Social Functioning of Children Surviving Bone Marrow Transplantation

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1 Journal of Pediatric Psychology, Vol. 23, No. 3, 1998, pp Social Functioning of Children Surviving Bone arrow Transplantation Kathryn Vannatta, PhD, eg Zeller, PhD, Robert B. Noll, PhD, and Kristine Koontz, S Children's Hospital edical Center, University of Cincinnati Objective: To evaluate the behavioral reputation and peer acceptance of pediatric bone marrow transplant (BT) survivors. ethods: Forty-eight BT survivors (8-16 years of age) were compared to 48 nonchronically ill, sameclassroom, same-gender comparison peers (COP). Peer, teacher, and self-report data were collected. Results: Relative to COP, BT survivors had fewer friends and were described by peers, but not teacher or self-report, as more socially isolated. In addition, peers described BT survivors as being less physically attractive and athletically skilled. Further analyses suggested that these nonsocial attributes (physical appearance and athletic ability) and treatment variables (whether cranial irradiation was received) mediated the social difficulties of BT survivors. Conclusions: These data are suggestive of an unremitting pattern of difficulties with peers that has the potential to disrupt normal social and emotional development. Differences between peer, teacher and self-reports highlight the need for multiple informants in future work. Key words: bone marrow transplant; peer relationships. Bone marrow transplantation (BT) is a highly aggressive therapy used with increasing frequency for a variety of severe, life-threatening pediatric diseases. Decreases in morbidity and mortality rates, growth of the National arrow Donor Program, and development of new sources of hemopoietic stem cells are likely to contribute to even greater use of this treatment modality in the future (Chopra & Goldstone, 1992; Parkman, 1994). A clear obligation exists to understand the impact of BT on quality of life and developmental outcomes. BT is a difficult ordeal. Near lethal doses of chemotherapy, with or without radiation, are given All correspondence should be sent to Kathryn Vannatta, Children's Hospital edical Center, Division of'hematology/oncology, 3333 Burnet Ave., Cincinnati, Ohio 4S vannattak@ichmcc.org. to destroy tumor cells and/or eradicate existing bone marrow and immune function. Following this therapy, the patient is "rescued" with an infusion of healthy marrow stem cells. For a minimum of 2-4 weeks, patients have no functioning bone marrow. Numerous toxic side effects are common during this time frame, including nausea, pain, infections, and even major organ failure. Hospitalization typically lasts 1-2 months and, even after discharge, contact with nonfamily members is often restricted due to protracted poor immune system functioning. School attendance is often not allowed for 3-9 months, and at times an entire academic year is missed. ost youngsters experience greatly diminished contact with peers. To the extent that BT follows failure of prior treatment, these physical 1998 Society of Pediatric Psychology

2 170 Vannatta, Zeller, Noll, and Koontz traumas and life disruptions take place after earlier ordeals. Numerous chronic and delayed complications of BT can also occur, such as chronic graftversus-host disease, endocrine abnormalities, or pulmonary complications (Buchsel, Leum, & Randolf, 1996). These complications have the potential to make enduring changes in observable, nonsocial attributes of the child, such as general appearance and athletic abilities. During the initial hospital phase of BT, children and their parents are likely to experience considerable psychological distress (see Powers, Vannatta, Noll, Cool, & Stehbens, 1996, for review). As increased numbers of children have become long-term survivors of BT, several reports have focused on their adjustment posthospitalization. BT survivors have been described as being emotionally labile and agitated, lethargic, and withdrawn from family and peers (Pot-ees, 1989). It has been suggested that BT survivors may be experiencing symptoms of posttraumatic stress (PTS) (Stuber, Nader, Yasuda, Pynoos, & Cohen, 1991). Interestingly, quality of life surveys have not identified difficulties in the domains of return to school, medical complications, and global quality of life ratings (Schmidt et al., 1993); however, questions about the validity of the measure used by Schmidt and colleagues for children make conclusions difficult to substantiate. In a recent study using wellstandardized, child-focused measures, Phipps and ulhern (1995) obtained a different picture. Parents of children who were at 6-12 months posttransplant reported deficits in their children's social competence, and children's self-reports showed significantly more anxiety and lower self-esteem post- BT. However, these parents did not describe difficulties with internalizing symptomatology, and their report of total problems on the Child Behavior Checklist (Achenbach & Edelbrock, 1983) demonstrated declines before and after the BT. Although these prior findings are quite intriguing, interpretation is limited by the lack of a suitable comparison group. Conclusions from prior work has been based on comparison to instrument norms. Even widely used, standardized measures that have been carefully normed, such as the Child Behavior Checklist, demonstrate regional (Sandberg, eyer-bahlburg, & Yager, 1991) and cohort effects (Achenbach & Howell, 1993). This is noteworthy because pediatric BT programs typically treat patients from a wide geographical region and varied demographic backgrounds. In addition, while the existing literature suggests social difficulties, no data are available from peers and teachers. This is a serious omission given the centrality of peer relationships to normal emotional development and the strong record of reliability and predictive validity of peer nominations (Parker & Asher, 1987). Insofar as pediatric BT survivors are found to be experiencing difficulties with peer relationships, it will be critical to identify the source of these problems and whether they remit over time. While internal psychological processes resulting from the trauma of BT may be the source of difficulties, consideration needs to be given to other mechanisms that might affect ongoing transactions between the child and his or her social environment. One possibility is that illness and intensive medical intervention result in enduring changes to nonsocial attributes of the child, such as appearance and athletic abilities, that are highly valued by peers (Lerner et al., 1991). Information is also needed regarding risk to social development engendered by specific components of medical treatment. Extensive empirical work has documented neurocognitive morbidity associated with whole brain radiation therapy (WBRT) (Fletcher & Copeland, 1988), and some recent work has suggested social vulnerabilities associated with this treatment (Noll, Ris, Davies, Bukowski, & Koontz, 1992). It is possible that subtle neurocognitive changes could occur that are associated with the types of social problems we identified (Rourke, 1995). Impairments in social functioning among low achieving or mainstreamed learning-disabled students have been previously reported (Gresham, 1992; Haager & Vaughn, 1995; Vaughn, Hogan, Kouzekanani, & Shapiro, 1990). This study had four goals. The first goal was to evaluate the social behavior (what is the child like?) and acceptance (is the child liked?) of children who have survived BT in comparison to same-gender classmates from the perspective of peer, teacher, and self-report. We hypothesized that survivors of BT would receive fewer friendship nominations and lower ratings of social acceptance than comparison peers. In addition, we hypothesized that BT survivors would be described by teachers, peers, and self-report as more socially withdrawn and isolated. The second goal was to evaluate peer perceptions of nonsocial attributes of BT survivors. These attributes included (a) physical appearance, (b) athletic competence, (c) academic performance, (d) fatigue,

3 Social Functioning of Pediatrtc BT Survivors 171 (e) frequent illness, and (f) school absenteeism.we hypothesized that BT survivors would be perceived by peers as lower on a, b, and c, and higher on d, e, and f. The third goal was to examine whether differences in nonsocial attributes mediate (Baron & Kenny, 1986) the impact of BT on social functioning. We hypothesized that nonsocial attributes would mediate differences between the groups. The fourth goal was to examine whether social difficulties and nonsocial attributes are related to (a) time since BT, and (b) whether WBRT or total body irradiation (TBI) had been administered to the child. We hypothesized that differences would lessen over time and would be more severe for children who received WBRT or TBI. ethods Participants BT Survivors (BT). Inclusion criteria required potential participants to be 8-16 years of age, have previously undergone BT, and since returned to school full-time. Children receiving full-time special education services were excluded since the small class sizes typical of self-contained classrooms may compromise the reliability and validity of peer measures. Nine children were excluded due to fulltime special education placement (three had evidenced mental retardation prior to diagnosis with cancer (e.g., Down's syndrome); three were transplanted for genetic disorders affecting neurological function (e.g., adrenal leukodystrophy); and three experienced deterioration in neurological function after BT, presumably as a result of cranial radiation. Six children did not qualify for inclusion due to lack of school attendance, five for medical reasons (e.g., relapsed on severe chronic graft versus host disease) and one home schooled by parental choice. Fifty-five additional children met eligibility requirements, but four could not be located. Fiftyone parents gave permission to contact their child's school, and three schools declined to participate. The final sample was 44% female with a mean age of 11.7 years. Thirty-nine of these children were European-American, seven were African-American, and two were of Hispanic or Indian descent. Twenty-two had been diagnosed with leukemia, 13 with anemia (aplastic or Fanconi's), 8 with solid tumors, 4 with lymphoma, and 1 with severe combined immune deficiency. Thirteen had received autologous BT and 35 had received allogeneic BT. Of the 34 patients transplanted for malignancies, 3 had experienced a relapse and regained remission before participating in our study. Amount of time lapsed since BT ranged from 9 months to 8 years (mean = 3.6 years). Comparison Group (COP). In our case-by-case matching procedure, one peer was chosen from each classroom for the comparison sample. Lists were made of all classmates who were the same gender as the target child. The peer with the median date of birth was selected for comparison. Previous research has shown that similar procedures have resulted in comparison groups that are highly similar in terms of parental age, education, income, marital status, number of children living at home, and occupational prestige (Noll et al., 1996). Instruments Revised Class Play (RCP). The RCP (asten, orison, & Pellegrini, 1985) was included to measure social reputation from teacher, peer, and self-report along three dimensions: (a) Sociability-Leadership, (b) Aggressive-Disruptive, and (c) Sensitive-Isolated. The RCP is a descriptive matching instrument requiring peers or teachers to "cast" classmates/ students into 30 different behavioral roles (e.g., "someone who fights a lot" or "would rather play alone than with others") in a hypothetical play. Nominations by teachers and peers were aided by a printed roster of all children in the class who were the same gender as the BT survivor. Single-gender RCP nominations were required to increase the probability of nominating the BT or COP child and to eliminate sex-role stereotyped nominations. Children are assigned "item scores" according to the number of times they were nominated for each role by peers. Children also completed a second version of the RCP indicating which roles they felt they could play best (RCP self-nominations). Item scores are summed for each source to create dimension scores (e.g., sociability/leadership). Each RCP score is standardized within classrooms (resulting in scores with a mean of 0 and a standard deviation of 1) to adjust for unequal class sizes and participation rates. Dimension scores of the RCP have been shown to be both internally consistent (peer a's range from.81 to.95; teacher a's range from.58 to.76; self a's range from.71 to.99) and stable; RCP-peer correlations across a 17-month interval range from.63 to.65 (asten et al., 1985; Noll et al., 1992; Noll, Le- Roy, Bukowski, Rogosch, & Kulkarni, 1991). Peer

4 172 Vannatta, Zeller, Noll, and Koontz nominations on the RCP correlate significantly with teacher (.35 to.51) (Davis, 1994; Noll et al., 1991) and self (.14 to.22) nominations (Zeller, 1992). oreover, in two longitudinal studies, the Sociability-Leadership score in childhood was shown to be predictive of later indices of competence, whereas the Aggressive-Disruptive and Sensitive-Isolated scores were shown to be predictive of psychopathology and behavioral problems (Hymel, Rubin, Rowden, & Leare, 1990; orison & asten, 1991). Recommendations (Rubin & ills, 1988) regarding subdivision of the Sensitive-Isolated dimension into two subscales, Passive-Anxious and Active-Isolation, were adopted to provide more detail about the nature of problems occurring for BT survivors. Passive-Anxious consists of items regarding shyness or self-preference to play alone; Active-Isolation reflects actual rejection by peers such as often left out. For this study, nine additional roles were included related to illness (three roles), physical appearance (two roles), athletic competence (two roles), and academic competence (two roles) (Noll et al., 1991). Each item was standardized within classroom and the two items assessing each competence domain were combined to create a single score that was higher when a child was perceived as attractive, athletic, or academically competent. Three Best Friends. Children were asked to choose the three peers in their class whom they thought of as their best friends. Each youngster was given (a) an acceptance score based on the number of times he or she was chosen as a friend by peers and (b) a mutual friendship score indicating how many of their friendship selections were reciprocated. This methodology provides a stable index of peer acceptance (Bukowski & Hoza, 1989). Total and reciprocated best friend scores were converted to z scores ( = 0, = 1) separately for boys and girls within each classroom to adjust for unequal numbers of participating children and classroom gender compositions that would be expected to affect these scores. Liking Rating Scale. Children were asked to rate all of their classmates on a five-point scale in which "1" meant "someone you do not like" and "5" meant "someone you like a lot" (Asher, Singleton, Tinsley, & Hymel, 1979). An average liking score was computed for each child based on the ratings the child received from peers. This approach to assessment of peer acceptance was utilized because it provides a measure of overall social acceptance that is complimentary to the sociometric measure of friendships (Bukowski & Hoza, 1989). It has been shown to be a reliable and stable measure of acceptance (Asher et al., 1979). ean ratings were standardized separately for boys and girls within each classroom. Procedure After receiving permission from parents of BT survivors and school principals, each child's regular (elementary) or English class teacher was contacted. Teachers (N = 48) were visited (within a 100-mile radius) or mailed a packet of information and contacted by phone, to explain the study, attain their cooperation and informed consent, and complete the RCP. Children returning parental consent forms (927 classmates, representing 83% of classmates) completed all measures in group data collection sessions. The study was introduced to classmates as a "friendship project" with no mention of the target child, chronic illness, or children's hospital. All responses were coded with subject numbers and confidentiality was maintained. Results Goal 1: Group Differences in Social Reputation and Acceptance Peers selected BT survivors significantly more often for Passive-Anxious and Active-Isolation roles (Table I). In contrast, teachers nominated BT survivors significantly less often for Aggressive- Disruptive roles, and self-reports on the RCP were not significantly different between the two groups. Holm's correction (Holland & Copenhaver, 1989) for multiple comparisons was applied to each data source to control Type I error, resulting in the loss of one significant difference between BT survivors and COP. These data provide mixed support for our hypothesis that BT survivors would be described by teachers, peers, and self-report as more socially withdrawn and isolated. BT survivors were chosen by peers significantly less often as a best friend ( BT = 2.04, = 1.70; COP = 3.06, = 1.97) and were less likely to have their best friend choices reciprocated (Table II). However, the two groups received comparable like ratings ( BT = 3.51, =.72; COP = 3.71, =.55). These data provide partial support for our hypotheses that BT survivors would be less accepted by peers.

5 Social Functioning of Pediatric BT Survivors 173 Table I. Peer, Teacher, and Self-Report of the Social Reputation of BT Survivors and COP BT(n = 48) COP (n = 48) r(46) Peer report RCP Sociability-Leadership Aggressive-Disruptive Passive-Anxious Active-Isolation Teacher report RCP' Sociability-Leadership Aggressive-Disruptive Passive-Anxious Active-Isolation Self-report RCP' Sociability-Leadership Aggressive-Disruptive Passive-Anxious Active-Isolation.13" * ' *< *** 3.28** * "Based on nominations from approximately 927 peers, about per each of 48 classrooms. This number varies slightly between measures because not all students completed all items from all questionnaires. 'RCP dimension scores are standardized within classrooms resulting in scores that have a = 0and = l. e Not significant after Holm's correction for multiple comparisons. 'Based on nominations from 48 teachers. 'Based on self-report from 95 participants. *p <.05. "p <.01. ***p <.001, all two-tailed tests. Table II. Peer Report of Social Acceptance of BT Survivors and COP BT (n = 45-^*8) COP (n = 46-48) Sociometric Scores" «46) No. of best friends No. of mutual best friends ean liking rating -.22"' -.38*.10"' " 3.36" 1.83 "Based on nominations from 927 peers in 48 classrooms, number of subjects varies slightly between measures because not all students completed all items from all questionnaires. "Sociometric scores were standardized within classrooms resulting in scores that have a = 0 and = 1. 'Raw scores are presented in text to aid interpretation of these results. **p <.01, all two-tailed tests. Holm's correction (Holland & Copenhaver, 1989) for multiple comparisons, applied to control Type I error, did not result in loss of any significant findings. Goal 2: Group Differences In Peer Report of Nonsocial Attributes BT survivors received significantly more peer nominations for two RCP roles related to illness and missing school (Table III). Classroom absentee data available from 38 classrooms supports these results ( BT = days, = 15.56; COP = 5.21 days, = 6.24), r(74) = 3.13, p <.01. Children in the BT group were also described by peers as less attractive and athletically skillful. Significant differences were not found for roles related to academic competence. These data provide support for our hypotheses that survivors of BT would be different on nonsocial variables. Goal 3: ediation of BT Impact on Social Functioning by Nonsoctal Attributes Peer perceptions of physical attractiveness and athleticism demonstrated significant correlations with multiple domains of social reputation and acceptance (Table VI). Hierarchical multiple regressions were utilized to test whether alterations in nonsocial attributes mediated the impact of BT on social functioning (Baron & Kenny, 1986). Three peer-report indices of social functioning that differentiated BT survivors from COP were the dependent variables: RCP Passive-Anxious, RCP Active-Isolation, and Total Best Friend nominations. Nonsocial attributes were entered into regres-

6 174 Vannatta, Zeller, Noll, and Koontz Table III. Peer Report of the Nonsocial Attributes of BT Survivors and COP BT(n = 47) COP (n = 47) K46) "Sick a lot" "isses a lot of school" "Tired a lot" Physical appearance Athletic competence Academic competence.89" "* 4.44"* 2.24*< 5.19*" 4.71*" 1.83 "Based on nominations from approximately 927 peers, about per each of 48 classrooms. This number varies slightly between measures because not all students completed all items from all questionnaires. 'All scores are standardized within classrooms to adjust for unequal class sizes and participation rates. Resulting scores have a = 0 and = 1. 'Not significant after Holm's correction for multiple comparisons. *p <.05. *"p <.001, all two-tailed tests. Table IV. Intercorrelations of Peer Perceptions of Nonsocial Attributes With Social Reputation and Acceptance Nonsocial attributes peer nominations Appearance Athletic Ability Academic Competence isses School Sick a Lot Tired a Lot Dimensions of peer report RCP Sociability-Leadership Aggressive-Disruptive Passive-Anxious Active-Isolation Peer acceptance Total best friend nominations Reciprocated best friend nominations ean liking rating.63*** *** -.60*".55***.51*".65***.36*" *" -.57***.39*".41***.42"*.52*" -.26" "* ** "".11-33" -.29** ** -.26* *.29** Correlations are reported for n = 90-96; based on nominations from approximately 927 peers, about per each classroom. These numbers vary slightly between measures because not all students completed all items from all questionnaires. "Not significant after Holm's correction for multiple comparisons. *p <.05 "p <.01. "*p <.001, all two-tailed tests. sions as potential mediators if they demonstrated two criteria: (a) a significant difference between BT and COP, and (b) a significant correlation with the dependent variable in that regression equation. Results show that nonsocial attribute scores made significant contributions to the prediction equation in addition to the variance attributable to the Type of Child variable (BT or COP) for each of the three dependent variables (Table V). In addition, changes in standardized beta weights ascribed to Type of Child from step 1 to step 2 (e.g., for Total Best Friend nominations:.27 to -.02) suggest that the effects of BT on Active-Isolation and Total Best Friend nominations are explained or mediated by differences in nonsocial attributes. In contrast, the effect of BT on the Passive-Anxious subscale was not mediated (-.44 to -.25) by nonsocial attributes. These data are generally supportive of our hypothesis that social differences would be related to nonsocial variables. Goal 4: Social Functioning as a Function of Time Since BT and Use of Radiation Correlations of social and nonsocial variables with time elapsed since BT were all nonsignificant except for peer nominations of "sick a lot," r(47) = -.40, p <.01, and "misses a lot of school," r(47) = -.47, p <.01. Comparisons were also made between BT survivors who had and had not received WBRT or TBI during the course of treatment. Children who had received either WBRT or TBI received more

7 Social Functioning of Pediatric BT Survivors 175 Table V. Results of Hierarchical ultiple Regressions Examining Nonsocial Attributes as ediators of the Impact of BT on Social Functioning Dependent variable Predictors (step and variables) Change R Beta (step 1) Beta (step 2) Passive-Anxious dimension RCP" Active-Isolation dimension RCP" Total best friend nominations" 1. Type of child (BT vs. COP) 2. Nonsocial attributes" a. Appearance b. Athletic ability 1. Type of child (BT vs. COP) 2. Nonsocial attributes" a. Appearance b. Athletic ability c. Academic competence 1. Type of child (BT vs. COP) 2. Nonsocial attributes" a. Appearance b. Athletic ability.20*".10".11*" 35*".07**.24*" -.44*" -.33*".27" -.25* * *" -.34"* *".12 'Based on nominations from 927 peers in 48 classrooms. *p <.05. "p <.01. '"p <.001, all two-tailed tests. nominations on the RCP Passive-Anxious scale from both peers ( radlaaon =.87, = 1.15; noradla. tion =.13, = 1.00), r(46) = 2.21, p <.05, and teachers ( radiatlon =.33, = 1.15; noradiation = -.35, =.63), t(46) = 2.55, p <.05. These two subgroups of BT survivors did not differ on any other dimensions of social reputation or measures of peer acceptance. These findings provide mixed support for our hypotheses that difficulties would lessen over time and would be more severe for children who received WBRT or TBI. Discussion The current study evaluated the social functioning of children who had survived BT. These youngsters were described by peers, but not teacher or selfreport, as more isolated and withdrawn than comparison classmates. Although sociometric ratings indicated that these children were not disliked overall, BT survivors received fewer best friend nominations and were less likely to have reciprocated friendships. These results validate and add considerable detail to previous reports of parent descriptions of impaired social competence among pediatric BT survivors (Phipps & ulhern, 1995). Interestingly, social functioning was not correlated with the length of time that had elapsed since BT. This suggests a pattern of unremitting difficulties and not just short-term struggles with school re-entry after a lengthy absence. It seems possible that the aversive experiences and life disruptions endured by children receiving BT could increase general adjustment problems that interfere with normal social and emotional maturation. The current results suggest that BT, in addition to prior treatment experiences, might initiate unfolding dysfunctional transactions between the child and the environment that disrupts social development. That is, initial reasons for diminished peer contact (e.g., hospitalization) and negative reactions from peers (e.g., appearance) may alter social selfperceptions, attributions, and expectancies in a way that would affect social initiation and behavior. Nonparticipation in normative peer activities (e.g., sports) and increased social withdrawal could, in turn, perpetuate peer perceptions of sensitivity and preference for being alone while doing nothing to improve social acceptance. If this pattern of social withdrawal and isolation were to continue unchecked, one would expect that children could fail to learn and practice skills central to making and keeping friends and social networks.

8 176 Vannatta, Zeller, Noll, and Koontz In addition to demonstrating that significant social deficits were present, the current work suggests possible mechanisms for initiation and maintenance of these differences. Children in the BT group were described by peers as sick a lot, missing school, less attractive, and less athletically competent than the COP. Chemotherapy and other components of BT treatment protocols may result in permanent hair loss or thinning (Baker et al., 1991), skin changes, delays in growth and maturation, and chronic medical difficulties (Buchsel et al., 1996). Although the current data suggest that peer perceptions of BT survivors as ill and missing a lot of school improves as time elapses posttransplant, peer perceptions of chronic fatigue, poor athleticism, and less desirable appearance do not change over time. ost important, our analyses showed that changes in appearance and athletic abilities mediate the impact of BT on peer perceptions of active isolation and social acceptance. Variation in nonsocial attributes did not mediate differences between BT and COP on peer reports of passive/anxious behavior. This dimension of social functioning did vary as a function of whether WBRT or TBI had been administered. BT survivors who had received cranial radiation were perceived as more passive, anxious, and socially withdrawn. There were no significant differences between these two groups on any of our other indices of social behavior or acceptance. Deleterious effects of cranial radiation on cognitive functioning have been well-documented in the literature; however, little is known about the effects of this treatment on social functioning. Recent work comparing children treated with malignancies that did and did not involve the central nervous system suggests that those with brain tumors are at risk for social withdrawal (Noll et al., 1992) and the current findings provide additional support for this pattern. Additional work is needed to examine the role of nonverbal or other learning disabilities and specific deficits in social information processing or problem solving that may explain the impact of cranial radiation on social isolation and withdrawal. Although findings from peers were generally supportive of our hypotheses, teachers did not report differences on either dimension of social isolation assessed. Teachers described BT survivors only as exhibiting lower levels of aggressive and disruptive behavior. These results suggest that teachers may be unaware of problems with social isolation and withdrawal and instead view BT survivors as not being a behavior problem. Earlier work has noted that there is less agreement between peer and teacher reports of socially withdrawn behavior than other dimensions of behavioral reputation (Rubin, Leare, & Lollis, 1990), and it has been suggested that peers may be more accurate at identifying socially withdrawn or isolated children than teachers (Rubin & Cohen, 1986). These findings highlight the need to obtain information from multiple sources. The current findings have clear clinical implications. BT survivors whose physical appearance is altered, or whose chronic physical problems impair athletic abilities, are at higher risk for problems with peer acceptance and social integration. BT survivors who received WBRT or TBI during treatment were described by peers as withdrawn and preferring to be alone, placing them, perhaps, at increased risk for internalizing difficulties. Psychosocial care providers should pay careful attention to nonsocial attributes and specific medical therapies as both appear to be important to peer relationships. Attention to these variables could help identify which children may still need services once they have returned to school. Ongoing school intervention, including education of peers and teachers about the effects of medical treatment, could prove beneficial beyond the initial reintegration of BT survivors into the classroom. Investigation is needed as to how children cope with and respond to peers about changes in their appearance and physical abilities and whether interventions to teach skills in this area could promote social competence for BT survivors. The data provided by teachers suggest they underestimate problems with peers for these children and would be unlikely to initiate a request for services. The current study does not provide us with information regarding the self-reported emotional well-being of long-term survivors of BT. Prior research suggests that peer perceptions of social withdrawal are associated with increased risk for internalizing difficulties (Hymel et al., 1990). Further research is especially needed to examine psychological mechanisms that might underlie the current findings in addition to the nonsocial ones described. It has been suggested that BT survivors are at risk for symptoms of posttraumatic stress, which may include anxiety, depression, and social withdrawal (Stuber et al., 1991). Other researchers

9 Social Functioning of Pediatric BT Survivors 177 have presented intriguing findings regarding the role family processes may play in the adaptation of children after BT (Phipps & ulhern, 1995). Prospective, longitudinal studies of BT survivors and comparison peers are needed to examine the role of these additional mechanisms in the social functioning of BT survivors. Acknowledgments Portions of this article were presented at the Ninth Annual eeting of the American Society of Pediatric Hematology/Oncology, Chicago, October Received February 27, 1997; accepted ay 29,1997 References Achenbach, T.., & Edelbrock, C. S. (1983). anual for the Child Behavior Checklist and Revised Child Behavior Profile. Burlington, VT: University of Vermont. Achenbach, T.., & Howell, C. T. (1993). Are American children's problems getting worse: A 13-year comparison. Journal of the American Academy of Child and Adolescent Psychiatry, 32, Asher, S. R., Singleton, L. C, Tinsley, B. R., & Hymel, S. (1979). A reliable sociometric measure for preschool children. Developmental Psychology, IS, Baker, B. W., Wilson, C. L., Davis, A. L, Spearing, R. L., Hart, D. N. J., Heaton, D.C., & Beard,. E. J. (1991). Busulphan/cyclophosphamide conditioning for bone marrow transplantation may lead to failure of hair regrowth. Bone arrow Transplantation, 7, Baron, R.., & Kenny, D. A. (1986). The moderatormediator variable distinction in social psychological research: Conceptual, strategic, and statistical considerations. Journal of Personality and Social Psychology, SI, Buchsel, P. C, Leum, E. W., & Randolf, S. R. (1996). Delayed complications of bone marrow transplantation: An update. Oncology Nursing Forum, 23, Bukowski, W.., & Hoza, B. (1989). Popularity and friendship: Issues in theory, measurement, and outcomes. In T. Berndt & G. Ladd (Eds.), Contributions of peer relationships to children's development (pp ). New York: Wiley. Chopra, R., & Goldstone, A. H. (1992). odern trends in bone marrow transplantation for acute myeloid and acute lymphoblastic leukemia. Current Opinions in Oncology, 4, Davis, C. R. (1994). Behavioral reputation and social acceptance of youth with sickle cell disease. Unpublished master's thesis, University of Cincinnati. Fletcher, J.., & Copeland, D. R. (1988). Neurobehavioral effects of central nervous system prophylactic treatment of cancer in children. Journal of Clinical and Experimental Neuropsychology, 10, Gresham, F.. (1992). Social skills and learning disabilities: Causal, concomitant, or correlational? School Psychology Review, 21, Haager, D., & Vaughn, S. (1995). Parent, teacher, peer, and self-reports of the social competence of students with learning disabilities. Journal of Learning Disabilities, 28, Holland, B. S., & Copenhauer,. D. (1988). Improved Bonferroni-type multiple testing procedure. Psychological Bulletin, 104, Hymel, S., Rubin, K. H., Rowden, L, & Leare, L. (1990). Children's peer relationships: Longitudinal prediction of internalizing and externalizing problems from middle childhood. Child Development, 61, Lerner, R.., Lerner, J. V, Hess, L. E., Schwab, J., Jovanovic, J., Talwar, R., & Kucher, J. S. (1991). Physical attractiveness and psychosocial functioning among early adolescents. Journal of Early Adolescence, 11, asten, A. S., orison, P., & Pellegrini, D. S. (1985). A revised class play method of peer assessment. Developmental Psychology, 21, orison, P., & asten, A. S. (1991). Peer reputation in middle childhood as a predictor of adaption in adolescence: A seven year follow-up. Child Development, 62, Noll, R. B., LeRoy, S. S., Bukowski, W.., Rogosch, F. A., & Kulkarni, R. (1991). Peer relationships and adjustment of children with cancer. Journal of Pediatric Psychology, 16, Noll, R. B., Ris,. D., Davies, W. H., Bukowski, W.., & Koontz, K. (1992). Social interactions between children with cancer or sickle cell disease and their peers: Teacher ratings. Journal of Developmental and Behavioral Pediatrics, 13, Noll R. B., Vannatta K., Koontz K., Kalinyak K., Bukowski W.., & Davies W. H. (1996). Peer relationships and emotional well-being of youngsters with sickle cell disease. Child Development, 67, Parker, J. G., & Asher, S. R. (1987). Peer relations and later personal adjustments: Are low accepted children at risk? Psychological Bulletin, 102, Parkman, R. (1994). Overview: Bone marrow transplantation in the 1990's. American Journal of Pediatric Hematology-Oncology, 16, 3-5. Phipps, S. & ulhern, R. K. (1995). Family cohesion and expressiveness promote resilience to the stress of pedi-

10 178 Vannatta, Zeller, Noll, and Koontz atric bone marrow transplant: A preliminary report. Journal of Developmental and Behavioral Pediatrics, 16, Pot-ees, C. C. (1989). The psychosocial effects of bone marrow transplantation in children. Delft: Eburon Publishers. Powers S. W., Vannatta K., Noll R. B., Cool V. A., & Stehbens J. A. (1996). Leukemia and other childhood cancers. In. Roberts (Ed.), Handbook of pediatric psychology (2nd ed., pp ). New York: Guilford Press. Rourke, B. P. (Ed). (1995). Syndrome of nonverbal learning disabilities. New York: Guilford Press. Rubin, K. H., & Cohen, J. S. (1986). The revised class play: Correlates of peer assessed social behaviors in middle childhood. Advances in Behavioral Assessment of Children and Families, 2, Rubin, K. H., Leare, L. J., & Lollis, S. (1990). Social withdrawal in childhood: Developmental pathways to peer rejection. In S. R. Asher and J. D. Coie (Eds.), Peer rejection in childhood (pp ). New York: Cambridge University Press. Rubin, K. H., & ills, R. S. (1988). The many faces of social isolation in childhood. Journal of Consulting and Clinical Psychology, 56, Sandberg, D. E., eyer-bahlburg, H. F. L, & Yager, T. J. (1991). The Child Behavior Checklist nonclinical standardization samples: Should they be utilized as norms? Journal of the American Academy of Child and Adolescent Psychiatry, 30, Schmidt, G.., Niland, J. C, Forman, S. J., Fonbuena, P. P., Dagis, A. C, Grant,.., Ferrell, B. R., Ban, T. A., Stallbaum, B. A., Chao, N.J., & Blume, K. G. (1993). Extended follow-up in 212 long-term allogeneic bone marrow transplant survivors. Transplantation, 55, Stuber,. L., Nader, K., Yasuda, P., Pynoos, R. S., & Cohen, S. (1991). Stress responses after pediatric bone marrow transplantation: Preliminary results of a prospective longitudinal study. Journal of the American Academy of Child and Adolescent Psychiatry, 30, Vaughn, S., Hogan, A., Kouzekanani, K., & Shapiro, S. (1990). Peer acceptance, self-perceptions, and social skills of learning disabled students prior to identification. Journal of Educational Psychology, 82, Zeller,. (1992). The relationship among peer, teacher and self perceptions of social competence: Age and gender effects. Unpublished master's thesis, University of Cincinnati.

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