Perceived Social Support, Psychological Adjustment, and Functional Ability in Youths With Physical Disabilities

Abstract

Objective: To examine the relationship between perceived social support and psychological adjustment and functional ability in youths with physical disabilities. Participants: Thirty-seven youths with neuromuscular disease and 33 with spina bifida. Measures: Demographic and disability-related questions, Child Health Questionnaire, Functional Disability Inventory, and Multidimensional Scale of Perceived Social Support. Results: Social support from family, but not from friends, was significantly associated with better psychological adjustment. Significant interactions emerged between family support and age, as well as between friend support and gross motor functioning, in the prediction of functional ability. Conclusions: Social support appears to play an important role in psychological adjustment and functional ability in this population, and the nature of this role may be moderated, to some extent, by age and gross motor functioning. Future research and clinical implications are discussed.

Full text

Perceived Social Support, Psychological Adjustment, and Functional
Ability in Youths With Physical Disabilities
Sylia Wilson, Lindsay A. Washington, Joyce M. Engel, Marcia A. Ciol, and Mark P. Jensen
University of Washington
Objective: To examine the relationship between perceived social support and psychological adjustment
and functional ability in youths with physical disabilities. Participants: Thirty-seven youths with
neuromuscular disease and 33 with spina bifida. Measures: Demographic and disability-related ques-
tions, Child Health Questionnaire, Functional Disability Inventory, and Multidimensional Scale of
Perceived Social Support. Results: Social support from family, but not from friends, was significantly
associated with better psychological adjustment. Significant interactions emerged between family support
and age, as well as between friend support and gross motor functioning, in the prediction of functional
ability. Conclusions: Social support appears to play an important role in psychological adjustment and
functional ability in this population, and the nature of this role may be moderated, to some extent, by age
and gross motor functioning. Future research and clinical implications are discussed.
Keywords: social support, physical disabilities, psychological adjustment, functional ability
Youths living with physical disabilities face a variety of unique
stressors, including restrictions in routine daily activities and par-
ticipation, limited independence, and coping with differences be-
tween themselves and their peers (Varni, Setoguchi, Rappaport, &
Talbot, 1992). In addition to the demands associated with typical
development, these youths must also cope with disability-specific
stressors and, therefore, face increased psychological and physical
demands associated with their diagnosis (Patterson & Geber, 1991;
see also Appleton et al., 1997; Bennet, 1994; Holmbeck et al.,
2003; Lavigne & Faier-Routman, 1992; Wallander & Thompson,
1995).
A number of factors that may be associated with the psycho-
logical adjustment of this population have been examined in pre-
vious research, including perceived social support and functional
ability. Both of these have emerged as significant predictors of
adjustment in youths with physical disabilities. Higher levels of
social support and higher functional status are each positively
associated with good psychological adjustment in youths with a
number of physical disabilities. Varni, Setoguchi, Rappaport, and
Talbot (1991), for example, found that low levels of social support
from classmates increased the risk of depression and low self-
esteem in youths with limb deficiencies. Furthermore, Witt, Riley,
and Coiro (2003) found, in a nationally representative sample, that
lower youth functional status, independent of physical limitation,
was associated with psychosocial maladjustment. Similar results
have been found for a number of other diagnoses, including
diabetes (La Greca et al., 1995), limb deficiencies (Varni & Se-
toguchi, 1991; Varni et al., 1992), juvenile rheumatoid arthritis
(JRA; Varni, Wilcox, & Hanson, 1988; von Weiss et al., 2002),
and spina bifida (SB; Hommeyer, Holmbeck, Wills, & Coers,
1999). For more detailed reviews of the effects of social support
and functional status on psychological adjustment in youths, see
La Greca, Bearman, and Moore (2002), Lavigne and Faier-Rout-
man (1993), and Wallander and Varni (1995).
Although these studies focus on the role of social support in the
lives of youths with physical disabilities, there is a lack of research
investigating the relationship between social support and func-
tional ability. Given past research indicating that social support is
positively associated with psychological adjustment in youths with
physical disabilities and that physical disability often impacts
functional ability, the present study sought to specifically examine
the interaction between these factors.
A search of the relevant literature revealed a paucity of research
examining the relationship between social support and functional
ability in youths with physical disabilities, though a link may well
exist. Research with adults has examined the predictive effects of
social support on functional ability in persons with physical dis-
abilities and chronic illnesses. Evers, Kraaimaat, Geenen, Jacobs,
and Bijlsma (2003) and Travis, Lyness, Shields, King, and Cox
(2004) found that low levels of social support predicted poorer
functional ability in adults with rheumatoid arthritis and depres-
sion, respectively. This adult research suggests that it is likely that
youths with physical disabilities may also benefit from social
support. For example, youths who have mild-to-moderate gross
motor restrictions and who are able to participate in educational
and extracurricular activities may have more opportunity for in-
Sylia Wilson, Lindsay A. Washington, Joyce M. Engel, Marcia A. Ciol,
and Mark P. Jensen, Department of Rehabilitation Medicine, University of
Washington.
This research was supported by Grant PO1 HD33988 from the National
Institutes of Health and Child Health and Human Development, National
Center for Rehabilitation Research. We gratefully acknowledge the con-
tributions of Kristie Bjornson, Ciara Kim, Chiara LaRotonda, Kimberly
McKearnan, Laura Nishimura, and Emily Phelps, Department of Rehabil-
itation Medicine, University of Washington, in data collection and database
management.
Correspondence concerning this article should be addressed to Sylia Wil-
son, Department of Rehabilitation Medicine, University of Washington, Box
356490, Seattle, WA 98195-6490. E-mail: sylia@u.washington.edu
Rehabilitation Psychology
2006, Vol. 51, No. 4, 322–330
Copyright 2006 by the American Psychological Association
0090-5550/06/$12.00 DOI: 10.1037/0090-5550.51.4.322
322

teraction and friendship with peers compared with those with more
severe restrictions. This social interaction may, in turn, positively
influence these youths’ functional ability because it allows for
increased participation, encouragement from peers, and exposure
to extracurricular activities.
A number of studies have examined social support on a global
level (i.e., social support in general) and its association with
functioning in youths. For example, Wallander and Varni (1989)
found that children with a variety of chronic illnesses who reported
high levels of support from both family and friends exhibited
fewer behavior problems than did children who reported support
from only one source. Research suggests, however, that the dif-
ferent types of social support (i.e., that from family vs. that from
friends or peers) experienced by youths may play differential roles
in predicting psychological adjustment and functional status. Varni
et al. (1988), for example, found that family, but not peer, support
significantly predicted both internalizing and externalizing behav-
ior problems in youths with JRA.
It is also possible that different types of social support may play
different roles in adjustment as youths age (Kashani, Canfield,
Borduin, Soltys, & Reid, 1994). In examining psychological ad-
aptation in youths with diabetes, for example, Varni, Babani,
Wallander, Roe, and Frasier (1989) found that perceived family
support predicted adaptation in children whereas perceived friend
support predicted adaptation in adolescents. This suggests the
possibility that perceived social support from friends might in-
crease in importance as children move into adolescence.
To better understand the role that social support may play in
persons with physical disabilities, the present study investigated
the relationship between perceived social support and psycholog-
ical adjustment and functional ability in youths with neuromuscu-
lar disease (NMD) and SB. These two disability types were in-
cluded both because of their commonality in the general
population and because little is as yet known about them. The
potentially moderating roles that age and gross motor functioning,
an indicator of functional ability, may play in the association
between social support and functioning are also examined. Given
previous research in this area, our primary hypothesis was that
higher perceived social support would be associated with better
psychological adjustment in the sample, as indicated by higher
scores on a mental health scale. On the basis of research with
adults with physical disabilities and chronic illnesses, we further
hypothesized that youths with higher perceived social support
would report higher functional status. Finally, our third hypothesis
was that age and gross motor functioning would moderate the
association between perceived social support and both psycholog-
ical adjustment and functional status of participants. Specifically,
we predicted that perceived friend support would be more impor-
tant for psychological adjustment in older youths and that per-
ceived family support would be more important for younger
youths. Similarly, we predicted that perceived social support
would show a stronger association with functioning among youths
with higher gross motor functioning than among youths with lower
levels of gross motor functioning.
Method
The data for this study came from a larger ongoing study of youths with
physical disabilities on the nature and scope of pain in this population. The
present article is the first to examine data from this larger study. The
present analyses focus on a subset of the measures obtained during youth
interviews and from parent questionnaires that address issues related to
youth-reported perceived social support, psychological adjustment, and
functional ability, as well as parent/guardian-reported demographic infor-
mation and disability level.
Participants
Participants were a convenience sample of youths with NMD (n⫽37)
and SB (n⫽33), and their parents/guardians, from the greater Seattle,
Washington, metropolitan area. Inclusion criteria included (a) a primary
diagnosis of NMD or SB; (b) chronological age between 8 and 20 years; (c)
capacity for expressive communication using augmentative communica-
tion devices as needed, although, in fact, none of the participants in the
present study used such devices during the interview; (d) no more than
mild cognitive impairment as determined by a brief telephone screening
with the parent/guardian and a minimum passing score of 17/25 on a
modified Mini-Mental Status Examination (MMSE; Roccaforte, Burke,
Bayer, & Wengel, 1992); and (e) use of English as the primary language.
The MMSE has been successfully used in children as young as 4 years
(Ouvrier, Goldsmith, Ouvrier, & Williams, 1993). The minimum passing
score of 17/25 is the cutoff score suggested by Roccaforte et al. If the
MMSE was conducted over the telephone, as opposed to in person,
participants were not assessed on the motoric component of the examina-
tion and, therefore, required a passing score of 15/22. See Table 1 for
further demographic information.
Materials
Structured interviews for the youths and questionnaires for the parents/
guardians included questions and measures that assessed demographic
information; disability level; psychological adjustment; impact of pain,
illness, and disability on functioning; and perceived social support.
Demographic data. Descriptive demographic data collected from the
parent/guardian included the youth’s age and sex and the total family
household income.
Disability level. To assess gross motor functioning, we asked parents/
guardians to respond to a modified version of the Gross Motor Functioning
Classification Scale (GMFCS; Palisano et al., 1997). The GMFCS was
developed for use with the cerebral palsy population. The items were
adapted slightly in the present study to accommodate for the multiple
physical disabilities represented in our sample. The specific items used in
the present study were the following: I ⫽walks without restrictions but has
limitations in more advanced gross motor skills; II ⫽walks without an
assistive device and has limitations walking outdoors and in the commu-
nity; III ⫽walks with an assistive mobility device and has limitations
walking outdoors and in the community; IV ⫽limited self-mobility with
assistance or device (e.g., another person, walker, wheelchair) and uses
power mobility outdoors and in community only; and V ⫽severely limited
self-mobility even with the use of assistive technology (e.g., power mo-
bility). Lower scores on the gross motor functioning scale indicate a higher
level of functioning.
Psychological adjustment. Youth participants answered questions
from the Mental Health (MH) Scale from the child form of the Child
Health Questionnaire (CHQ–CF87; Landgraf, Abetz, & Ware, 1996). The
CHQ–CF87 is an 87-item self-report measure designed to assess youths’
physical and psychosocial well-being. The questionnaire is divided into 12
scales and includes a 16-item MH Scale, which measures the frequency of
negative and positive states and is designed to capture anxiety, depression,
and positive affect. Using this measure, participants rate how often they
experienced different moods and feelings in the past 4 weeks on a 5-point
Likert scale ranging from 1 (all of the time)to5(none of the time). A low
score on the CHQ–CF87 MH Scale indicates that the child feels anxious
323
PERCEIVED SOCIAL SUPPORT IN YOUTHS

and depressed all of the time, whereas a high score indicates that he or she
feels peaceful, happy, and calm all of the time. The CHQ–CF87 is scored
by first computing a raw score, then transforming raw scores to standard-
ized scores, using the method outlined by Landgraf et al. Standardized
scores range from 0 to 100. The CHQ–CF87 MH Scale has demonstrated
adequate internal consistency in samples of youths with psychological and
physical diagnoses (e.g., attention deficit hyperactivity disorder, asthma,
JRA, and epilepsy; Cronbach’s ␣⫽.82–.86; Landgraf et al., 1996). The
alpha for our sample was .88. The scale has also demonstrated substantial
validity for measuring youths’ psychosocial well-being (Landgraf et al.,
1996).
Impact of illness, pain, or disability. Youth participants reported the
impact of illness, pain, or disability on their physical and psychosocial
functioning in everyday social roles by answering questions from the
Functional Disability Inventory (FDI; Walker & Greene, 1991). The FDI is
used to provide information on disruption of typical physical and social
activities, including schoolwork, caused by illness, pain, or disability.
Though this measure does not isolate pain as the primary contributor to
functional impairment, it does provide insight into activity interference, an
important aspect of this study. The FDI is comprised of 15 behaviors
related to functioning in child-relevant settings, such as “In the last few
days, would you have had any physical trouble or difficulty doing these
activities (e.g., being at school all day)?” Using the FDI, respondents rate
the amount of difficulty of each activity on a 5-point Likert scale ranging
from 0 (no trouble)to4(impossible). The FDI is scored as a total sum of
items. This score ranges from 0 to 60. We prorated FDI items left blank in
the present study by calculating means based on answered items. The FDI
is scored such that lower scores indicate a higher level of functional ability.
The FDI has demonstrated good internal consistency in samples of youths
with minor health complaints (e.g., dysmenorrhea, gastrointestinal upset,
upper respiratory infections) and pediatric abdominal pain (Cronbach’s
␣⫽.85–.92; Walker & Greene, 1991). It has also been used in studies of
recurrent headache, juvenile idiopathic arthritis, and sickle cell disease
(Logan & Scharff, 2005; Peterson & Palermo, 2004). The alpha for our
sample was .82. Evidence for the validity of the FDI as a measure of
illness, pain, or disability comes from its significant correlation with scores
on other measures of physical and emotional health (Walker & Greene,
1991).
Perceived social support from family and friends. Youth participants
reported on perceived social support from family and friends by answering
8 items from the Multidimensional Scale of Perceived Social Support
(MSPSS; Zimet, Dahlem, Zimet, & Farley, 1988). The original MSPSS is
a 12-item self-report measure of perceived social support from family (4
items), friends (4 items), and a significant other (4 items). For the present
study, we used only those 8 items assessing perceived social support from
family and friends, as we did not anticipate that the majority of participants
in the present study would have a “significant other.” For each item,
participants rate their level of agreement on a 7-point Likert scale ranging
from 1 (very strongly disagree)to7(very strongly agree). The MSPSS is
scored as a total summed score for each of the subscores (family support
and friend support). These subscores can range from 4 to 28. Higher scores
on the MSPSS indicate a higher level of perceived social support. The
MSPSS was shown to have good internal consistency in a typically
developing adult sample (Cronbach’s ␣⫽.88 for the global score; Zimet
et al., 1988). Our sample had similarly high alphas (.86 for the global score,
.80 for the family score, and .88 for the friend score). Validity of the
original MSPSS scale comes from research that demonstrates its significant
negative association with depression and anxiety (Zimet et al., 1988). To
our knowledge, the MSPSS has not yet been used to assess perceived social
support in samples of youths.
Procedure
The study participants were recruited through mailings from clinics at
the local regional children’s hospital, as well as through public postings,
word of mouth, and, for some of the participants with NMD, a local
summer camp for youths with muscular dystrophy. All of the participants
and participating parents/guardians gave written informed assent/consent,
and the study was approved by Children’s Hospital and Regional Medical
Center’s Institutional Review Board (Seattle, WA). Youth participants
completed one-time, in-person interviews in the participant’s home, at the
University of Washington Medical Center, at a local summer camp, or over
the telephone. Youths were interviewed in a private setting whenever
possible to minimize potential response interference from family members
and to ensure privacy. Parents/guardians of participating youths also com-
pleted brief questionnaires, either during the youth interview or by mail.
Table 1
Demographic Characteristics
Variable n%
Sex
Male 42 60
Female 28 40
Ethnicity
a
Caucasian 57 81
Asian 6 9
African American 3 4
Hispanic 3 4
American Indian 1 1
Family income
b
Under $10,000 3 6
$10,000–$20,000 3 6
$20,000–$30,000 5 10
$30,000–$40,000 10 20
$40,000–$50,000 5 10
$50,000–$60,000 4 8
$60,000–$70,000 3 6
Over $70,000 17 34
Neuromuscular disease diagnosis
a
Duchenne muscular dystrophy 11 30
Myotonic muscular dystrophy 6 16
Spinal muscular atrophy 6 16
Charcot–Marie–Tooth 5 14
Becker muscular dystrophy 2 5
Congenital muscular dystrophy 2 5
Limb-girdle muscular dystrophy 2 5
Facioscapulohumeral muscular dystrophy 1 3
Other 2 5
Spina bifida diagnosis
Myelomeningocele 24 73
Meningocele 5 15
Other 4 12
Hydrocephalus 23 70
Gross motor functioning
c
I2130
II 18 26
III 3 4
IV 14 20
V1420
Note. N ⫽70. Age: M⫽14.51, SD ⫽3.06, range ⫽9 –20.
a
Percentages may not equal 100% because of rounding.
b
Total Nmay
not equal 70 because of missing data.
c
I⫽walks without restrictions but
has limitations in more advanced gross motor skills; II ⫽walks without an
assistive device and has limitations walking outdoors and in the commu-
nity; III ⫽walks with an assistive mobility device and has limitations
walking outdoors and in the community; IV ⫽limited self-mobility with
assistance or device (e.g., another person, walker, wheelchair) and uses
power mobility outdoors and in community only; V ⫽severely limited
self-mobility even with the use of assistive technology (e.g., power
mobility).
324 WILSON, WASHINGTON, ENGEL, CIOL, AND JENSEN

Data Analysis
Correlation coefficients were computed between continuous measures of
demographic/descriptor variables (age and gross motor functioning), cri-
terion variables (psychological adjustment and functional disability), and
predictor variables (perceived family and friend support) to estimate the
strength of the associations between the variables used in this study. We
performed ttests to determine if sex or ethnicity (coded as Caucasian/non-
Caucasian) were associated with the criterion and predictor variables. A
series of chi-square and t-test analyses were conducted to determine
whether participants with NMD and SB differed on demographic/descrip-
tive (age, sex, ethnicity, and gross motor functioning), criterion (psycho-
logical adjustment and functional disability), or predictor (perceived family
and friend support) variables. Any significant differences on these variables
would suggest that the two groups were too dissimilar to collapse for
primary regression analyses and should, therefore, be analyzed separately.
Regression analyses were used to test the hypothesis that perceived
social support was significantly associated with psychological adjustment
and functional ability. In these analyses, the CHQ–CF87 MH Scale and the
FDI were the criterion measures, and the MSPSS Family and Friend
subscales were the primary predictors. We followed West, Aiken, and
Krull’s (1996) suggestion that predictor variables be centered prior to
computing interaction terms by first subtracting the mean score from each
participant’s MSPSS family and friend score. Any significant univariate
associations between demographic control variables (sex and ethnicity)
would suggest the possibility that such variables might confound the
association between perceived social support and psychological adjustment
or functional ability, and, therefore, any such variable that showed a
significant univariate association with the criterion variables was entered as
control variables in the first step of the regression analyses. The primary
predictors (perceived family and friend support) were then entered as a
block in the next step. To determine the extent to which age or gross motor
functioning might act as moderators of the association between perceived
social support and psychological adjustment and functional ability, we
entered age and the participants’ gross motor functioning scores next in
separate regression analyses, and we entered, stepwise, a term representing
the interaction between age and the gross motor functioning score and each
primary predictor in a final step (Cohen & Cohen, 1983).
Results
Participants with NMD and SB did not differ significantly on
demographic/descriptive (age, sex, ethnicity, and gross motor
functioning), criterion (psychological adjustment and functional
disability), or predictor variables (perceived family and friend
support). The two groups were, therefore, collapsed for all further
analyses. In addition, neither of the potential demographic control
variables (sex and ethnicity) showed a significant univariate asso-
ciation with the criterion variables, so these variables were not
included in the regression models.
Table 2 provides descriptive statistics for each of the measures
used in the present study. Correlation analyses between demo-
graphic/descriptive (age and gross motor functioning), criterion
(psychological adjustment and functional disability), and predictor
variables (perceived family and friend support) revealed signifi-
cant associations between family support and psychological ad-
justment, friend support and family support, friend support and
functional disability, and gross motor functioning and functional
disability (see Table 3). Ttests examining the relationship between
sex or ethnicity and the criterion and predictor variables, however,
revealed no significant effects.
The regression analyses predicting psychological adjustment
indicated a significant effect for the perceived social support
measures, with 19% of the variance in the CHQ–CF87 MH Scale
accounted for by the MSPSS Family and Friend subscales. The
beta weights in the final equation of these models indicated that
perceived family support made a significant and positive indepen-
dent contribution to the prediction of participant mental health (see
Table 4), whereas friend support made a negative, but nonsignif-
icant, contribution. Neither age nor gross motor functioning, nor
interactions between family or friend support and these terms,
contributed significantly to the models.
The regression analyses predicting functional ability indicated
that both perceived family and friend support showed significant
direct associations with functional ability. Higher perceived family
support predicted lower functional ability, as measured by higher
scores on the FDI, whereas higher perceived friend support pre-
dicted higher functional ability, as measured by lower scores on
the FDI. Furthermore, after controlling for age in the first model
predicting functional ability, a significant interaction between per-
ceived family support and age emerged (see Table 4). After con-
trolling for gross motor functioning in the second model predicting
functional ability, and as might be expected, lower gross motor
functioning scores were significantly associated with lower func-
tional ability, as measured by higher scores on the FDI. In addition,
a significant interaction between perceived friend support and
gross motor functioning was found (see Table 4).
To plot these interactions as continuous data, we reran regres-
sion analyses predicting functional ability, including only family
support, age, and the interaction of these two terms, and friend
support, gross motor functioning, and the interaction of these two
terms (see Table 5). As would be expected, on the basis of the
omnibus analyses, the interactions were still significant.
The beta weights from these interactions were used to plot the
effects of these interactions (see Figures 1 and 2), as recommended
by Cohen and Cohen (1983). The three regression lines used in
Figure 1 represent three levels of age and were created by substi-
tuting the age score representing one standard deviation below the
mean (11.45 years old), that representing the mean (14.51 years
old), and that representing one standard deviation above the mean
(17.57 years old) in the regression equation for the first model
predicting functional ability, and then solving for the criterion
variable, functional ability.
As is evident in Figure 1, the slopes of the regression lines for
younger, mid-range, and older youths indicate that, among rela-
tively older youths, higher levels of perceived family support were
associated with higher functional ability, whereas, among younger
Table 2
Descriptive Statistics for Each Measure
Measure nM SD Range ␣
Mental health scale
(CHQ–CF87) 70 76.54 14.44 32.81–100.00 .88
FDI 70 11.38 8.95 0–32.00 .82
MSPSS family support 70 24.33 3.77 13.00–28.00 .80
MSPSS friend support 70 22.74 5.56 3.00–28.00 .88
Note. CHQ–CF87 ⫽Child Health Questionnaire, child version; FDI ⫽
Functional Disability Inventory; MSPSS ⫽Multidimensional Scale of
Perceived Social Support (family and friend subscores).
325
PERCEIVED SOCIAL SUPPORT IN YOUTHS

youths, higher levels of perceived family support were actually
weakly associated with lower functional ability. The three regres-
sion lines used in Figure 2 represent three levels of gross motor
functioning and were created in the same manner, but by substi-
tuting the three gross motor functioning scores (mild restriction ⫽
1.18, moderate restriction ⫽2.74, and severe restriction ⫽4.30) in
the regression equation for the second model predicting functional
ability, before solving for the criterion variable. The slopes of the
regression lines for the three gross motor functioning levels indi-
cate that, for those youths with severe ambulatory restrictions,
higher functional ability was strongly associated with higher per-
ceived friend support.
Discussion
The present study investigated the relationship between per-
ceived social support and psychological adjustment and functional
ability in youths with NMD and SB, while also examining age and
gross motor functioning as potential moderating factors in this
relationship. The finding that higher perceived social support pre-
Table 3
Correlation Matrix Illustrating Relationship Between Demographic/Descriptive and Criterion
and Predictor Variables
Variable
Demographic
variable Criterion variable
Predictor variable
Age GMF MH FDI
MSPSS family
support
MSPSS friend
support
MSPSS friend support .05 ⫺.06 .12 ⫺.27* .51** —
MSPSS family support ⫺.12 .03 .42** ⫺.16 —
FDI .07 .40** ⫺.19 —
MH ⫺.19 .22 —
GMF .16 —
Age —
Note. GMF ⫽gross motor functioning; MH ⫽Mental Health Scale of the Child Health Questionnaire, child
version; FDI ⫽Functional Disability Inventory; MSPSS ⫽Multidimensional Scale of Perceived Social Support
(family and friend subscores).
*p⬍.05. ** p⬍.01.
Table 4
Multiple Regression Analyses Examining the Association of Perceived Social Support With
Concurrent Age, Gross Motor Functioning, Mental Health, and Functional Ability
Step and variable Total R
2
R
2
change Fchange
Final
unstandardized ␤
Mental Health Scale (CHQ–CF87)
1. Social support .19 .19 7.63**
Family support 1.74**
Friend support ⫺0.27
2. Age .20 .02 1.38 ⫺0.62
Mental Health Scale (CHQ–CF87)
1. Social support .19 .19 7.63**
Family support 1.78**
Friend support ⫺0.27
2. GMF .22 .04 3.17 1.80
Functional ability (FDI) with age as controlled variable
1. Social support .07 .07 2.64
Family support 3.51*
Friend support ⫺0.46*
2. Age .08 .01 0.45 0.52
3. Family Support ⫻Age .16 .08 6.57* ⫺0.24*
Functional ability (FDI) with GMF as controlled variable
1. Social support .07 .07 2.64
Family support ⫺0.19
Friend support 0.53
2. GMF .22 .15 12.20** 2.44**
3. Friend Support ⫻GMF .27 .05 4.66* ⫺0.29*
Note. CHQ–CF87 ⫽Child Health Questionnaire, child version; GMF ⫽gross motor functioning; FDI ⫽
Functional Disability Inventory.
*p⬍.05. ** p⬍.01.
326 WILSON, WASHINGTON, ENGEL, CIOL, AND JENSEN

dicted better psychological adjustment was consistent with our first
hypothesis. Specifically, perceived social support contributed sig-
nificantly to the prediction of participant mental health, explaining
19% of the variance in this criterion measure. This finding was
explained primarily by the effect of perceived family support,
which showed a positive and significant association with psycho-
logical adjustment, whereas friend support showed a negative, but
nonsignificant, association with psychological adjustment.
The lack of significant association between perceived friend
support and psychological adjustment is inconsistent with Varni et
al.’s (1989) finding that adaptation in adolescents with diabetes
was predicted by perceived social support from friends. One ex-
planation for this discrepancy may be the probable relative differ-
ence in the amount of time that youths with physical disabilities
spend with family members, in contrast to youths with chronic
illnesses that do not involve physical limitations. For example,
many youths who have physical disabilities may rely more on
family for assistance with everyday tasks, such as getting out of
bed, dressing, and transportation, including transportation to
school or social activities with friends. In addition, older adoles-
cents who use a wheelchair or have other mobility limitations
might differ from peers in their capacity to participate indepen-
dently in activities with friends. Many adolescents who are typi-
cally developing experience greater independence when they turn
16 years old, as they often no longer need to rely on another person
for transportation. It is possible that youths with physical disabil-
ities, many of whom cannot drive themselves, either spend an
increased amount of time at home, presumably with family mem-
bers, or require a family member’s assistance to travel from place
to place.
The finding that higher perceived friend, but not family, support
predicted higher functional ability was partially consistent with our
second hypothesis. Findings were inconsistent with our specific
Low High
Younger
Functional Ability (FDI)
Mid-Range
Older
Low Support High Support
Family Support (MSPSS)
Figure 1. Effect of age on the relationship between family support, as
measured by the Multidimensional Scale of Perceived Social Support
(MSPSS), and functional ability, as measured by the Functional Disability
Inventory (FDI). The regression lines were created by substituting three
levels of age in the regression equation and solving for functional ability.
Low High
Functional Ability (FDI)
Mild Restriction
Moderate Restriction
Severe Restriction
Low Support High Support
Friend Support (MSPSS)
Figure 2. Effect of gross motor functioning on the relationship between
friend support, as measured by the Multidimensional Scale of Perceived
Social Support (MSPSS), and functional ability, as measured by the Func-
tional Disability Inventory (FDI). The regression lines were created by
substituting three levels of gross motor functioning in the regression
equation and solving for functional ability.
Table 5
Multiple Regression Analyses Examining the Association of Perceived Social Support With
Concurrent Age, Gross Motor Functioning, and Functional Ability
Step and variable Total R
2
R
2
change Fchange
Final
unstandardized ␤
Functional ability (FDI) with age as controlled variable
1. Family support .03 .03 1.75 2.99*
2. Age .03 .00 0.17 0.41
3. Family Support ⫻Age .10 .08 5.66* ⫺0.23*
Functional ability (FDI) with GMF as controlled variable
1. Friend support .07 .07 5.32* 0.45
2. GMF .22 .14 12.15** 2.41**
3. Friend Support ⫻GMF .27 .05 4.55* ⫺0.28*
Note. FDI ⫽Functional Disability Inventory; GMF ⫽gross motor functioning.
*p⬍.05. ** p⬍.01.
327
PERCEIVED SOCIAL SUPPORT IN YOUTHS

hypotheses about the nature of the moderating effects of age and
gross motor functioning on the association between perceived
social support and psychological adjustment and functional ability,
although unanticipated moderating effects were found. In the first
model predicting functional ability, a significant interaction be-
tween perceived family support and age emerged, but follow-up
analyses revealed that higher levels of perceived social support
from the family were associated with higher functional ability
among older youths, not younger youths, as predicted. Although
conclusions about the reliability of these findings must await
further research and replication, the finding that, among younger
youths, higher levels of perceived family support were actually
weakly associated with lower functional ability was surprising. It
is possible that family support may, in fact, be expressed through
an excess of assistance, so that these younger youths are not given
the opportunity or are not motivated to perform at a level at which
they are actually capable. As these youths age, however, they may
experience improvements in their functional ability as a result of
the cumulative positive effect of family support while they were
young. Future research should explore this possibility through
longitudinal studies.
In addition, if these results are replicated, these findings suggest
that family support may be particularly important in older youths
with disabilities. Perhaps, again, because older youths with dis-
abilities may be more dependent on their family than same-age
peers who do not have a disability, family support may be even
more important as children with disabilities age than when they are
younger. Although as children move into adolescence the signif-
icance of friendships increases and the presence of such relation-
ships is important for social maturity development (Frey & Ro¨th-
lisberger, 1996), youths with physical disabilities may be limited
in their ability to forge and maintain strong relationships with
peers because of several factors. These may include physical
restrictions, cognitive impairments, rehabilitation and medical ob-
ligations like physical therapy and checkups, and social stigma
toward people with disabilities (La Greca et al., 2002). As a result,
older youths may continue to find the social support they need for
high functional status primarily from family members.
In the second model predicting functional ability, a significant
interaction between perceived friend support and gross motor
functioning emerged. Further follow-up analyses of this interaction
indicated that the nature of the moderating effect of gross motor
functioning on the association between perceived social support
and functional ability was inconsistent with our prediction. We had
anticipated that perceived social support would show a stronger
association among participants with mild ambulatory restrictions.
Instead, we found that, among youths with severe ambulatory
restrictions, higher functional ability was associated with higher
perceived social support from friends. As this is the first time that
such a moderating effect has been examined, its reliability cannot
be assumed. If reliable, however, this moderating effect could be
influenced by the positive effects of perceived social support. For
example, youths with severe ambulatory restrictions who nonethe-
less have strong friend support and frequent involvement with
peers might be invited or encouraged to do more physical activities
with and by their peers. This, in turn, may increase the likelihood
that these youths may both participate in these activities and
develop skills useful for independent functioning.
Certain limitations should be highlighted in the present study.
First, it is important to note that our study populations included
only youths with SB and NMD. Although youths with these
disabilities experience a number of complications and physical
restrictions that are common to other physical disabilities, it is
possible that our results may not generalize to youths with all types
of physical disabilities. Future research should, therefore, include
youths with other diagnoses.
A second limitation concerns the measures used in the present
study, as well as the method used to administer the measures. The
exclusive use of self-report data to assess the primary predictor and
criterion variables has the potential to bias results with regard to
the ability of participants to accurately evaluate social support and
the capability of performing activities, as well as creating the
possibility of a general source bias. Given that there are few
previously published studies in this area, it is difficult to demon-
strate the validity of these self-reported results by comparison with
other research. Additional research on the impact of perceived
social support on psychological adjustment and functional disabil-
ity for youths is needed to determine the reliability of our findings.
Future research could potentially assess social support from other
sources, such as through parent and teacher reports, to supplement
findings from primary sources.
The use of the MSPSS to assess perceived social support is also
a limitation of the measures used in the present study. Although the
internal consistencies of the scores from this measure in our
sample were high, the MSPSS has at present only been validated
for use with adults. Furthermore, it measures perceived social
support by using only eight items and does not assess other
important aspects of social support, such as network size and
density. It is possible, for example, that the findings of the present
study are in fact a reflection of the fact that a significant number of
participants had few or no close friends, or had infrequent contact
with peers. The limitations of the MSPSS may account for the
unexpected finding that friend support was negatively, but not
significantly, associated with psychological adjustment. Future
research would benefit from the use of measures that assess addi-
tional aspects of social support.
The measures used were originally developed and validated as
paper-and-pencil questionnaires but were interview-administered
in the present study. As participants indicated answers to each
question to an interviewer, instead of privately marking answers,
responses may reflect demand characteristics. This methodology
was used nevertheless because of the potential for restrictions in
fine motor functioning of the participants. Moreover, the strong
internal consistencies found for each of the measures supports their
reliability in the sample, even with this altered methodology.
A final limitation is the potential for selection bias in the study
sample. Owing to the nature of our recruitment sites, participants
in the present study had parents/guardians who were not only
involved in their children’s medical care and recreation but who
were also willing and able to contact researchers regarding enroll-
ment. In addition, the study did not include youths with more than
mild cognitive impairment. It is possible that the inclusion of
youths with moderate-to-severe cognitive impairment might have
affected the sample in terms of severity of physical disability, as
well as the presence and strength of peer relationships. The scales
used in this study, however, require the participants to reflect
accurately on recent emotions, as well as evaluate their physical
capabilities, therefore necessitating that the youths possess a cer-
328 WILSON, WASHINGTON, ENGEL, CIOL, AND JENSEN

tain level of cognitive functioning. The use of multiple informants
in gathering future data may be a means of circumventing this
issue, as this would allow for the inclusion of youths with mod-
erate-to-severe cognitive impairment.
Despite the limitations of the present study, however, the find-
ings offer several important new contributions. First, the results are
consistent with previous research indicating that higher perceived
social support predicts better psychological adjustment. Further-
more, expanding on earlier studies, the present findings suggest
that perceived family and friend support play a particularly im-
portant role for youths with physical disabilities. Moreover, we
found that family and friend support interacted with age and gross
motor functioning, respectively, to predict participant psycholog-
ical adjustment and functional ability in the present sample. This
suggests the possibility that perceived social support may be
particularly important for functioning among older youths and
among youths with more severe gross motor limitations. To our
knowledge, this is the first study to examine the role of perceived
social support on functional ability of this population. Future social
support research should take into consideration the moderating
roles of age and gross motor functioning on the psychological
adjustment and functional ability in youths with physical
disabilities.
If the findings from the present study replicate in future studies,
they would then argue for interventions to help families and
friends of youths with physical disabilities to provide more effec-
tive support to bolster psychological and physical functioning in
this population. Interventions could include social support training
programs and support groups for the parents/guardians and sib-
lings of these youths. Moreover, the finding that higher perceived
friend support is associated with higher functional ability in youths
with severe ambulatory restrictions has implications for academic
settings. Future research should examine the effects of supportive
interactions between youths who are typically developing and
youths with physical disabilities, particularly if the youths have
severe physical restrictions and are, therefore, less likely to have
opportunities for peer interactions. It is hoped that research of this
nature, and the development of interventions based on the findings
of such research, will help to continue to improve the quality of life
of youths with physical disabilities.
References
Appleton, P. L., Ellis, N. C., Minchom, P. E., Lawson, V., Bo¨ ll, V., &
Jones, P. (1997). Depressive symptoms and self-concept in young people
with spina bifida. Journal of Pediatric Psychology, 22, 707–722.
Bennet, D. S. (1994). Depression among children with chronic medical
problems: A meta-analysis. Journal of Pediatric Psychology, 19,
149 –169.
Cohen, J., & Cohen, P. (1983). Applied multiple regression/correlation
analysis for the behavioral sciences (2nd ed.). Hillsdale, NJ: Erlbaum.
Evers, A. W. M., Kraaimaat, F. W., Geenen, R., Jacobs, J. W. G., &
Bijlsma, J. W. J. (2003). Pain coping and social support as predictors of
long-term functional disability and pain in early rheumatoid arthritis.
Behavior Research and Therapy, 41, 1295–1310.
Frey, C. U., & Ro¨ thlisberger, C. (1996). Social support in healthy adoles-
cents. Journal of Youth and Adolescence, 25, 17–31.
Holmbeck, G. N., Westhoven, V. C., Phillips, W. S., Bowers, R., Gruse, C.,
Nikolopoulos, T., et al. (2003). A multimethod, multi-informant, and
multidimensional perspective on psychosocial adjustment in preadoles-
cents with spina bifida. Journal of Consulting and Clinical Psychology,
71, 782–796.
Hommeyer, J. S., Holmbeck, G. N., Wills, K. E., & Coers, S. (1999).
Condition severity and psychosocial functioning in pre-adolescents with
spina bifida: Disentangling proximal functional status and distal adjust-
ment outcomes. Journal of Pediatric Psychology, 24, 499 –509.
Kashani, J. H., Canfield, L. A., Borduin, C. M., Soltys, S. M., & Reid, J. C.
(1994). Perceived family and social support: Impact on children. Journal
of the American Academy of Child and Adolescent Psychiatry, 33,
819 – 823.
La Greca, A. M., Auslander, W. F., Greco, P., Spetter, D., Fisher, E. B., &
Santiago, J. V. (1995). I get by with a little help from my family and
friends: Adolescents’ support for diabetes care. Journal of Pediatric
Psychology, 20, 449 – 476.
La Greca, A. M., Bearman, K. J., & Moore, H. (2002). Peer relations of
youth with pediatric conditions and health risks: Promoting social sup-
port and healthy lifestyles. Developmental and Behavioral Pediatrics,
23, 271–280.
Landgraf, J. M., Abetz, L., & Ware, J. E. (1996). Child Health Question-
naire (CHQ): A user’s manual. Boston: The Health Institute, New
England Medical Center.
Lavigne, J. V., & Faier-Routman, J. (1992). Psychological adjustment to
pediatric physical disorders: A meta-analytic review. Journal of Pedi-
atric Psychology, 17, 133–157.
Lavigne, J. V., & Faier-Routman, J. (1993). Correlates of psychological
adjustment to pediatric physical disorders: A meta-analytic review and
comparison with existing models. Developmental and Behavioral Pedi-
atrics, 14, 117–123.
Logan, D. E., & Scharff, L. (2005). Relationships between family and
parent characteristics and functional abilities in children with recurrent
pain syndromes: An investigation of moderating effects on the pathway
from pain to disability. Journal of Pediatric Psychology, 30, 698 –707.
Ouvrier, R. A., Goldsmith, R. F., Ouvrier, S., & Williams, I. C. (1993). The
value of the Mini-Mental State Examination in childhood: A preliminary
study. Journal of Child Neurology, 8, 145–148.
Palisano, R., Rosenbaum, P., Walter, S., Rassell, D., Wood, E., & Galuppi,
B. (1997). Development and reliability of a system to classify gross
motor function in children with cerebral palsy. Developmental Medicine
and Child Neurology, 39, 214 –223.
Patterson, J. M., & Geber, G. (1991). Preventing mental health problems in
children with chronic illness or disability. Children’s Health Care, 20,
150 –161.
Peterson, C. C., & Palermo, T. M. (2004). Parental reinforcement of
recurrent pain: The moderating impact of child depression and anxiety
on functional disability. Journal of Pediatric Psychology, 29, 331–341.
Roccaforte, W. H., Burke, W. J., Bayer, B. L., & Wengel, S. P. (1992).
Validation of a telephone version of the Mini-Mental State Examination.
Journal of the American Geriatrics Society, 40, 697–702.
Travis, L. A., Lyness, J. M., Shields, C. G., King, D. A., & Cox, C. (2004).
Social support, depression, and functional disability in older adult pri-
mary-care patients. American Journal of Geriatric Psychiatry, 12,
265–271.
Varni, J. W., Babani, L., Wallander, J. L., Roe, T. F., & Frasier, S. D.
(1989). Social support and self-esteem effects on psychological adjust-
ment in children and adolescents with insulin-dependent diabetes mel-
litus. Child and Family Behavior Therapy, 11, 1–17.
Varni, J. W., & Setoguchi, Y. (1991). Correlates of perceived physical
appearance in children with congenital/acquired limb deficiencies. De-
velopmental and Behavioral Pediatrics, 12, 171–176.
Varni, J. W., Setoguchi, Y., Rappaport, L. R., & Talbot, D. (1991). Effects
of stress, social support, and self-esteem on depression in children with
limb deficiencies. Archives of Physical Medicine and Rehabilitation, 72,
1053–1058.
Varni, J. W., Setoguchi, Y., Rappaport, L. R., & Talbot, D. (1992).
329
PERCEIVED SOCIAL SUPPORT IN YOUTHS

Psychological adjustment and perceived social support in children with
congenital/acquired limb deficiencies. Journal of Behavioral Medicine,
15, 31– 44.
Varni, J. W., Wilcox, K. T., & Hanson, V. (1988). Mediating effects of
family social support on child psychological adjustment in juvenile
rheumatoid arthritis. Health Psychology, 7, 421– 431.
von Weiss, R. T., Rapoff, M. A., Varni, J. W., Lindsley, C. B., Olson,
N. Y., Madson, K. L., & Bernstein, B. H. (2002). Daily hassles and
social support as predictors of adjustment in children with pediatric
rheumatic disease. Journal of Pediatric Psychology, 27, 155–165.
Walker, L. S., & Greene, J. W. (1991). The Functional Disability Inven-
tory: Measuring a neglected dimension of child health status. Journal of
Pediatric Psychology, 16, 39 –58.
Wallander, J. L., & Thompson, R. J. (1995). Psychosocial adjustment of
children with chronic physical conditions. In M. C. Roberts (Ed.),
Handbook of pediatric psychology (2nd ed., pp. 124 –141). New York:
Guilford Press.
Wallander, J. L., & Varni, J. W. (1989). Social support and adjustment in
chronically ill and handicapped children. American Journal of Commu-
nity Psychology, 17, 185–201.
Wallander, J. L., & Varni, J. W. (1995). Appraisal, coping, and adjustment
in adolescents with a physical disability. In J. L. Wallander & L. J.
Siegel (Eds.), Adolescent health problems (pp. 209 –231). New York:
Guilford Press.
West, S. G., Aiken, L. S., & Krull, J. L. (1996). Experimental personality
designs: Analyzing categorical by continuous variable interactions.
Journal of Personality, 64, 1– 48.
Witt, W. P., Riley, A. W., & Coiro, M. J. (2003). Childhood functional
status, family stressors, and psychosocial adjustment among school-aged
children with disabilities in the United States. Archives of Pediatrics and
Adolescent Medicine, 157, 687– 695.
Zimet, G. D., Dahlem, N. W., Zimet, S. G., & Farley, G. K. (1988). The
Multidimensional Scale of Perceived Social Support. Journal of Per-
sonality Assessment, 52, 30 – 41.
Received August 4, 2005
Revision received December 1, 2005
Accepted February 7, 2006 䡲
330 WILSON, WASHINGTON, ENGEL, CIOL, AND JENSEN