.
In turn,
or
One's self-perceptions
actions influence o n e s s e l f
These authors identified seven aspects of self-
concept as hierarchial, multifaceted,

developmental,
valuative,
organized,
relatively stable,
and differentiable.
Neuman (1989) does not explicitly define self-concept.

However,
an inference can be made from Neuman's model
that
self-concept is influenced through experience with the

environment. The environmental
influence is implicit in many
of the definitions of self-concept to be discussed.

Self-concept is learned and is an extremely important
aspect of growth and development.
Cooley (1912)
stated that
self-concept is consequentially influenced by what indi vi du

als believe others to think of them. Felker (1974) defined
self-concept as the unique perceptions,
an individual has about the self.
ideas,
Further,
the sum total view one holds of oneself

Self-concept is defined by Burns
and attitudes
self-concept is
(Felker,
1974).
(1979) as m u l t i d i m e n
sional, being composed of what one thinks one is, what one
thinks that others think of oneself, what one thinks one can
become,
and what one would like to become.
unique and personal
Self-concept is
to each i n d i v i d u a l . It is a dynamic
valuative process whereby personal development evolves

through transactions with both the internal and external
environment
(Burns,
1979).
Self-concept consists of two levels.
The basic level
of
self-concept is learned and is relatively stable as age

increases.
The functional
level is continuously evolving
with each new relationship and situation.

levels,
Based on these
it can be surmised that self-concept develops over
time through an individual's perceptions of exchanges with

the social
environment
(Foltz,
1987). This view of self-
concept is consistent with Neuman's systems model
(Neuman,
1989).
There are many theories that describe self-concept.
Common to all theories is the belief that self-concept is an
abstract quality with cognitive and affective components.
Self-concept is learned as the result of experience and,
some extent,
to
is a determinant of behavior.
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Self-concept is useful in coping with chronic illness

and achieving psychological,
as well as biological,
cure. As
defined by van Eys (1987), psychological cure is acceptance

of having had cancer in one's past without evidence of
influence on education,
growth, and development. As new
treatment methods are refined and the numbers of survivors

of childhood cancer increase,
the pediatric client must be
assisted in adjusting emotionally,
intellectually, psych oso
cial ly, and developmentally to life with a chronic illness

(Klopovich,
1983).
Psychosocial responses to childhood cancer and its

treatment are essentially unstudied areas. However,
edge of psychosocial
kn owl
responses to childhood cancer stressors
is necessary so that psychological

(Koocher, O'Malley, Gogan,
cure can be achieved
& Foster,
cal phenomenon of self-concept,
1980). The psychologi
in its multidimensions,
is
the focus of this study.

Social support.
The environment is composed of the
internal and external
forces surrounding a person. The
environment consists of all factors affecting or affected by

an individual
(Neuman,
1989).
Social support can be viewed
as an environmental variable potentiating or alleviating

stress for an individual.
Social support is differential,
comprehensive, multidimensional,
1985). Social
and parsimonious
support is viewed as informal,
noncontractual.
(V eiel,
reciprocal,
and
It also acts to buffer stress by preventing
or reducing stress effects
(Tilden 6. W e i n e r t , 1987).
10
Social support may meet individual needs by fulfilling

the social
functions of social
integration,
attachment,
nurturance, guidance in difficult circumstances,

ance of self-worth (Alloway & Bebbington,
or reassur
1987). Cohen and
Syme (1985) define social support as the resources provided

by others. This help provided by others may be in the form
of feedback, validation,
extent,
or satisfaction of needs. To some
our emotional well being is dictated by the support
of significant others
(Galanter,
1988).
Kane (1988) views negative supports as stressors so

that social support is entirely positive,
nurturing.
encouraging,
and
Cobb (1976) defined social support as information
that leads one to believe that they are loved, cared for,
valued,
and a member of a network with mutual
Social support, as defined by Cobb,

support,
esteem support,
includes emotional
and network support.
ly omitted tangible or material
obligations.
Cobb explicit
support from his definition.
An inductive definition of social support is offered by

Gottlieb (1978), who includes tangible support in three of
four categories of social support.
emotionally sustaining behavior,
ence,
environmental
action,
These categories include
indirect personal
influ
and problem-solving behavior.
In
1981, Gottlieb described social support as supporting the

three constructs of social integration,
interactions,
Weinert
social network
and access to resources in peer relationships.
(1987) considered social support to be composed of
provisions for attachment;
social
integration;
opportunities
11
for nurturing behavior;

accomplishment;
reassurance of individual worth and
and informational, material,
and emotional
aid.
According to Caplan (1974),
mastery of the environment.
social support facilitates
Social
support is a pattern of
ties serving to m aintain psychological and physiological

integrity.
Individuals who receive consistent feedback about
behavior and performance,
and information about resources,
are able to cope most effectively with environmental st r e s s

ors. This definition of social support is difficult to
operationalize but
lends support to the n otion that social
support prevents or reduces the negative effects of stress

on health.
Lin, Dean,
and Ensel
(1986) break down social
into the two concepts of social and support.
support
The social
component reflects the connection of the individual

social
environment at varying levels of intimacy.
to the
The s u p
port component reflects activities deemed to be in strumen

tal,
expressive,
and essential.
Social support is further
seen as attachments serving to promote emotional mastery,

offer guidance,
or provide identity and performance feedback
to the i n d i v i d u a l .
Social
support can be viewed as a coping strategy in
the face of stress. Mutually reciprocated social support is

not protective
(Tilden,
1985).
Several m odels have been
suggested that serve to explain the relationship among

stress,
social
support,
and coping
(Roberts,
1988).
Coping
12
and social support may function as a barrier to stressors.

Social support and coping may alter health habits influ enc
ing symptoms.
Coping and social
support may also alter
adjustment to the stressors of illness. Roberts states that

self-concept is highly related to social support and may be
related to the measurement and presence of social
Malone
support.
(1988) suggests that social network is an u m
brella concept encompassing social support.
Social support
consists of the positive outcomes occurring within the

social network.
According to Malone,
social support and
social dissupport exist along a fluid and dynamic continuum.

Social support generates self-concept and assists the i n d i
vidual
in assuming proper societal
roles.
Social support may
play a part in protecting the self-concept,

stressful
life conditions
(Malone,
especially under
1988).
Stress occurs when situational demands surpass one's

ability to cope with given events.
characteristic of the social
Social
support is a
environment that acts to c u s h
ion the effects of stressors by lessening the severity of

the reaction to the stressor,
efforts,
and empowering the individual
stressor as less stressful

ment,
enhancing individual
including social
overall physical
O'Reilly-Knapp,
(Northouse,
support,
to perceive the
1988).
is a potential
and psychological well being

1994). The loss of social
The envir on
resource for
(Cobb,
1976;
support can be a
factor in both physical disease and psychological

(Bruhn & Phillips,
coping
stress
1984).
13
The literature suggests that social support may play an

important function in coping with cancer diagnosis and
treatment.
Social support plays a critical
role in mediating
the effects of cancer on both family units and individuals.

The loss of social support has been associated with cardio
vascular disease,
accidental injury, suicide, mental ill
ness, school phobias,
cancer,
and gastrointestinal di so r
ders. This suggests that social support may be a source of

prevention.
Social support has been shown to modify the
effects of negative stress as well as to strengthen hope.

social support is positive,
If
it enhances health and well
being. The ability to reciprocate social support is affected

by numerous factors including age, sex,
self-concept
(Bruhn 8 Phillips,
learned coping,
and
1984).
Social support exists everywhere and in everyone by

some definition. As the individual's environment changes,
the individual grows and develops,
support,
or
the need for social
and use of social support changes.
Change in p h y s i
cal and psychosocial functioning of the individual
can
affect their perception of the need and availability of

social support.
If an individual does not perceive that
social support is available,

Phillips,
it cannot be utilized (Bruhn &
1984).
Social support may serve to explain m u c h of the u n e x

plained variance of self-concept in this study.
the multidimensional
Therefore,
concept of social support is included
in this study.
14
Definition of Terms
For the purpose of this research the following d ef ini
tions are provided:
1. Self-concept--a multidimensional composite of unique
perceptions,
attitudes,
and ideas that an individual de vel
ops about the self. This composite develops over time

through transactions between the self and the environment.
Self-concept is the unique and personal sum total view one
holds of oneself.
the individual
Operationally,
self-concept is defined as
total score on the Piers-Harris Children's
Self-Concept Scale (Piers & Harris,
1969).
2. Social support--Information that one is cared for

and loved, esteemed and valued,
a network or community of mutual
Social
and a sense of belonging to

obligation (Cobb,
support is described as empathy,
nurturance, behavior,
1976).
encouragement,
and information that confirms reci
procity and recognition of competence.

support is defined as the individual
Operationally,
social
score obtained on the
Personal Resource Questionnaire Part 2 (Brandt & W e i n e r t ,

1985).
3. School
age children--Children 8 to 12 years of age
without obvious physical
or mental
limitations who are or
have been receiving anticancer therapy at one of two major

pediatric oncology treatment centers.
4. Leuk emi a--Oncological disorder affecting the bone
marrow and specifically confirmed by appropriate pathology
and laboratory evaluation.
Leukemia is the most common
15
cancer diagnosis in children age 2 to 9 years. Types of

leukemia include acute lymphocytic leukemia,
phocytic leukemia,
and T-cell
acute nonlym-
leukemia.
Significance
The A m er ic an Nurses'
Association
(1980) defines nursing
as the "diagnosis and treatment of human responses to actual

or potential heal th problems"
(p.9). The primary focus of
nursing is the prevention of illness and the maintenance of

optimal health.
The American Nurses' Assoc iat ion also notes
the need for n u rsi ng research to identify determinants of

wellness and heal th functioning,
Social support relates health,
such as social support.
environment,
which guide the discipli ne of nursing

& Kuo, 1979).
(Lin,
and person,
Simeone,
Ensel,
The Associ ati on of Pediatric Oncology Nurses
has also selected late effects of childhood cancer and l on g

term sequelae as research priorities for the future
(Education Committee, A sso cia ti on of Pediatric Oncology
Nurses,
1985; Hinds et a l ., 1990; Hinds et a l ., 1994).
The results of this research are useful

education,
practice,
and research.
in nursing
Nurses need to know what
to include when educating the client and the family regard

ing care of the child w ith cancer.
Educators need to know
what to teach n ursing students to provide the best client

outcomes for children with cancer.
The basis for future interpersonal
during the school
relations is laid
age years. The extent to w hich pediatric
cancer and its treatment interferes with social peer
16
relations may determine the overall compromise of psyc ho so

cial adaptation with associated long-term consequences
(LaGreca,
1990).
Social support may be a critical

and maintenance of health.
factor in prevention
Specific interventions need to be
recognized that may require high levels of individualization

for total cure of the child wi th cancer to occur.
If a
relationship between self-concept and social support can be

supported,
children at risk for less than optimal
can be identified,
outcomes
and a foundation can be developed upon
which to base nursing interventions.
Data obtained from
clients could assist nursing educators and practicing nurses

in better meeting the needs of the child with leukemia.
It is obvious that the diagnosis and treatment of
childhood cancer have the potential
psychological,
disruption.
sociocultural,
for physiological,
spiritual,
and developmental
Total cure of the child with cancer involves
treating the child as a cancer survivor from the point of

diagnosis.
Children with cancer have an increased risk for p s y c h o
social maladaptation,
underscoring the need to identify the
risks and protective factors that may help explain indiv idu
al differences.
The multitude of chronic stressors b o mb ard
ing the child with cancer interact to impede psychosocial

adjustment. The child with cancer must be physically and
emotionally capable of handling teasing,
tions,
comments,
ques
and innuendos from peers in addition to coping with
17
their own concerns about feeling different and unattractive.

Studying the relationship of psychological adjustment,
including self-concept,
with perceived social support may
lead to better understanding of the resilience of the child

with cancer.
Studies of self-concept and social support may
provide empirical evidence for the development of cognitive

behavioral
interventions to prevent or decrease psychosocial
maladaptation (Varni, Katz, Colegrove,
& Dolgin,
1994).
It is essential that the pediatric oncology nurse have

a sound scientific basis for anticipatory guidance and
interventions into actual and potential
alterations of self-
concept and its relationship with social support.
The rela
tionship between self-concept and social support must be

confirmed and fully understood in the child with leukemia so
that survivors will truly be cured.
Summary
In this chapter,
the purpose of the research was s t a t
ed. Research questions were formulated,
and the theoretical
basis for the research was reviewed. Finally the signifi

cance of the study was addressed.
Chapter II
Review of Research
The purpose of this research was to ascertain if there
is a relationship between self-concept and social support in
school
age children with leukemia. A review of research was
conducted to support the study.
Self-concept and self-esteem
are considered identical concepts in the majority of the

literature and so are used interchangeably in the review of
research.
Limited research has been reported describing the
psychological
effects of childhood cancer. Areas of review
included self-concept and chronic illness,

responses to childhood cancer,
psychosocial
social support and health,
and the relationship of self-concept and childhood cancer.

The terms self-concept and self-esteem are used i nterchange
ably throughout much of the literature and are considered
synonymous for the purpose of this review of research.
Self-Concept and Chronic Illness
Robinson,
cial
Greene,
and Walker
(1988) studied p s y c hos o
factors possibly associated with recurrent somatic
complaints in 115 adolescents seen for the first time.

Adolescents with functional
complaints had significantly
greater negative life events,
lower self-esteem,
and a lower
self-evaluation than those adolescents coming for routine

health care.
It was concluded that functional somatic

18
19
complaints are associated with poor psychosocial

in reaction to stressful
adjustment
life events and m ay result in poor
self-esteem in adolescents.
Self-esteem expresses approval
or disapproval
of o n e
self and is used interchangeably with self-concept as p o i n t

ed out by Riffee (1980). Riffee studied se lf-esteem in
hospitalized school age children undergoing surgery,
age children in the hospital,
hospitalized.
12 years.
school
and school age children not
The sample consisted of 63 children,
age 9 to
Total self-esteem scores were lower for the c h i l
dren hospitalized for surgery than either of the other

groups. This finding is applicable to pediatric oncology
because many children with solid tumors must undergo repeat
ed surgery for tumor debulking and staging.
Beddell, Giordani, Amour,
Tavormina,
and Boll
(1977)
examined the relationship of self-concept and the stresses

of life in chronically ill children.
the chronically ill completed several
Children at a camp for

tools including the
Piers-Harris Children's Self-Concept Scale (Piers & Harris,

1969). Children with low life stress had a more positive
self-concept and scored higher in the subscales of behavior,
intellectual
attributes,
and school status,

popularity,
physical appearance and
and happiness and satisfaction.
Both
the low life stress and the high life stress groups scored
equally on the anxiety subscale.
The low life stress group
experienced fewer health problems than the high stress

children.
The authors concluded that social and
20
environmental
influences were important in determining the
psychological well being of chronically ill children. Highly

stressed,
chronically ill children evaluate themselves
negatively. The presence of chronic illness in childhood is

not sufficient to produce psychopathology but does increase
the risk and increases vulnerability to the stressors of
life (Beddell et a l ., 1977).
The self-concept of children with cerebral palsy,
age 4
to 8 years, was found to be similar to the self-concept of a

control group in a study conducted by Teplin, Howard,
and
O'Connor (1981). While the children in both groups rated

themselves similarly,
teachers rated the handicapped c h i l
dren as having lower self-concept than the control
subjects.
Parent ratings of the behavior of their children revealed no

group differences in self-concept.
The researchers concluded
that children may begin to regard themselves as different as

early as the age of 4 years,
permanent or obvious until
Several
but these views do not become
the child is school age.
studies found no differences in self-concept
and psychosocial
functioning among children with a chronic
illness. Tavormina, Kastner,
Slater,
and Watt
(1976) c o n
ducted standardized psychological assessments of children

with diabetes,
asthma,
and cystic fibrosis.
The overall
pattern of scores obtained demonstrated normalcy rather than

deviancy. Wadden,
Foster,
and Brownell
(1984) found no
significant differences in Piers-Harris Children's SelfConcept Scale scores
(Piers & Harris,
1969) between obese
21
and normal weight children in Grades 3 through 8. They

reported no interaction among weight,
Magill and Hurlbut
grade,
or sex.
(1986) measured the self-concept of
children age 13 to 18 with cerebral palsy. No significant

differences were found between the handicapped and the
nonhandicapped children. However,
a significant interaction
was found between sex and disability, with the handicapped

females scoring lower than the handicapped males.
verse was found in the healthy children.
The re
No significant
differences were found between sexes on overall self-concept

(Magill & Hurlbut,
1986).
The Piers-Harris Children's Self-Concept Scale (Piers 6

Harris,
1969) was utilized to assess the self-concept scores
of black obese children in Grades 4 through 12 (Kaplan &

Wadden,
normal
1986). The self-concept scores were all within

range and were not affected by age or sex. The re
searchers concluded that the consequences of childhood

obesity may be less harmful psychosocially than formerly
presumed.
The promise of enhanced self-concept would fail to
motivate weight
loss in many children. While obesity was not
associated with impaired self-concept,
leanness was a ssoci
ated with enhanced self-worth (Kaplan S Wadden,

Cadman,
Boyle,
1986).
S z a t ma ri, and Offord (1987) ascertained
that children with chronic health problems are at signifi

cantly greater risk for psychiatric problems, social and
school
adjustment problems, neuroses,
disorders than their healthy peers.
and attention deficit
The authors studied
22
children age 4 to 16 who had a chronic illness or disability

and found an association between chronic health problems and
mental health problems,
term disability.
especially in children with a long
They suggested that poor social adjustment
and school problems may include poor self-concept and may be

precursors of psychiatric problems.
Children with sickle cell disease were the focus of a
self-concept study conducted by Kumar,
Haywood (1976).
P o w a r s , Allen,
and
The researchers utilized the Piers-Harris
Children's Self-Concept Scale (Piers & Harris,
1969) and
ascertained that children with sickle cell disease were not

different than the control group on the personal,
social,
and total adjustment scores. The children with sickle cell

disease did tend to withdraw and had lower level social
skills than the control group.
Interestingly,
the children
with sickle cell disease showed considerably less anxiety

than the control group (Kumar et a l ., 1976).
Psychosocial Responses to Childhood Cancer
Mattson (1972) identified malaise,
symptoms,
pain, physical
reasons for illness, hospitalization,
procedures,
painful
and specific stressors related to the illness as
frequent causes of psychological
stress associated with
chronic illness. Children with cancer have been reported as

missing more school than their healthy peers.
Psychosocial
problems have been associated with this increase in school

absences
(1983)
(Weitzman, Walker,
& Gortmaker,
emphasized this point,
1986).
Klopovich
stating that children with
23
cancer continue to miss school

apparent physical
even years after there is no
cause. Older children and adolescents are
at higher risk for developing school phobias than young

children (Lansky,
Lowman, Vats,
& Guylay,
Early research on psychosocial
1975).
problems in childhood
cancer was conducted in suboptimal psychological
conditions.
Mo r e recent research has shown that children who have open

communication and appropriate information about their di ag
nosis and prognosis have better long-term psychosocial
adjustment.
They have a higher level of self-regard and
remain closer to family members. Wi th a more open approach

to children and families currently being employed,
of early studies of psychosocial
adjustment to childhood
cancer may not apply to children diagnosed today

Copeland,
results
(Micheal
&
1987).
Chronic stressors of childhood cancer,

gain or loss,
school
ment related pain,
absences,
separation from peers,
chronic nausea,
act to impact psychosocial
such as weight
and alopecia,
adjustment.
treat
all in te r
Demographic variables
may explain a small amount of variance in psychosocial

adjustment of kids with cancer.
sized that social
Varni et a l . (1994) h y p o t h e
environment variables might explain some
of the variance in adaptation of children with cancer.

study,
lasting 4 years,
Their
included subjects ranging in age
from 8 to 13 years. M u l t ipl e regression analyses revealed

that children with de creased perceived social
support had an
increased risk for psychological adjustment problems.
The
24
researchers concluded that social
skills training might
increase social competence, which in turn will decrease

adjustment problems.
Social
competence is viewed as a p r e
ventative intervention, w h ich increases over time
(Varni et
al., 1994).
Brunquell and Hall
(1982)
researched children age 6 to
10 years of age who supposedly were unaware of the fatal

nature of their cancer.
These children showed clear evidence
of an awareness of the seriousness of their illness.
The
fatally ill child showed excessive anxiety and preoccupation

with threats to body integrity,
and made overt references to
death.
Spinetta
(1981) found that the child's level
of anxiety
and feelings of isolation were directly related to family

patterns of communication.
Children with cancer who come
from families with open communication have a better selfconcept,
are less defensive,
and have a closer relationship
with family members.

Koocher et a l . (1980) have performed extensive studies
of children with cancer.
They have found that developmental
disruptions engendered by cancer treatment are more marked

and more persistent when they occur in middle childhood and
adolescence,
as compared to infancy.
These researchers
studied former pediatric oncology clients and found that 59%

had lingering psychosocial
problems.
Children who were
younger at diagnosis had fewer adjustment problems.

of treatment was not found to be important,
Duration
but age at
25
diagnosis and time since diagnosis were significant factors.

Depression,
anxiety, and poor self-concept were experienced
by a significant number of children who survive pediatric

cancer experiences
(Koocher
Research was conducted
et a l ., 1980).
by Kimsey (1990) to investigate
parent's response to a cancer diagnosis in their child and

to assess the relationship of these variables to the psycho
logical adaptation of the child during diagnosis and treat
ment. Results indicate that diagnosis and prognosis are not
related to parent or child adjustment to the disease.
child's psychological
The
functioning before diagnosis is the
best index of their adjustment to the disease process.

Fergusson (1976) studied 18
subjects who had been treated
for cancer between the ages
of 2 to 5 years. This
researcher
concluded that psychologic damage does not necessarily

follow treatment for cancer in early childhood.
Children who
had their diagnosis fully discussed with them were function

ally normal.
Factors identified as contributing to the
child's well being during hospitalization and treatment for

cancer included the parent-child relationship,
family structure,
(Fergusson,
changes in
and interaction with the health care team
1976).
Hymovich and Roehnert
(1989) report that survivors of
childhood cancer with severe medical

poorer self-concept,
symptomatology,
effects may have a
lower popularity, more depressive
and more external
locus of control than
survivors with mild or moderate late medical
effects. Girls
26
exhibit greater anxiety and concern than boys about their

physical appearance. Factors associated with better ps ycho
social adjustment for long-term survivors of childhood
cancer include younger age at onset,
diagnosis,
relapse,
longer time since
shorter treatment duration,
remission without
early knowledge of the disease,
communication,
open and supportive
and higher social maturity.
Resources gen er
ally considered to enhance a long-term survivor's ability to

resist detrimental
adaptive individual
effects of childhood cancer include

coping skills and an emotionally sup
portive social network.
Development of effective interven
tion programs is hindered by the lack of research investi

gating the psychosocial
diagnosis
consequences of a childhood cancer
(Hymovich & Roehnert,
Feelings of anxiety,
1989).
depression,
fear,
and helplessness
often accompany the diagnosis of childhood cancer.
Survival
rates have drastically improved while the impact of the

diagnosis has not. The impact of childhood cancer may be
physical
or psychological
pacts may be obvious,
or both. While the physical
the psychological
im
impact may be more
subtle (Hockenberry et a l ., 1990). Bossert and Martinson

(1990) utilized kinetic family drawings to determine the
impact of cancer on the family from the perception of the
child with cancer. The authors found a trend in type of
cancer,
sex, and status of cancer.
age or in family dynamics.
They found no trend in
The scores of children with
leukemia were significantly lower on communication and
27
self-image,
emotional
while children with solid tumors scored lower on
tone and had poorer scores over time. W h e n com par
ing cohesive families to fragmented families,
no trends were
identified.
The authors suggest that, f ro m the child's
perspective,
their family's attitudes and emotions become
more regular as time from diagnosis increases

Martinson,
(Bossert S
1990).
Neff and Beardslee

children with cancer.
(1990) studied body knowledge of
They hypothesized that anticipatory
anxiety is a conditioned behavioral

invasive procedures.
response to repeated
The authors found that fatally ill
children had significantly higher levels of anxiety.

comparison was made of children with cancer,
problems,
and healthy school age children.
orthopedic
Children with
cancer were found to have more knowledge about body func

tioning than the other groups. Children w i t h cancer also
indicated significantly m o re bodily concerns.
It was con
cluded that body integrity concerns are m o re likely to be

expressed when a child anticipates,
ed with,
or is actually c o nf ron t
a stressor that has the potential
to violate body
integrity.
Gregory,
Parker,
returning to school
cancer.
and Craft
(1994) studied 14 children
after extended absence for treatment of
The researchers utilized a control group of healthy
children and a group of 11 siblings of children with cancer.

Behavioral
rating scores showed no significant differences
in socialization,
emotional behavior,
performance.
28
adaptation,
or learning disabilities.
Teachers anticipated
many problems when the child with cancer returned to school,

but few problems were actually experienced.
cited support from staff,
and physicians,
The researchers
including nurses, social workers,
as being invaluable as evidenced by the ease
with which the children with cancer reintegrated with their

peers.
Both diagnosis and treatment of cancer are sources of
stress to the client with cancer. Wi th the reduction of
therapy toxicities,
psychosocial
difficulties may become one
of the major long-term complications of treatment. R e

searchers studying survivors of Hodgkin's disease found that
37% suffered from persistent energy loss.
The remainder of
the subjects reported requiring 12 to 16 months for energy

levels to return to normal.
of the sample.
Depression was indicated in 18%
The inability to per fo rm usual activities and
the resulting loss of social
contact clearly undermined
self-concept and generated feelings of guilt in a small

percentage of the sample (Fobair et a l ., 1986).
Van Dongen-Melman and Sanders-Woudstra (1986) conducted
an extensive review of the literature pertaining to the
psychosocial
aspects of childhood cancer.
Their review
indicated that the more complex the cancer treatment regimen

the more likely it is to interfere with psychosocial
bilitation.
reha
The child w ith cancer experiences greater a n x i
ety with the progression of the disease and with every

clinic visit.
This results in greater susceptibility to
29
psychosocial problems. Recurrent procedures pose problems in

psychosocial adjustment, which may include such symptoms as
insomnia, nightmares,
anorexia, withdrawal,
Factors that seem related to optimal
and depression.
long-term psychosocial
adjustment include a short treatment course, continuous

remission without relapse,
early knowledge of the disease,
supportive and open communication,
and age at disease onset.
The researchers point out that limited attention has been

given to the emotional aspects of living with the diagnosis
of cancer.
Social
Support and Health
Social support appears to enhance effective coping with

stressors.
Social support may buffer stress by intervening
between the stressor and the outcome by weakening a stress

or perceived threat appraisal.
It may play a role in inter
vention between the threat appraisal
and outcome by altering
the reaction to the perceived threat through offering a

solution or decreasing the importance of the threat
(McNett,
1987).
Families appear to be the principal
environmental
source of social support for children (Boyce,
1985).
Boyce
defines childhood social support as those resources provided

to the child through intimate relationships and social
interactions. There is limited information regarding the
origin and character of the social support that children
receive and provide, or of the evolution of supportive
family interactions.
Childhood family attachment is
30
essential
in the evolution of social support. Development of
attachment to the social environment is crucial
in order for
the child to fulfill a need for stability and develop a

capacity for successful
social
interactions.
Stressors act
on the health of a child through their ability to undermine

the child's sense of stability or permanence.
Social support
may function to promote some sense of permanence and c o n t i

nuity, which are representative of the meaning of social
support in a child's life (Boyce,
Woodbury
1985).
(1992) examined the characteristics and e f
fects of children's social support in relation to sel f

esteem and behavior problems.
Data suggest that children who
are less stressed have higher self-esteem and fewer behavior

problems.
Social support has a tendency to enhance a dju st
ment over time for children with both high and low levels of
stress. Results also indicate that satisfaction and social
support act as a buffer against poor adjustment to stressful
life circumstance in 13 to 14 year old subjects.
support does show developmental
Social
change and is essential
to
the maintenance of a child's emotional health (Woodbury,

1992).
Marital
status and social
support in relation to c h i l d
ren's self-esteem was studied by Read
(1991). The Piers-
Harris C h i l d r e n s Self-Concept Scale was used to compare

levels of self-esteem of children, age 8 to 10 years, whose
parents had divorced versus self-esteem of children from
traditional
two-parent families.
The researchers found that
R ep ro d u ced with p erm ission of the copyright ow ner. Further reproduction prohibited w ithout p erm ission .
31
the level
of social support perceived by the child was
proportional
to the level of the child's self-esteem.
perceived higher intrapersonal
Girls
social support than boys.
longer parents had been divorced,
The
the higher the child's
self-esteem.
Support systems of college students were studied by
Parish and Parish (1991). The researchers were concerned
with the impact of changes in family configurations and
support systems,
occurring during school age and a d o l e s
cence, and their effects on support systems and self-concept

in later college years. Results showed that college students
whose parents divorced were significantly more likely to
encounter support system failures including parental h o s t i l
ity, perceived lack of caring,
of teacher concern,
inadequate supervision,
and increased financial hardship.
lack
These
support system failures were associated with decreased selfconcept and decreased social
skills
(Parish & Parish,
1991).
It has been determined that the quality of life of

children with cancer is influenced to a great extent by
family members,
policies.
health care providers,
and health care
This influence comes from the availability of
supportive resources for the child with cancer.

influence quality of life include internal
as how the child relates to the self;
Factors that
environment,
immediate environment,
including significant others and health care providers;

institutional
environment,
such
such as public and social
and
sys
tems .
32
In a study by Chekryn,
Deegan,
and Reid (1986),
chi l
dren with cancer identified socialization with peers as what

they liked best about school.
the most common fear,
tal source of support.
Although peer rejection was
classmates were viewed as a fundamen

Play with peers provided an opportu
nity for stress release and respite from the sick role. The
results of the study indicate that a positive school
experi
ence can provide the child with a sense of accomplishment

and social acceptability,
strengthening self-esteem,
decreasing maladaptive emotional

In a study of maternal
fants,
Capuzzi
and
responses to cancer.
attachment to handicapped i n
(1989) found that the stressor of having a
handicapped infant interferes with the development of m a t e r

nal attachment.
Social support facilitates attachment by
reducing the stress of having a handicapped infant.
Capuzzi
suggested that social support plays an important role in

buffering the stressors of having a handicapped child.
Therefore,
social
support systems should be promoted and
increased.
People wi th cancer often experience a loss of a sense
of self.
a degree,
1982).
This perceived loss can be relieved or lessened,

by support from significant others
(Maxwell,
Studies of cancer patients suggest that social
port is associated with better psychosocial

the illness
(Mishel & Braden,
1987).
sup
adjustment to
It has been postulated
that the uncertainties and fears associated with cancer

generate the need for social
to
support in oncology patients.
33
Further,
adequate communication with significant others
facilitates the cancer patient's ability to deal with the

diagnosis and treatment of cancer. Findings of the study
conducted by Mishel and Braden support the proposition that
social support functions change over time. Also, social
support influences varying aspects of the uncertainty of the
cancer diagnosis.
The authors conclude that social support
may have a direct as well as indirect influence on adjust

ment to life with a chronic illness.
Stewart
(1989) reviewed social support instruments
created by nurse investigators. Measures of structure,

function,
and nature of social support were found to be
common to all instruments reviewed.
The three sources of
social support most consistently measured were family,

friend,
and spouse.
Burnout and social support were studied in family

caregivers
(Lindgren,
1990).
identified as a personal
Social support was conceptually
resource for coping with the stress
of giving care and is negatively related to the degree of

burnout experienced.
Study participants who felt they re
ceived social support reported a sense of accomplishment.

This is reinforced by commendations from others that enhance
the individual's sense of self-esteem.
Riegel
(1989) determined that effective social support
is directly and positively related to positive

tion;
self-evalua
increased self-concept; mastery over the environment;
and enhanced feelings of love, worth, importance,
and
34
esteem.
Social support that has positive effects on well
being and adjustment to chronic illness may actually be

serving as a buffer to the stressors of the illness.
Social
support may lead to negative effects and feelings when the

receiver of the support fears inadequacy,
loss of freedom.
indebtedness,
or
These feelings may in turn lead to a p e r
ceived loss of competence and decreased self-concept.

support is a major factor influencing self-concept,
ceived functioning capacity, mood,
Social
per
and adjustment to life
with a chronic illness ( R i e g e l , 1989).
It is concluded that
the quality of social support is a major determinant of an

individual's adjustment to life with a chronic illness.
Quality of social support is affected by chronic ill
ness
(Tilden & Weinert,
1987).
The chronically ill person
may be unable to reciprocate the received support.

lead to strain on the social network.
is stigmatizing or anxiety ridden,
If the chronic illness
the social support n e t
work may eventually dilute or withdraw,
resulting in social
isolation or impaired social interaction.

ing to social
This may
Factors c on tribut
isolation include altered physical appearance,
altered mental state, altered states of wellness,
d e vel op
mental delays or changes,
resources.
Ineffective social
dysfunctional
iors.
and inadequate personal
exchange may include social discomfort,
communication,
and inappropriate social b e h a v
Self-concept disturbances and major emotional d i s o r
ders are common factors to both social

paired social
isolation and im
interaction (Tilden & Weinert,
1987).
35
Cherry
(1991) compared self-esteem of adolescents wit h
cerebral palsy or spina bifida to the self-esteem of ablebodied adolescents age 13-19 years. The author identified
other variables that may correlate with self-esteem.
Results
indicated no significant differences between the two groups

for self-esteem or for social support from family.
The able-
bodied adolescent perceived higher levels of social support

from peers and perceived larger social
support networks.
The
able-bodied adolescent participated more frequently in

shared peer activities. Multiple regression analysis re
vealed four factors that accounted for 77.4% of self- est ee m
variance in the physically disabled adolescent group.
factors were social support from peers,
from father,
pendence.
team sport participation,
reflected appraisals
and functional
included social
support from friends,
These factors
social support from
and frequency of attending a school
athletic event.
The researcher concluded that perceived social

peers,
inde
Three factors accounted for 54.8% of the variance
in self-esteem for the able-bodied adolescent.
family,
These
support
from
shared activities with peers related to self-esteem,
and family influences on self-esteem were important.

Chronic illness places the individual
social
isolation or impairment.
at high risk for
Social support is often
strained or disrupted and may even disintegrate under the

stressors of chronic illness and its treatment.
The effects
of chronic illness may reduce the individual's ability to

maintain,
develop,
or reciprocate social support.
Lowered
36
self-concept,
depression,
and dependency may result.
It is
suggested that nursing intervention should focus on finding

new methods of reciprocation to prevent deterioration of the
social support network and to promote a more positive selfconcept
(Tilden & Weinert,
1987).
Noll, B o k o w s k i , Davies, Koontz,

examined the psychosocial
and Kulkarni
(1993)
adaptations of children age 11 to
18 years who were primarily off treatment
for cancer.
The
researchers used a variety of sources for information,

multiple standardized measures,
and matched controls.
The
subjects were found to have a reputation of being socially

isolated,
however,
friendship,
no differences were found in popularity,
self-concept,
or loneliness.
The researchers
extended the study longitudinally to ascertain if there were

long-term problems with peer relationships and to determine
whether the children with cancer showed differences in
loneliness,
depression,
and self-concept.
Results suggested
that whether the child was receiving treatment or had com

pleted treatment for cancer had little effect on social
reputation,
popularity,
friendships,
or self-concept.
The
study indicates that adolescents with cancer may experience

social
overall
isolation,
popularity,
self-concept.
social
but the isolation has minimal

friendships,
effect on
loneliness, depression,
and
Further research is suggested in the area of
competence and social support of children with can
cer .
R ep ro d u ced with p erm ission of the copyright ow ner. Further reproduction prohibited w ithout p erm ission.
37
Self-Concept and Childhood Cancer

Utilizing the Piers-Harris Children's Self-Concept
Scale (Piers & Harris,
1969),
40 pediatric oncology clients
were studied by Carr-Gregg, White, Hughes,
and Vowels
(198-
5). Healthy children were matched with pediatric oncology

clients for age, sex, race, and socioeconomic status. R e
sults indicated significant relationships between selfconcept and family adjustment and support. Almost 75% of the
pediatric oncology clients scored below the published norms
on the self-concept tool
(Carr-Gregg et a l ., 1985). Carr-
Gregg and White (1987) studied self-concept in relation to

disease type among adolescents with cancer. Their results
suggested that adolescents with solid tumors have a poorer
self-concept than those adolescents with leukemia.
A study by South (1988) compared the self-concept of
school
age survivors of acute leukemia and the self-concept
of healthy school
age children.
Instruments utilized were an
investigator constructed demographic tool and the PiersHarris Children's Self-Concept Scale (Piers & Harris,
1969).
One-way analysis of variance revealed a significant differ

ence in self-concept between the two groups.
Significant
differences were also found between the two groups on the

Physical Appearance and Attributes subscale and the Intel
lectual and School Status subscale of the self-concept tool.
Twenty-two subjects were included in the study. No attempt
was made to measure or control developmental stage, previous
adaptive capacity,
the meaning of the illness to the child
38
and family,
the parent-child relationship,
reaction to changes in equilibrium.

knowledge concerning diagnosis,
and the child's
The child's
level of
disease state, and prognosis
was not assessed.

Benson (1987) studied children ages 7 to 18 who were
attending a pediatric oncology camp for the first time.
Fourteen subjects were pretested and posttested utilizing
the Piers-Harris C h i l d r e n s Self-Concept Scale (1969) and
kinetic family drawings,
t tests showed no significant
differences in self-concept.
Since self-concept is relative
ly stable and does not change over a short period of time,

this finding is to be expected.
Self-concepts of school
age children with leukemia were
compared to self-concepts of healthy school age children by

Scungio (1981).
It was ascertained that children with leuke
mia reported significantly lower self-concepts than the

healthy school
age children.
Burns and Zweig (1980) studied self-concept of well

children and children with cancer.
The sample consisted of
54 children with oncological disorders and 115 healthy

school age children ranging in age from 3 to 12 years. The
mean self-concept scores of the children with cancer did not
differ significantly from the scores of the healthy chil
dren. The researchers recognized the possibility that the
child with cancer may deny a poor self-concept.
with cancer viewed themselves as friendlier,
The children
possibly to
overcompensate for feelings of social isolation.
It was also
39
found that dying children rely strongly on such coping

mechanisms as denial,
repression,
and hope,
and can use
those mechanisms to maintain equilibrium between ego ideal

and a more realistic self-concept.
Burns and Zweig stressed
the importance of identifying the psychosocial
effects of a
chronic illness so that appropriate intervention can be

provided.
Summary
The research cited provided the background for this
study.
The literature was placed within the categories of
self-concept in chronic illness,
psychosocial
responses to
childhood cancer, social support and self-concept in rela

tion to health and well being,
cancer.
social
and self-concept in childhood
There were no studies of relationships between

support and self-concept in children with chronic
i 1 In e s s .
Variations in research findings may be due to v ari a
tions in methods of data collection,
such as use of c on
trols, sources of information, use of nonstandardized m e a

sures,
and problems with observer bias. Very little data
could be found relevant to the adjustment of children with

chronic illness within their social peer group.
The review of research indicates that social support
may be an especially vulnerable area for children with
cancer
(Koocher et a l ., 1980). Many of the stressors a s s o c i
ated with pediatric cancer develop in the structure of
40
coping w i th peer pressure and the social consequences of

having a chronic illness
(LaGreca,
1990).
Children with cancer are dealt with more openly today,

so that early research in the areas of psychosocial
ad jus t
ment may no longer be valid when applied to children cur

rently diagnosed with cancer.
ing psychological
ric oncology,
Studies previously invest iga t
factors and stress in relation to p ed i a t
and studies of social support, have had poor
methodological
rigor, so that conclusions based on results
of early studies must remain imprecise and general.

fore,
T here
limited evidence is actually available concerning
psychosocial
factors associated with the occurrence and
subsequent treatment of cancer.
There is a paucity of re
search specifically related to self-concept and social

support in children with a chronic illness.
Chapter III
Methodoloqy
The purpose of this research was to ascertain if there
is a relationship between self-concept and social support of
school age children with leukemia.
the design of the study,
In the following chapter,
instrumentation,
procedure will be described.
subjects,
and
The method of data analysis and
limitations of the research will also be presented.

Design
This study is descriptive in design.
The variables
included in the research are stage of antileukemia therapy,

age, gender,
race, social support as measured by the Person
al Resource Questionnaire,
Weinert,
1985),
Part 2 (PRQ 85)
(Brandt &
and self-concept as measured by Piers Harris
Children's Self-Concept Scale
(PHCSCS)
(Piers S Harris,
1969).
Instrumentation
A demographic and information questionnaire was devel
oped by the researcher in order to obtain factual informa
tion concerning the diagnosis,
treatment,
and stage of therapy for each subject.
age,
race, gender,
The demographic
questionnaire also served as the consent form and was signed

by at least one parent and the child when completed.
41
42
The PRQ 85 Part 2 was utilized to measure social s u p
port as perceived by each subject.
The PRQ was originally
developed by Brandt and Weinert in 1981. Following extensive

testing and modification,
the PRQ 85 has evolved as the
current version of the tool. The tool consists of a twopart,
self-administered questionnaire.
Part 1 describes
situational support in the context of life situations.

2 describes perceived social
support consisting of a five-
factor structure of intimacy,

ce, worth,
Part
social
integration,
nurturan-
and assistance.
Part 2 of the PRQ 85 was utilized for the present study

and consists of 25 items on a 7 point Likert scale.
The PRQ
85 Part 2 requires approximately 10 min to complete.

ble scores range from 25 to 175.
Scores greater than 150
indicate higher levels of perceived social support

& Tilden,
P o s si
(Weinert
1990).
Weinert and Tilden (1990)
report internal
consistency
coefficients ranging from 0.87 to 0.90 for the total social

support scale.
Subscale reliability coefficients have ranged
from 0.70 to 0.88.
Total scale to subscale correlations
range from 0.70 to 0.81
(Weinert,
1987).
Construct validity information was obtained with corre

lations between the PRQ 85 and the social support subscale
of the Cost and Reciprocity Index (Tilden S Galyen,
1987).
Correlation coefficients ranged from 0.53 to 0.58,

indicating that both tools are measuring the same construct
yet are not highly redundant
(Weinert & Tilden,
1990).
43
Royeen (1985) studied the use of Likert scaling with

children.
Likert scaling was found to be the most widely
used and recognized as the easiest and most reliable tec h

nique for data collection.
Children reported less anxiety
during administration of Likert scaling instruments when

they were told it was a game and not a test.
Rephrasing
items from statement to question format made them more

comprehensible for children. Most items were clearly u n d e r
stood by the children unless the item had two parts such as:
Does it bother you to have your socks pulled up, after they
have fallen down? Royeen suggested that all items have only
one straightforward concept with no dependent clauses.
It
was concluded that Likert scaling is appropriate for use in

children. The PRQ 85 has been chiefly administered to
adults, but has been utilized in adolescents.
PRQ 85 measures the theoretical
Because the
concept of social support,
as well as its multidimensionality,
it was deemed a p p rop ri
ate for the purpose of this study.

The PHCSCS
(Piers & Harris,
1969) was utilized to
measure self-concept of each subject.
The PHCSCS is a self-
report instrument that consists of 80 items.
It requires
about 20 min to complete and is appropriate for a wide age

range (Piers & Harris,
1969). The PHCSCS provides a total
self-concept score as well as subscores for:

(b) intellectual
and attributes,
and school
status,
(d) anxiety,
ness and satisfaction (Piers,
(a) behavior,
(c) physical
(e) popularity,
appearance
and (f) h a p p i
1984).
44
M uch of the reliability of the PHCSCS is based on the
original standardization study.
Piers
(1984) obtained i nter
nal consistency coefficient scores ranging from 0.88 to 0.93

using the KR-20 formula on the total scores of a normative
sample of 6th and 10th graders.
Lefley
(1974) utilized the
PHCSCS with native Americans ranging in age from 7 to 14

years.
Split-half reliability,
formula,
Rogers
using the Spearman-Brown
gave a reliability coefficient of 0.91.
Smith and
(1978) administered the PHCSCS to subjects age 6 to
12 years who had learning disabilities.
They reported an
alpha coefficient of 0.89 for the total scores obtained.

Reliability coefficients for the six subscales were
based on the standardization study sample of children in
Grades 4 through 12 and a sample of children from three
psychiatric clinics. The alpha coefficients ranged from 0.73
to 0.81
for each of the subscales, while the coefficient for
the total score was 0.90.

to be 0.72,
0.71,
Stability coefficients were found
and 0.72 over a 4-month period
(Piers,
1984) .
Franklin,
Duley, Rousseau,
and Sabers
(1981) studied
convergent and discriminant validity of the PHCSCS by c o m

paring it to the Self-Esteem Inventory
(Coopersmith,
1967).
Convergent validity was evidenced by a correlation co e f f i

cient of 0.78. Multiple correlations produced coefficients
not exceeding 0.25 between self-concept and academic a c h i e v
ement,
socioeconomic status,
ethnic background,
special
grade placement,
education placement,
sex, and age variables.
45
Possible intervening variables were identified through

literature review and logic. The variables considered prior
to hypotheses testing were age,
race, and sex. The effects
of these variables have been evaluated to identify interac

tion patterns that reflect valid group differences on the
PHCSCS. The sample on which the PHCSCS was standardized did
not indicate differences in self-concept according to age.
The standardization sample included subjects in Grades 4, 6,
8, 10, and 12 (Piers & Harris,
1964). Multiple studies
utilizing the PHCSCS have reported no significant d iff erenc

es due to gender
Ketcham & Snyder,
by Bentler
(Crase, Foss,
& Colbert,
1977; Piers & Harris,
1981; Devoe,
1964).
1977;
In a review
(1972), no significant sex or grade differences
in means were identified.
Bentler states that reliability
and validity are present and sufficient,
and recommends the
PHCSCS for use in research.

The PHCSCS is simple to administer and score. When
administered individually or in a group,
items should be read aloud for clarity.
defining terms are also given.
the directions and

Instructions for
Each item has been written so
that it is scored in the direction of high self-concept.
The
key for scoring each item is included in the test manual.

Norms and stanine scores are given, which take into account
the negative skewness,
or the tendency of the general p o p u
lation to respond in a generally positive fashion.

The items on the PHCSCS are constructed to reflect the
concerns children have about themselves.
Piers
(1984) states
46
that variability of scores decreases as grade level in cre as
es. Piers further reports that all high scores cannot be
assumed to reflect true positive self-attitudes,
but it can
be assumed that low scores reflect true negative self -at ti

tudes .
Subjects
The sample for this research consisted of children,
8 to 12 years, who had a diagnosis of leukemia.
age
All pa r t i c i
pants were able to read and write and were physically able
to complete the instruments.
or mental
limitations,
Children with obvious physical
other than those related to cancer
diagnosis and treatment,
were excluded from the study.
Participants were chosen by convenience at two pediatric

oncology treatment centers in the southeastern United
States. There was no random selection of subjects.
Children
were contacted at the time of their regular clinic a p poi nt

ment. All
children who met the inclusion criteria,
and who
had a parent available to give consent, were asked to p a r

ticipate in the research.
Setting
Data collection for this study took place at two p e d i
atric oncology/hematology clinics.
The researcher attended
outpatient clinics in an effort to identify those children

eligible for the study.
identifying subjects.
Clinic receptionists assisted in
Subjects and their parent or guardian
met the researcher or interviewer in an examination room or
R ep ro d u ced with p erm ission of th e copyright ow ner. Further reproduction prohibited w ithout perm ission.
47
the patient interview room. A parent or guardian was present

at all times, in addition to the interviewer.
Procedure for Data Collection
In order to safeguard the human rights of the p a rt ici
pants in the research,
the researcher secured permission to
conduct the research from the Institutional Review Board of

the University of Alabama at Birmingham.
Writt en approval
to enter the agencies and seek the participation of subjects

was obtained from the appropriate administrators.
The p h y s i
cians caring for children with cancer at the major medical

centers were contacted by formal
letter and telephone r e
questing permission to seek participation of their clients

in the research.
These physicians signed permission forms
for their clients to participate.

A letter of information and consent/assent was given to
all children and their parents at the time of the regular
clinic visit.
Assent was obtained from each child who p a r
ticipated in the study,
and informed consent was obtained
from at least one parent of each participant.
The researcher
attended clinic and gave consent/assent forms to all on colo

gy clients with leukemia who met inclusion criteria. All
clients who met inclusion criteria and agreed to participate
were included in the research.
Children who agreed to participate,
agreed to allow participation,
Harris,
and whose parents
completed the PHCSCS (Piers &
1969) and the PRQ 85 Part 2 (Brandt & Weinert,
1985)
in a parent interview room. The parent accompanying the
48
child completed the demographic and information q u e s tio n

naire developed by the researcher.
Specific guidelines were
developed for approaching children and administering the

research tools so that the procedure did not vary with each
child.
The researcher scored the PHCSCS and the PRQ 85 Part 2,
and coded the demographic information.
No other individual
reviewed the information or was able to identify the s u b

jects.
In this way confidentiality and anonymity of subjects
were maintained.
All data are reported as group data so that
no individual score can be identified.

to withdraw,
Children were allowed
or be withdrawn by a parent or guardian,
point in the study until
at any
completion of the instruments and
questionnaire.
Analysis
The statistical hypotheses are stated in the null form:
(a) There will be no statistically significant relationship
between the total scores on the PHCSCS and the PRQ 85 Part 2
among school age children with leukemia,
and (b) there will
be no statistically significant relationship between the

subscale scores on the PHCSCS and the PRQ 85 Part 2 among
school
Regression analyses were computed to ascertain if

significant relationships existed at the 0.05 level between
total
scores and subscale scores on the PHCSCS and the PRQ
85 Part 2 of school age children with leukemia.
Stepwise
multiple regression begins with no variables and adds
variables one at a time. After adding each variable,
all
previously added variables are reevaluated for significance.

If a variable is considered that does not contribute signif
icantly to an increase in variance,
equation.
In this way,
it is removed from the
the unique significance of each
variable can be ascertained (Norusis,

predictive variables are considered;
1988). All potential

and the combination of
variables providing the most predictive power are selected

(Polit & Hungler,
1983).
The effects of a predictor variable
on a criterion variable can be isolated,
and fraudulent
influences can be controlled for by using stepwise multiple

regression.
Incremental variance accounted for by a set of
variables can also be investigated.

can be explained,
The more variance that
the stronger the findings and conclusions.
Limitations
The target population for this research is restrictive.
Therefore,
conclusions are limited to the specific p op ula
tion. The subjects for this study were selected by conve

nience rather than randomly selected. This also limited the
generalizability of the results.
Parents or guardians were
not separated from their children for the administration of

the research questionnaires.
The presence of the parent or
guardian may have influenced the child's responses.
Data
were self-reported and so may represent only what the s u b

ject is willing to report.
Present mood of the subject may
also affect responses.
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50
Summary
This chapter has examined the methodology of the p r e s
ent research. The design of the study,
subjects have been identified.
data analysis were presented,
instrumentation,
and
The procedure and methods of

as well as limitations of the
study.
Chapter IV
Findings
The purpose of this study was to describe social sup
port and self-concept in school
age children with leukemia
and to ascertain the relationship between social support and

self-concept in school age children with leukemia.
Demo
graphic descriptions of the study sample and findings of the

social support scale and the self-concept scale are p r e s e n t
ed in this chapter.
The results of the correlation and
regression analyses are also presented.

Des cri pti on of Subjects
Subjects were predominately m al e (70.6%) with 41% being
White male and 29% being Black male.
Subjects ranged in age
from 8 to 12 years with a mean age of 10.2 years and a

standard deviation of 1.79 years. The majority of the s a m
ple,
or 82%, were diagnosed with acute lymphocytic leukemia.
The remaining 18% were diagnosed with T cell
leukemia.
Children who were off therapy constituted 41% of the sample,

while 24% of the subjects had relapsed at least once since
their original diagnosis.
Eighteen percent of the sample
were newly diagnosed and in the remission induction phase of

therapy.
An additional
18% of the subjects were more than 6
weeks into therapy and on maintenance regimens.
Subjects
attended one of two pediatric oncology treatment centers.

51
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52
Both centers were members of the Pediatric Oncology Group so
that all subjects were receiving similar treatment.
Demo
graphic description of the sample is represented in Table 1.

Table 1
Frequency Distribution of Subjects by Age, Race,
and Sex
Sex
Race
Female
Ma le
Black
White
Age
29.4
5.9
23.5
11.8
17.6
11.8
5.9
5.9
11.8
10
11.8
11.8
11
11.8
11.8
12
35.3
17.6
17.6
17
100.0
29.4
12
70.6
Total
0
11.8
0
0
2
11.8
17.6
17.6
41.2
10
58.8
Analysis of the Data

R esearch Q uestion 1 . What is the self-concept of school
age children with leukemia? The mean score for the selfconcept of the total sample was 63.6, with a standard d e v i a
tion of 15.03.
Two scores,
or 11.8%, were below the average
score stated by Piers and Harris

within the average range.
(1969).
Two scores were
The remaining 76.4% was above the
stated average score for self-concept.
Descriptive s t ati s
tics of the self-concept scores are displayed in Table 2.
53
Descriptive statistics for the six subscale scores are also

presented in Table 2.
Table 2
Descriptive Statistics for Self-Concept Scores
Mdn
Mde
8.65
10
10
5.49
2.34
3-10
13.41
14
14
13.76
3.71
4-16
Popularity
8.94
4.43
2.11
4-12
Physical
appearance
10.41
12
13
9.88
3.14
4-13
Intelligence
14.24
16
16
12.19
3.49
4-17
Anxiety
10.65
11
11
8.62
2.94
3-14
Total score
63.65
70
72
225.87
15.03
23-76
M
Happiness &
satisfaction
Behavior
Variance
SD
Range
Research Question 2. What is the social support of

school
age children with leukemia? The mean score for social
support of the sample was 146 with a standard deviation of

16.14.
Scores ranged from 88 to 162. Fifty-three percent of
the scores were considered moderate scores
(n = 9). The
remaining 47% of scores were in the high range. There were

no low range scores.
Therefore,
moderate to high social support.
all subjects perceived

The social support s t ati s
tics are given in Table 3.

R esearch Question 3 . Is there a relationship between
social support and self-concept of school
age children with
leukemia? Correlation coefficients were calculated using the

total score from the self-concept tool, the social support
scores,
and the six subscales of the self-concept tool. A
54
statistically significant positive correlation was obtained
between the social support scores and the self-concept
scores (r = 0.545, p. = 0.012). Thus, as social support
scores increase,
the self-concept scores also increase.
Significant positive correlations were also obtained

between the social support scores and each of the selfconcept subscales of Happiness and Satisfaction,
Anxiety,
Popularity,
and Attributes.
Behavior,
Intelligence, and Physical Appearance
Regression analyses were obtained to examine
the relationships between the variables.
Perceived social
support was entered as Step 1 in the equation.

variable entered into the equation was sex,
The second
followed by
race. Age, stage, and diagnosis did not enter the equation.
The findings revealed that 30% of the variance of selfconcept was accounted for by the variable of social
support
(p < 0.05). Additionally 38% of the variance of self-concept

was accounted for by both social support and sex (p < 0.05).
By forcing race into the equation with sex and social s u p
port, 44.5% of the variance of self-concept could be a c
counted for (p < 0.05). The regression summary is reported
in Table 4.
To measure the strength of the linear relationship
between the observed values of self-concept and those p r e
dicted by the regression equation
(Goodness of Fit test), a
correlation coefficient was computed between observed and

predicted values. This coefficient was significant at the
0.05 1e v e l .
55
In order to gain further insight into the relationship
between self-concept and social support,
regression analyses
were then computed for each of the six subscales of the

self-concept instrument.
Statistically significant results
were obtained for the subscales of Behavior,

and Satisfaction.
and Happiness
These results are displayed in Table 5 and
6.
Table 3
Frequencies for Social Support Scores
Scores
Raw score range
25-74
Low
75-149
Moderate
53
88-149
High
47
150-162
150-176
Table 4
Stepwise Multiple Regression Summary for
Self-Concept Total Scores
Step
Variable
Cumulative
SE of b
R 2__________ _________________________________
Social
Support
0.297
0.719
0.224
0.0068
Sex
0.378
-11.488
7.439
0.1465
________________________0.445_______
3
Race
-8.054
Note, b = slope
6.398________ 0.230
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56
Table 5
Stepwise Mult ipl e Regress ion for Behavior Subscale
Step
Variable
Cumulative
R
SE of b
Social
Support
0.398
0.183
0.053
0.0045
Sex
0.469
-2.482
1.776
0.1856
0.481
-0.823
1.527
0.5990
3
Race
N o t e . b = slope
Table 6
Stepwise Multiple Regression Summary for Happiness and

Satisfaction Subscale
Step
Variable
Cumulative
R
SE of b
Social
Support
0.266
0.112
0.035
0.0064
Sex
0.357
-1.933
1.147
0.1158
0.458
-1.536
0.986
0.1434
3
Race
N o t e . b = slope
Incidental Findings
Descriptive statistics were completed for the mean

self-concept scores by levels of perceived social
support.
It was noted that those subjects with higher levels of

social support had higher mean self-concept scores. One-way
analysis of variance revealed that these means were s i gni fi
cantly different at the 0.05 level.
This information is
summarized in Table 7.
Self-concept scores were grouped by stage of treatment.
r
Social support scores were also grouped by stage of treat

ment.
These results are shown in Table 8. The mean self-
concept and social support scores,
by stage of treatment.
57
were not statistically significant at the 0.05 level.

interesting to note, however,
It was
that during the relapse stage
both the social support scores and the self-concept scores

were the lowest and were below the total mean scores.
Table 7
Descriptive Statistics for the M e a n Self-Concept Score by
Levels of Perceived Social Support
f
Scores
High (greater than 150)
Moderate
(75 to 149)
Low (less than 75)
sd
47
70.750
4.7434
53
57.333
18.3507
100
63.647
15.0289
0
17
Total
Mean
Table 8
Self-Concept and Social
Support by Stage of Therapy

Social support
Self -concept
Stage
Mean
SD
Induction
154.00
9.17
61.67
12.34
Maintenance
155.67
1.53
73.00
1.0
Off therapy
146.14
4.95
64.71
19.02
Relapse
132.75
29.86
56.25
14.57
Total
17
146.06
16.14
63. 65
15.03
M ean
SD
In an attempt to further describe the sample,

as self-concept and social
support scores,
statistics were computed by age,
as well
descriptive
race, and sex of the s a m
ple. This information is given in Tables 9, 10, and 11.

Table 9
Self-Concept and Social Support by Race
Social support
Race
Self-concept
Mean
SD
Mean
SD
Black
141.29
23.87
64.86
14.51
White
10
149.40
7.31
62.80
16.10
Total
17
146.06
16.14
63.65
15.03
Table 10
Self-Concept and Social Support by Aqe
Social support
Age
Mean
Self-concept
SD
Mean
SD
152.80
4.21
73.00
2.24
139.50
2.12
49.50
37.48
10
156.00
0.0
72.00
11
155.00
9.89
56.50
12.02
12
139.14
22.69
61.86
12.99
17
146.06
16.14
63.65
15.03
Total
59
Table 11
Self-Concept and Social
Support by Sex
Social
f
support
Self-concept
Mean
SD
135.4
26.78
64.00
14.35
Male
12
150.4
6.71
63.50
15.92
Total
17
146.1
16.14
63.65
15.03
Sex
Female
Mean
SD
Correlation coefficients were obtained for the selfconcept tool,
the social support tool, and the six self-
concept subscales with age,

ment.
race, sex, and stage of treat
Social support and stage of treatment were noted to be
significantly negatively correlated (r = -0.48, = 0.026).

No other statistically significant correlations were o b
tained with age,
race,
sex,
or stage of treatment.
Summary
Findings and analysis of data have been presented.
Demographic data were analyzed utilizing descriptive s tat i s
tics .
Measures of central
self-concept and social
tendency were used to analyze the

support scores.
Correlations were
utilized to ascertain if there was a relationship between

self-concept and social
support.
Stepwise multiple regres
sion was then chosen to determine the combination of v a r i

ables providing the most predictive power for the selfconcept of school
60
The research questions were addressed in this chapter.

The mean self-concept score was 63.65. Almost one third of
the scores fell below the mean.
The me an social support
score was found to be 146, with slightly less than one

fourth of scores falling below the mean.
Significant positive correlations existed between
social
support and the self-concept scores,
of the six subscale scores,
as well as each
and stage of therapy.
Stepwise
multiple regression revealed that nearly one half of the

variance in self-concept scores was accounted for by the
social
Age,
support variable when controlling for sex and race.
stage,
and diagnosis were not found to significantly
contribute to self-concept at the 0.05 level.
Chapter V
Summa ry, Discussion, Conclusions.
Implications, and Recommendations
Summary
This chapter provides discussion of the findings of the
study in relation to the review of the literature.
are summarized from the analysis of data.
Findings
Conclusions and
implications are postulated along with recommendations for

future research.
The purpose of this study was to describe self-concept
and social support in school
age children with leukemia and
to ascertain if there is a relationship between self-concept

and social support in school age children with leukemia.
The
PHCSCS was administered to subjects to discover the selfconcept.
The PRQ 85 Part 2 was used to obtain a description
of perceived social support.
The PHCSCS,
the PRQ 85 Part 2,
and a demographic questionnaire developed by the researcher

were utilized to ascertain the relationship between social
support and self-concept.
The data were analyzed by computing descriptive s t a t i s
tics,
correlational matrices,
sis. The 0.05 level

analyses.
and stepwise regression a n a l y
of significance was u tilized for all
SPSS Studentware (Norusis,
1988) was used to
compute all statistics.

61
62
Data analysis revealed the following findings:
1. The mean self-concept scores of school age children
with leukemia was 63.65 with a standard deviation of 15.03.
This mean score is above the average range of scores from 46
to 60, stated by Piers
(1984). The data revealed that 88% of
the subjects had average or above average self-concept

scores.
2. The mean social support scores of school age c h il
dren with leukemia was 146 with a standard deviation of
16.14.
All scores were within the moderate or high range for
perceived social support.
The mean of 146 is within the
moderate range reported by Brandt and Weinert
(1985).
3. A statistically significant relationship existed

between social support and self-concept scores of school age
children with leukemia.
Social support was associated with
29.7% of the variance in self-concept. A total
of 44.5% of
variance in self-concept was associated with social support

by controlling for sex and race.
4. Additionally a statistically significant relation
ship existed between social support and the Behavior s u b sc
ale and the Happiness and Satisfaction subscale scores on
the PHCSCS at the 0.05 level of significance.
Social support
was associated with 39.8% of variance in the Behavior s u b sc

ale of self-concept.
equation,
By controlling for race and sex in the
a total of 48.1% of the variance in self-concept
was accounted for.
Similarly, social support was associated
with 26.6% of the variance in the Happiness and Satisfaction
63
subscale of self-concept.
By controlling for sex and race
bias, total variance accounted for by social support i n

creased to 45.8%.
Discussion
The findings of the present study are similar to s t u d
ies conducted by Carr-Gregg et a l ., (1985), Read (1991),
Parish and Parish (1991), Mishel and Braden (1987), Riegel
(1989), Cherry
(1991),
and Fobair et a l ., (1986).
Common to
all these studies is the conclusion that self-concept and

social support are related. Read concluded that the level of
social support is proportional
to the level of self-concept.
This finding is supported by the present research, which

concluded that social support is positively related to selfconcept and may be a determinant of an individual's a d jus t
ment to live with a chronic illness.
The findings of the present study also support the work
of Beddell et a l . (1977), who found a relationship between
self-concept and life stress in chronically ill children.
They concluded that environmental
nants of psychological well being.
influences were d e t erm i

Based on their findings
and the findings of the current study,

that environmental
influences,
it can be deduced
such as social support,
affects the self-concept of chronically ill children.

Varni et a l . (1994)
similarly studied children age 8 to
13 years and found that those with decreased social

had increased risk for psychological
support
Cadman et a l . (1987) also concluded that poor social
64
adjustment and school problems include poor self-concept and

may be precursors of psychological
chronic illness.
study.
problems in children with
This finding is supported by the present
In the present sample decreased social
fact, does result in decreased self-concept,

indicator of further psychological
support,
in
which may be an
The present findings support research done by Woodbury

(1992).
Social support may buffer against poor adjustment to
the stressors of cancer as evidenced by higher self-concept

wit h higher levels of perceived social
wit h Wood bu ry and the present findings,
support.
Consistent
Parish and Parish
(1991) associated support system failures with decreased

self-concept.
The current study does not support the work of Noll et
a l . (1993),
who found that adolescents with cancer experi
ence social
isolation, but this isolation has little effect
on self-concept.
South (1988) found that children with
leukemia had significantly lower self-concept scores when

compared to a control group of healthy school age children.
While the present findings do indicate self-concept scores
to be w ith in the established norms,
to a control
group.
Similarly,
there was no comparison
Carr-Gregg et a l . (1985)
found that 75% of pediatric oncology clients scored below

the published norms for the PHCSCS
(Piers,
1984). However,
the present study found the maj ori ty of self-concept scores

to be wi thin the established norms for the self-concept
t o o l . This is consistent w i t h research conducted by Burns
65
and Zweig
(1980) who found that the self-concept scores of
well children and children with cancer did not differ s i g

nificantly.
Van Dongen-Melman and Sanders Woudstra
(1986) found
that the more complex the treatment for cancer the more
likely children were to have psychosocial
problems.
Inter
estingly the present study indicates that self-concept and

social support may be related to the intensity of treatment,
because both self-concept and social support scores were
lowest for children in the intensive stages of beginning
therapy and those in relapse. This is an area in need of
further study.
Neuman's Systems model
(Neuman,
1989) provided an
excellent basis for guiding this research. The Neuman model

is congruent with pediatric oncology nursing. The pediatric
oncology client has unique needs and responses to stressors
that the nurse must identify,
assess,
and understand in
order to provide appropriate care so that the client can

achieve optimal wellness biologically as well as p syc hol og i
cally,
socioculturally,
d e v e l o p m e n t a l l y , and spiritually.
Neuman's Systems model suggests dynamic energy exchange

between the person and the environment. Nursing is concerned
with conserving energy to move toward wellness rather than
illness.
This model
can assist pediatric oncology nurses to
identify appropriate responses to stress related situations

and possible reactions of the client, such as decreasing
self-concept.
Nursing intervention can then be focused on
66
decreasing stress factors and opposing conditions,

low perceived social support,
such as
that could affect optimal
client functioning and response to treatment.

Ultimately nursing must keep the client system rela
tively stable.
Stability is achieved through accurate a s
sessment of environmental stressors,
their effects,
and
responses of the client and in assisting the client to

adjust.
Stress occurs when situational demands surpass one's
ability to cope with certain events. Social support cushions

effects of stressors by lessening the severity of the re ac
tion to the stressor,
enhancing coping efforts,
and empower
ing the person to perceive the stress as less stressful.

The Neuman model has the ability to integrate health
related theories and concepts,
social support,
including self-concept and
and to elucidate the relationship of va ri
ables in nursing care. Nursing actions should include a s

sisting the pediatric oncology client in retaining,
at tain
ing, or maintaining optimal wellness through specific in ter

ventions aimed at reducing or relieving stressors.
tion should be based on client data,
Interven
relevant theory, and
research.
The concepts of prevention through intervention are
already used in oncology nursing,
Systems model
so that use of Neuman's
(Neuman, 1989) does not involve a major shift
in focus. The model
can provide theoretically valid and
consistent means to assess and intervene at the appropriate

level of prevention. With more open approaches used today,
67
early studies of psychosocial
adjustment and consequences of
pediatric cancer and treatment may not apply to children

being treated today. Treatment for childhood leukemia does
not necessitate psychological damage.
Limitations
Conclusions may not be generalized beyond the sample
because a sample of convenience was utilized and because of
the small sample size.
It was difficult to recruit subjects
mainly due to small total potential subjects available.
The
average age of the child with acute lymphocytic leukemia is

2-9 years. Adolescents are more commonly affected by acute
nonlymphocytic leukemia. Therefore the pool of potential
subjects was severely limited.
about 3 years.
Data collection continued for
Despite small sample size, adequate power
was shown (0.89).

Conclusions
The results of the research show that school
age ch il
dren with leukemia with low levels of perceived social

support are significantly more likely to have low selfconcept in comparison to children with higher perceived
social support. For the present sample the following conclu
sions can be made:
(a) Perceived social support of school
age children with leukemia is moderate to high;
(b) reported
self-concept of school age children with leukemia is average

to high;
(c) there is a strong positive relationship between
social support and self-concept in school age children with

leukemia;
(d) if race and sex are controlled for, social
68
support can account for nearly one half of the variance in

self-concept;
and (e) stage of therapy and age of subject
does not significantly impact self-concept.

Implications
Clinical
implications emerging and supported by this
research include:
1. Client and family teaching should include strategies
for dealing with disease specific social
2. Social
situations.
concerns of children with cancer can be
recognized early,
before they interfere with treatment or
future psychosocial
adaptation.
3. Positive and effective coping strategies should be

identified and reinforced from the point of diagnosis and
initiation of treatment.
4. Crisis points,
relapse of disease,
such as remission induction and
can be anticipated.
Psychosocial
inter
vention efforts can be intensified in preparation for these

crisis points.
5. Children at increased risk for psychosocial problems
should be identified,
and intense attention should be
focused on those children.

6. Methods of promoting social support of the child
with cancer should be identified,
including interventions
through community education.

Recommendations
The following recommendations are submitted for further
study based on the findings,
conclusions,
and implications:
69
(a) Studies of self-concept and social
support in childhood,
to include a broader age and developmental
range,
conducted in order to examine developmental

studies of self-concept and social
should be
influences;
(b)
support in children with
solid tumors as well as hematogenous malignancies should be

performed;
(c) studies of self-concept and social support in
children with other chronic illnesses should be conducted;

and (d) a control
group of healthy children should be u t i
lized to study self-concept and social support in children

with chronic illnesses such as cancer.
Treatment for childhood cancer has been refined,
prognosis has improved remarkably since the 1970s.
and
Children
are informed openly and honestly about their disease today.

For all these reasons,
early research may not be applicable
to children diagnosed with cancer today.
In the 1970s c hil
dren diagnosed with cancer universally died.

rather than imminent death,
Today survival,
can be anticipated.
examination of the role of social
Further
support as it pertains to
self-concept,
as well as psychosocial
is essential.
Psychological
adjustment to stress,
as well as biological
cure must
be the aim and outcome of interventions.
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Appendix A
Institutional Review Board Approval Forms
80
THE UNIVERSITY OF
ALABAMA AT BIRMINGHAM
Ortice (it th e Institutional R ev iew Board for H um an U se
FORM 4: IDENTIFICATION AND CERTIFICATION OF

RESEARCH PROJECTS INVOLVING HUMAN SUBJECTS
THE INSTITUTIONAL REVIEW BOARD (IRB) MUST COMPLETE THIS FORM FOR ALL APPLI
CATIONS FOR RESEARCH AND TRAINING GRANTS, PROGRAM PROJECT AND CENTER GRANTS,
DEMONSTRATION GRANTS, FELLOWSHIPS, TRAINEESHIPS, AWARDS, AND OTHER PROPOSALS
WHICH MIGHT INVOLVE THE USE OF HUMAN RESEARCH SUBJECTS INDEPENDENT OF SOURCE
OF FUNDING.
THIS FORM DOES NOT APPLY TO APPLICATIONS FOR GRANTS LIMITED TO THE SUPPORT
OF CONSTRUCTION, ALTERATIONS AND RENOVATIONS, OR RESEARCH RESOURCES.
PRINCIPAL INVESTIGATOR: LISA SOUTH, RN

PROJECT TITLE: THE RELATIONSHIP BETWEEN SELF-CONCEPT AND SOCIAL SUPPORT IN
CHILDREN WITH ACUTE LEUKEMIA AT DIFFERENT STAGES OF CANCER
THERAPY
1.
THIS IS A TRAINING GRANT. EACH RESEARCH PROJECT INVOLVING HUMAN

SUBJECTS PROPOSED BY TRAINEES MUST BE REVIEWED SEPARATELY BY THE
INSTITUTIONAL REVIEW BOARD (IRB).
_X___ 2. THIS APPLICATION INCLUDES RESEARCH INVOLVING HUMAN SUBJECTS. THE

IRB HAS REVIEWED AND APPROVED THIS APPLICATION ON NOVEMBER 13, 1991
IN ACCORDANCE WITH UAB'S ASSURANCE APPROVED BY THE UNITED STATES
PUBLIC HEALTH SERVICE. THE PROJECT WILL BE SUBJECT TO ANNUAL
CONTINUING REVIEW AS PROVIDED IN THAT ASSURANCE.
THIS PROJECT RECEIVED EXPEDITED REVIEW.
_X_
THIS PROJECT RECEIVED FULL BOARD REVIEW.
3.
THIS APPLICATION MAY INCLUDE RESEARCH INVOLVING HUMAN SUBJECTS.

REVIEW IS PENDING BY THE IRB AS PROVIDED BY UAB'SASSURANCE.
COMPLETION OF REVIEW WILL BE CERTIFIED BY ISSUANCE OF ANOTHER
FORM 4 AS SOON AS POSSIBLE.
4.
EXEMPTION IS APPROVED BASED ON EXEMPTION CATEGORY NUMBER(S)_______
fitiHUX CunjwyAvu'Hj-iQ
DATE: NOVEMBER 13, 1991
RUSSELL CUNNINGHAM,,MID.
INTERIM CHAIRMAN OF THE
INSTITUTIONAL REVIEW BOARD
The
i I. j , m : i M ill
nt ALikmi.i .it
!
^ I V. p e j - i r \ R< MiU-v.irJ I A R
81
THE UNIVERSITY OF
ALABAMA AT BIRMINGHAM
O ffice o f the Institutional R eview Board for H u m an b s e
FORM 4: IDENTIF ICATION AND CERTIFICATION OF

OF FUNDING.

THERAPY

INSTITUTIONS REVIEW BOARD (IRB).
X
2.
THIS APPLICATION INCLUDES RESEARCH INVOLVING HUMAN SUBJECTS. THE

IRB HAS REVIEWED AND APPROVED THIS APPLICATION ON NOVEMBER II, 1992
3.

REVIEW IS PENDING BY THE IRB AS PROVIDED BY UAB'S ASSURANCE.
4.
EXEMPTION IS APPROVED BASED ON EXEMPTION CATEGORY NUMBER(S)
DATE: NOVEMBER 11, 1992

RUSSELL CUNNINGHAM,M.D.
The l.'mver'irv '! Al.iKim.t .it Birmineh.un

MTtinier I.>r.i.m H ill i-I'l ntver-ir. Bmiiev.ira ' AH
82
I M B S THE UNIVERSITY OF
O H P ALABAMA AT BIRMINGHAM
O ffice o f the Institutional R eview Board for H um an Use
FORM 4: IDENTIFICATION AND CERTIFICATION OF

OF FUNDING.

THERAPY
I.

INSTITUTIONAL REVIEW BOARD (IRB).
X___2. THIS APPLICATION INCLUDES RESEARCH INVOLVING HUMAN SUBJECTS. THE

IRB HAS REVIEWED AND APPROVED THIS APPLICATION ON DECEMBER 08, 1993
_X_
3.

REVIEW IS PENDING BY THE IRB AS PROVIDED BY UAB'SASSURANCE.
4.
EXEMPTION IS APPROVED BASED ON EXEMPTION CATEGORY NUMBER(S)_______
DATE: DECEMBER 08, 1993

i 1
Russell cunningham
cunningh
, m .d
T h e U n iv ersity o f A labam a at Birm ingham

212 M ortim er Jordan H all 1825 U niversity Boulevard
B irm ingham , A labam a 35294-2010 (205) 934-3789 FAX (205) 975-5977
Appendix B
Program Director Approval Form
84
I grant permission for Lisa South to seek the p a r t i c i

pation of children with leukemia in her research study, and
to administer the Pier's Harris Children's Self-Concept
Scale and the PRQ 85, Part 2 to these participants.
(Circle o n e ) :
YES
Date
NO
Signature
Appendix C
Guidelines for Administration of Re search Tools
86
G uidelines for Administering the

Self-Concept Tool an d the Social Support Tool
1. Offer the parent or guardian a copy of the questionaires and the information and demographic form. Explain that
the questionaires "Consists of simple questions about how
the child feels about themselves.
right or wrong answers.
Explain that there are no
If the child answers the way they
really feel, then the answer is right."

2. Allow the parent or guardian time to read the infor
mation letter and to complete and sign the
demographic/consent form.
Ask if they have any questions
and answer these. Ask the child if they agree to participate

and complete the questionaires.
If the child agrees, and
parent or guardian has signed consent, proceed with the

questionaires.
3. To develop rapport with the child, state "The p u r
pose of this scale is to find out how you really feel about
yourself.
If you answer the way you really feel, then it's
the right answer.
Sometimes
your parents or teachers might
be asked to say how they think you f e e l , but this is your

chance to say how you feel".
4. To assure that the child answers the questions on
the PHCSCS scale honestly,
instruct them to "answer each
item on the scale the way you really feel and not the way
you think you ought to feel".
5. To assure that the child does not become anxious
about completing the scale,
like a game.
state,
"This is not a test, more
So there are no right or wrong answers.
87
6. Give a booklet and pencil
to the child and ask the
child to turn to the first page and complete the identifying

information.
Then state,
"I would like you to read the
directions silently as I read them aloud.

7. Emphasize that every item should be circled YES or
NO. All items should be answered even if they have a hard
time deciding which answer to mark.
8. Since some children may have difficulty reading and
understanding the items,
read each item aloud as the child
reads it silently. Read each item twice.
I give the child
the option of reading the questions and answering them

silently or having me read the items for them as they a n
swer.
Younger children may require/request the items be
read.
9. Check to make sure the child is completing the scale
correctly. Ask if there are any questions.
10. Any word that the child does not understand,
or is
uncertain about, may be briefly defined.

11.
If some children are reluctant to give a simple YES
or NO answer,
tell them that they should answer the item the
way they u sually f e e l .

12.
Items 32 and 72 should not be omitted even if the
child is an only child.
Those children who do not have a
sibling should be told to answer No to item 32 and YES to

i t em 72.
88
13. Allow the child to proceed at his or her own pace.

14. After the PHCSCS is completed,
collect the booklet
and hand out the PRQ-85 Part 2.

15. State "These are some questions to find out more
about you. You will mark these statements differently.
are 7 possible answers.
There
Look at the scale at the top of the
page (Point out the scale).
#1 means that you really don't
agree with the sentence at all. #2 means that you Mostly

don't agree with the sentence.
#3 means that you disagree a
little bit. #4 means that you don't have any feeling about
the sentence on way or another.
#5 means that you agree a
little bit. #6 means that you mostly agree with the s e n

tence.
#7 means that you really agree with the sentence.
16. Be sure that the child understands the scale before

beginning.
17. Offer to read each statement aloud as the child
reads them silently.
18. Ask the child completes the questionnaire,
there are any questions.
ask if
Offer to explain the scale again if
needed at any time while the questionnaire is being c o m ple t

ed.
19. Allow the child to work at his own pace.
20. Collect the questionnaire when the child has f in
ished. Offer thanks for participation.
Remind them that they
may call the number on the information letter if they have

any questions.
Appendix D
Cover Letter
90
Dear Parent,
I am a graduate student in nursing at the University of
Alabama School of Nursing, University of Alabama at
Birmingham.
My major is maternal-child nursing.
In order to complete dissertation research requirements for
my doctoral degree, I am conducting a study of self-concept
and social support of school age children with leukemia.
Because you have a child fitting this description, I am
asking that you give permission for your child to partici
pate in the study.
Participation in the study involves completion of the dem o
graphic questionnaire attached, by the parent of the child.
After the questionnaire has been returned, your child will
be asked to complete the Piers-Harris Children's Self C o n
cept Scale and the PRQ 85, Part 2 Social Support Scale.
It
will take approximately 30 minutes for your child to com
plete the tools.
All information obtained for this study will be treated
confidentially and individual names will remain anonymous.
The questionnaires are assigned numbers, so that no names
will be used,
all information will be recorded as group
data, so that no individual can be identified.
No risks to
participants has been identified.
Results of the study will
be made available to you upon request.
Participation in the study is voluntary and you may withdraw
your child from the study until the point at which the data
have been collected.
If you agree for your child to p ar tic
ipate in the study, I would appreciate you completing,
signing, and returning the attached questionnaire.
Your
willingness to participate will be greatly appreciated.
Should you have any questions regarding the study, please
feel free to contact me at (205) 822-6507.
Sincerely,
Lisa South, R . N . , D.S.N.
candidate
Appendix E
Demographic Questionnaire/Consent
92
Demographic Questionnaire
ChiId's Name:
Child's date of birth:
Child's sex (circle one):
MA LE
FEMALE
C h i l d s race
BLACK
WH ITE
(circle one):
Child's grade in school
(circle one):
OTHER:
3
Chi Id's d i a a n o s i s :
Date of d i a a n o s i s :
Stage of therapy:______
Present disease status:
Does your child have any chronic illness other than le uke
mia, or obvious physical or mental limitations?
(circle
one):
YES
NO
If yes, please specify illness or limitation:
_____________
The completion of this questionnaire and my signature below,

signify that consent is granted for my child to participate
in the study to be conducted by Ms. Lisa South.
I under
stand that I am not waiving any of my legal rights by s i g n
ing this form.
M y signature below indicates that I have
received a copy of the informed consent letter.
Date
Signature of Parent or Guardian
Date
Signature of Witness
As a school age child, I agree to participate in the re

search conducted by Ms. Lisa South.
I understand that my
participation involves answering simple questions about
myself.
Date
Signature of Parent,
Guardian,
or Child
G R A D U A T E SCH OOL
U N IV E R S IT Y O F A L A B A M A A T B IR M IN G H A M
D IS S E R T A T IO N A P P R O V A L F O R M
N a m e o f C a n d id a te
L is a p.
s out h__________________________________
M ajor S u b j e c t _______ M a t e r n a l C h ild H e a l t h N u r s i n g _______________

T itle o f D isserta tio n
The R e l a t i o n s h ip B e t w een S e l f C o n c e p t and
_________ S o ci al S u p p o r t
in S c h o o l A g e C h i l d ren w i t h L e u k e m i a
D isserta tio n C om m ittee:
/ ( . I - .
ILll
Z'-
C hairm an
A.
f'
D irecto r o f G raduate Program

D ea n , U A B G raduate S ch ool
D a te

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INFORMATION TO USERS

A Bell & Howell Information Com pany

THE RELATIONSHIP OF SELF-CONCEPT AND

Submitted in partial fulfillment of the requirements for

OMI Microform 9527022

D.S.N_______________ Major Subject

Maternal Child Nursing

Lisa Darlynne South_____________________________

The Relationship of Self-Concept and Social Support___________

ment of pediatric cancers. With the focus of care shifting

The purpose of this study was to describe

perceived social support and self-concept of school age

and to ascertain if there is a

relationship between social support and self-concept of

The Neuman Systems model

served as the organizing framework for the research.

The Piers Harris Children's Self-

Concept Scale and the Personal Resource Questionnaire,

Data analysis consisted

stepwise multiple regression,

one-way analysis of variance.

are significantly more likely to have lower self-concept in

age children with leukemia.

and relapse of disease,

such as remission induction

efforts can be intensified in preparation for these crisis

Children at increased risk for psychosocial

and more intense attention should be

focused on those children.

children should include children with solid tumors,

and children with other chron

The Neuman Systems Model would be of benefit

Abstract Approved by:

I would not be where I am today without these

for having known them all.

dedicate this work, and its continuation,

especially my chairperson, Dr. Kathy Jimmerson, who provided

great appreciation that I acknowledge Dr. Penny Wright,

expertise, and encouragement motivated me to

complete my work. Appreciation is also extended to Dr. Ann

for their continued support,

and Dr. John

constant but gentle nudging to complete this work.

time, and cheerleading,

faculty of 346 and the staff of 5SE. Their support and

for his computer expertise and for

always coming through in crisis,

I would like to thank Art

allowing me to work with children with cancer.

Self-Concept and Chronic Illness

TABLE OF CONTENTS (Continued)

Summary, Discussion, Conclusions, Implications

Institutional R eview B o a r d Approval Forms

Program Director Approval

Guidelines for A d m i n ist ra tio n of Research Tools ...

Cover Letter ..........................................

Descriptive Statistics for Self-Concept Scores.

Frequencies for Social Support Scores

Stepwise Multip le Regression Summary for

Stepwise Mu ltple Regression Summary for

Stepwise Multiple Regression Summary for

Descriptive Statistics for the Mean Self-Concept

Social Support by Race

Social Support by Age

Hubungan Konsep Diri&Dukungan Sosial Anak LLA

Hubungan Konsep Diri&Dukungan Sosial Anak LLA