Seminar 2 - Adol Health

PART VII: Special Topics
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Peer Relations
Annette M. La Greca Karen J. Bearman Hannah Moore
University of Miami
INTRODUCTION Peer relations and close friendships play extremely important roles in youngsters social and emotional development. By the early school years, children spend most of their daytime hours in school or play settings with classmates and friends (Ellis, Rogoff, & Cromer, 1981). This trend continues, and accelerates, through adolescence. In fact, research has documented the developmentally unique social behaviors that develop in the context of childrens peer interactions (see Asher & Coie, 1990; Hartup, 1983, 1996; La Greca & Prinstein, 1999). Despite the many positive functions of youngsters peer relations, they can also represent a source of stress. Substantial evidence indicates that children who experience interpersonal difculties during elementary school display internalizing difculties, such as depression, anxiety, and loneliness (Asher & Wheeler, 1985; La Greca & Stone, 1993; Strauss, Lahey, Frick, Frame, & Hynd, 1988). Over time, problematic peer relations may contribute to serious mental health and academic problems. For example, children who are actively rejected by their classmates have more mental health problems during late adolescence and early adulthood than their more accepted peers (Cowen, Pederson, Babijian, Izzo, & Trost, 1973), and drop out of high school at much higher rates than their classmates (Kupersmidt & Coie, 1990). Findings such as these underscore the critical role of peer relations in social and emotional adjustment. As a result, it is essential that professionals working in the schools pay close attention to childrens and adolescents peer relations and friendships. This is especially true when a child or adolescent has a chronic disease or a physically handicapping condition. Peers represent a signicant source of emotional support that can buffer the negative impact of stressors, such as adjusting to a chronic disease or coping with a difcult medical treatment (e.g., La Greca 657
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et al., 1995; Varni, Babani, Wallander, Roc, & Frasier, 1989). On the other hand, children and adolescents with a complicated, chronic, or time-consuming treatment are often very concerned about the social impact of their condition, and the possible disruption of their friendships. Thus, youngsters with pediatric problems may need special assistance in developing and maintaining peer relationships and friendship ties. With these issues in mind, the present chapter will examine the peer relations of youth with pediatric conditions. It is organized into several sections. The rst provides a developmental overview of childrens and adolescents peer relations and friendships. The next main section reviews relevant research in the area of peer relations and child healthspecically with respect to social competence, psychosocial adjustment, disease management, and the reduction of health-risk behaviors. The implications of existing ndings for practice within the schools are described. The last section of the chapter briey highlights general directions for future research and intervention.
THE DEVELOPMENTAL CONTEXT OF YOUNGSTERS PEER RELATIONS Elementary School Years Childrens peer relations have been most widely studied during the elementary school years (approximately ages 612 years). During this period, children typically spend the school day in self-contained classrooms with a set group of classmates, although some children interact with peers in special educational settings (e.g., services for youth with disabilities, enhancement activities for gifted children). After school and on weekends, many children are involved in organized activities with peers (e.g., sports, dance, scouts), as well as in unstructured play activities with friends and neighborhood youth. In these social contexts, two aspects of childrens peer relations become highly salient: their peer status and their close friendships. Peer status (or peer acceptance) refers to the extent to which a child is liked or accepted by the peer group. In contrast, peer friendships refer to close, supportive ties with one or more peers, and these friendships may occur within or outside the classroom (Furman & Robbins, 1985). Childrens peer groups and friendships serve different emotional needs. Peer group acceptance provides children with a sense of belonging or social inclusion, whereas friendships provide children with a sense of intimacy, companionship, and self-esteem (Furman & Robbins, 1985). Thus, peer acceptance and peer friendships are related, but distinct aspects of childrens peer relations. Both are critical for emotional health and development. Peer Acceptance. With respect to peer acceptance, it is important to distinguish between children who are accepted and those who are rejected by peers (e.g., Coie, Dodge, & Coppotelli, 1982; Coie, Dodge, & Kupersmidt, 1990). Popular children are well liked and have few detractors. Popular childrens acceptance from peers most likely reects their positive social skills and personal competencies, such as being helpful and considerate, and having good athletic and academic abilities (e.g., Coie et al., 1982, 1990; Dodge, Coie, & Brakke, 1982; Hartup, 1983). In contrast, children who are rejected by peers are widely disliked and lack friends or supporters; these children have the most interpersonal, emotional, and academic difculties. For example, rejected children often display academic problems (Green, Forehand, Beck, & Vosk, 1980; Stone & La Greca, 1990), and report symptoms of depression, loneliness, and social anxiety (Asher & Wheeler, 1985; La Greca & Stone, 1993). Moreover, rejected children are often aggressive, disruptive, or inattentive, and may have limited social skills (see Coie et al., 1990).
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Children who are neglected by peers (also known as social isolates) are neither liked nor disliked; they go unnoticed by their peers. Neglected children do not usually display behavior problems, but may be withdrawn (Coie & Dodge, 1988; Dodge et al., 1982) or socially anxious (La Greca & Stone, 1993). Although not as problematic as rejected youth, neglected children may have difculty developing supportive friendship ties, given their low sociability and low rates of social interactions with peers. Some of the research reviewed in subsequent sections of this chapter has examined the peer acceptance of youth with chronic or life-threatening diseases, because there is concern that illness may jeopardize childrens peer acceptance. In elementary school settings, children who are neglected or rejected by peers bear close monitoring, and this is especially the case with children who also have a chronic disease or another pediatric condition. Children who are disliked may need help developing better peer relations; for example, interventions may be needed to increase these childrens positive interaction skills, or to modify the aversive or annoying behaviors (or other personal characteristics) that contribute to peers dislike (see La Greca, 1993; La Greca & Prinstein, 1999). Children who are neglected, or who lack friends and playmates, may need assistance in developing friendship ties. Friendships. The ability to form and maintain supportive dyadic friendships also represents a critical social adaptation task (Parker & Asher, 1993a). Much of childrens social lives revolve around dyadic or small group interactions with their same-aged friends (Parker & Asher, 1993b). Research suggests that most children have close friends in school. For example, in a study of third to fth graders (Parker & Asher, 1993a), 78% had at least one reciprocal best friend in the classroom, and 55% of the children had a very best friend. Girls were more likely to have a best friend than boys (82% vs. 74%, respectively); girls also had signicantly more best friends than boys. Children who have at least one close friendship appear to fare better emotionally than those who lack such personal ties (Parker & Asher, 1993a). A variety of factors contribute to childrens friendship selection. One is social proximity; that is, children are likely to choose peers from their classroom, scouts group, or immediate neighborhood as friends (Hartup, 1983). Children also choose as friends others who are similar to themselves (e.g., same age, same gender), who share common interests (e.g., play sports, listen to music), and who are fun to be with (Hartup, 1996; Parker & Asher, 1993b). In addition, the quality of childrens friendships is important. Friends provide emotional support and are childrens primary source of companionship (Berndt, 1989; Cauce, Reid, Landesman, & Gonzales, 1990; Furman & Buhrmester, 1985; Reid, Landesman, Treder, & Jaccard, 1989). However, friendships can also vary tremendously in the amount and type of support they provide, the degree to which conict is present, and their level of reciprocity (Parker & Asher, 1993b). Furthermore, girls often report more intimate and supportive relationships with their friends than do boys. This may reect boys tendency to associate with peers in large groups that are often centered on sports and outdoor games, whereas girls are typically involved in dyads or small groups that spend time in conversation and quiet activities (e.g., Lever, 1976; Thorne, 1986). In general, the number and quality of childrens close friendships are important for childrens mental health. Because close, supportive friendships can help children manage the stress of a chronic illness, or life-threatening disease, school personnel and mental health professionals should pay attention to whether or not a child has close friends (both inside and outside the classroom). It will also be important to understand the qualitative features of these friendships. Helping children to develop more positive, supportive friendship ties may be an important goal for intervention.
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Adolescence During adolescence, peer relations take on increasing prominence and complexity. Most adolescents have a rich network of peers that includes their best friends, other close friends, larger friendship groups or cliques, social crowds, and even romantic relationships (Furman, 1989; Urberg, Degirmencioglu, Tolson, & Halliday-Scher, 1995). Some terms that are useful for understanding adolescents peer relations include peer crowds, cliques, and dyads. Peer crowds are reputation-based peer groups; that is, a large collective of similarly stereotyped individuals who may or may not spend much time together. Cliques typically are a small number of adolescents who spend time together; and dyads refer to pairs of friends or romantic partners (Brown, 1989, pp. 189190). Peer Crowds. To the extent that crowds reect adolescents peer status and reputation, they are an outgrowth of the social status groups observed in elementary school. Peer crowd afliation reects the primary attitudes or behaviors by which an adolescent is known to peers (Brown, 1989). Specic adolescent peer crowds may vary with age, with some changes occurring between middle school and high school (OBrien & Bierman, 1987), and also may vary with a particular school or neighborhood (Brown, 1989). Nevertheless, remarkable cross-setting consistencies have been observed. The most common peer crowds include: populars, brains, jocks, druggies or burnouts, loners, nonconformists or alternatives, and special interest groups (e.g., drama, dance; Brown & Clausen, 1986; Mosbach & Leventhal, 1988; Urberg, 1992). Some adolescents identify with more than one group, and many do not identify with any group or consider themselves to be average. Peer crowds vary in obvious and not-so-obvious ways. For instance, brains typically are smart, do well in school, and value academic activities; however, they also tend to be low in their levels of sexual activity, smoking, alcohol and drug use (e.g., La Greca, Prinstein, & Fetter, 2001; Mosbach & Leventhal, 1988). Jocks typically are involved in athletic activities or competitive sports but are less likely to smoke or use drugs than other teens. Thus, an adolescents peer crowd may say something about the adolescents behavior and reputation, and also about health-risk behaviors. From a developmental perspective, the signicance of peer crowds is that they contribute to adolescents reputation and identity, and provide a sense of belonging. Peer crowd membership also may determine the pool of individuals from which adolescents meet and select friends. Finally, peer crowd afliation may inuence behavior, in that an adolescent who wishes to be a part of a particular crowd may feel compelled to maintain behaviors that are compatible with the crowds reputation. For example, adolescents who afliate with the burnouts may smoke or drink alcohol to t in with others. Thus, from a health perspective, it becomes extremely important to understand the kind of peer crowd with which an adolescent identies, especially when the adolescent has a chronic disease. An adolescent with diabetes who afliates with the jock or brain peer crowds may be more likely to get support for a healthy lifestyle than one who afliates with the alternative or burnout crowds. Peer Rejection or Victimization Experiences. There is a paucity of data on peer rejection among adolescents, even though it is an area of concern. During adolescence, tting in with ones peers becomes a major priority for most teens (Bowker, Sippola, & Bukowski, 1996). In this context, peer rejection may be particularly stressful. Bowker et al. (1996) found that peer rejection experiences accounted for more than 50% of the peer-related hassles reported by seventh graders. In addition, Parkhurst and Asher (1992) found that many seventh and eighth graders were victimized and pushed around by peers in school, and that this type of rejection was associated with subjective distress.
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Others have studied aversive exchanges among adolescents. Vernberg, Ewell, Beery, Freeman, and Abwender (1995) surveyed 130 middle school students, and found that 73% of them reported at least one aversive exchange (i.e., teased, hit, threatened, or excluded by peers) during the prior 3 months. Many adolescents did not talk to anyone about these events, and when they did, they were more likely to disclose this information to a friend, classmate, or sibling than to an adult. This suggests that parents and other concerned adults (such as school personnel) may be completely unaware of these aversive exchanges. Furthermore, adolescents who reported more verbal and physical harassment or peer exclusion endorsed more loneliness, especially if they did not discuss these events with anyone else. Prospective studies further indicate that aversive exchanges with peers lead to feelings of internal distress. In one study, peer rejection experiences at the beginning of the school year predicted adolescents feelings of social anxiety later in the school year (Vernberg, Abwender, Ewell, & Beery, 1992). In addition, large-scale longitudinal investigations of bullying among Scandinavian youth (Olweus, 1993) have found that adolescents who are bullied frequently during early adolescence are likely to report low self-esteem and symptoms of anxiety as adults. In summary, although peer rejection and victimization (i.e., harassment, exclusion) have not received much empirical attention, they appear to be common occurrences and represent a signicant source of subjective distress for many adolescents. Because adolescents are not likely to talk about aversive peer exchanges with other adults, they may go undetected and underreported. Adolescents who have a medical condition, especially one that has some physical manifestation, may be concerned about teasing and harassment from peers (see La Greca, 1990), and need support and assistance. Friendships. Peer friendships are particularly salient during adolescence. Adolescents spend more time talking to peers than in any other activity and also describe themselves as happiest when talking to friends (Berndt, 1982). Adolescents interactions with friends primarily occur in dyads (friendship pairs, romantic partners) or in cliques. Cliques are friendship-based groupings that vary in size (usually 58 members), density (the degree to which each person regards others in the clique as friends), and tightness (the extent to which they are closed or open to outsiders; Brown, 1989; Urberg et al., 1995). Cliques constitute the primary base for adolescents peer interactions (Brown, 1989) and typically contain specic dyadic pairings (e.g., best friends; Urberg et al., 1995). An important determinant of adolescents friendships is similarity or homophily; that is, adolescents select as friends others who share similar attributes and characteristics, and are also inuenced by the behaviors and attitudes of the friends they choose. In addition to similarities in age, sex, and race, similarities in specic interests, school attitudes, achievement, orientation to the contemporary peer culture, and substance use are important factors in adolescents friendship choices (Berndt, 1982; Brown, 1989; Hartup, 1996). Once friendships are established, mutual socialization further enhances the similarities between friends (Hartup, 1996; Kandel, 1978). Furthermore, cross-sex friendships become increasingly common during adolescence (Bukowski, Gauze, Hoza, & Newcomb, 1993; Kuttler, La Greca, & Prinstein, 1999), and adolescents with cross-sex friendships appear to be better integrated into the peer network at school (Degirmencioglu & Urberg, 1996). Many of the qualities observed in childrens friendships (companionship, aid, validation and caring, trust) are important for adolescents (Berndt, 1982). However, a dening feature of adolescents friendships is their intimacy (i.e., sharing of personal, private thoughts and feelings; knowledge of intimate details about one another). Close friendships become increasingly more intimate during adolescence (Berndt, 1982). In addition, girls report more intimacy in their friendships than boys (Berndt, 1982), which may reect girls preference for exclusive
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relationships (Elder & Hallinan, 1978; Waldrop & Halverson, 1975). In contrast, boys appear to be more exible and open in their friendship choices (Urberg et al., 1995). Having an intimate friendship during adolescence has psychological benets (e.g., enhances self-esteem; reduces anxieties, loneliness). For example, Vernberg (1990) found that less contact with friends, less closeness with a best friend, and greater peer rejection experiences over the course of 6 months contributed to increases in adolescents depressive affect. In other studies, support from close friends has been positively associated with school involvement and achievement (Berndt & Keefe, 1992; Cauce, 1986), self-esteem and psychosocial adjustment (e.g., Buhrmester, 1990; Compas, Slavin, Wagner, & Cannatta, 1986), and peer popularity (Cauce, 1986). For adolescents with health problems, the presence of a mutual best friend in school may help such adolescents to cope more effectively with stresses that may result either from normal adolescent life circumstances, or the additional burden of managing a serious health condition. School personnel might encourage adolescents to involve their best friends in disease management and coping. This issue is discussed further in this chapter.
PEER RELATIONS: AN IMPORTANT CONSIDERATION FOR PEDIATRIC POPULATIONS Despite the importance of peers and friendships for all youth, including those with medical conditions, the peer relations of youth with pediatric problems have not been well studied (see La Greca, 1990, 1992). In this chapter section, we review some of the key ways that peer relations have been examined in pediatric psychology research. Specically, we review several areas of research and their implications for school settings: (1) the association between pediatric conditions and youngsters social adjustment, (2) the role of peers/close friends as a source of support for youth with pediatric conditions, (3) friends inuence on treatment adherence, and (4) peers/friends impact on healthy behaviors (e.g., exercise) and health-risk behaviors (e.g., smoking, drinking, etc.). The Social Adjustment of Youth With Pediatric Conditions Many children and adolescents express concern or worry about their peer relations. For example, Brown, Clausen, and Eicher (1986) found that the most common stressors reported by youngsters 1018 years of age were fear of negative evaluations from others and ghts with or rejection by a friend. These concerns can be especially prominent for youth with a chronic pediatric condition (Wolman, Resnick, Harris, & Blum, 1994). Nevertheless, in general, children with chronic disease do not appear to have more social difculties than their healthy peers. This literature can best be divided into studies of youth with and without cognitive impairments associated with their pediatric condition. No Cognitive Impairments. The most extensive work on the peer relations of youth with chronic pediatric conditions has come from Noll and colleagues (e.g., Noll, Bukowski, Davies, Koontz, & Kalkarni, 1993; Noll, Bukowski, Rogosch, LeRoy, & Kulkarni, 1990; Noll, LeRoy, Bukowski, Rogosch, & Kulkarni, 1991; Noll et al., 1996, 1999). These investigators have used child, peer, teacher, and parent reports to examine various aspects of childrens social adjustment, such as popularity, social acceptance, and loneliness. Specically, in the rst of a series of studies, children with cancer were compared with matched classroom controls on measures such as popularity, friendship, and social reputation (Noll et al., 1990). Based on peers ratings, the children with cancer were seen as less sociable,
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less prone toward leadership, and more socially isolated and withdrawn than controls. However, two follow-up studies (Noll et al., 1991, 1993) found no differences between the two groups of children in terms of their general social acceptance, self-concept, and loneliness, even though the children with cancer were perceived to have more illness and to be more socially isolated than their classmates. When teacher reports were included as a measure of social reputation, children with cancer were nominated more often for sociability-leadership roles and less often for aggressive-disruptive roles. More recent work has shown that children with cancer were remarkably similar to controls in terms of their emotional functioning and social adjustment (Noll et al., 1999). Work with children who have asthma suggests that their peer relations are comparable with their classmates, even though peers perceive these youth as being sicker and missing more school (Graetz & Shute, 1995). However, those with more severe asthma (e.g., more hospitalizations) were perceived as less preferred as playmates and as being more sensitiveisolated; these children also reported more loneliness than did children with less severe asthma. Some preliminary work suggests that adolescents with asthma may have higher than average levels of social anxiety, suggesting a high degree of worry or concern about peer relations (Bearman, La Greca, Glickman, & Kuttler, 2001). In a study of children with sickle cell disease (SCD), gender appeared to be an important determinant of peers perceptions of the affected childs social competence (Noll et al., 1996). Girls with SCD were perceived by peers as being less sociable and less well accepted than comparison girls, whereas boys with SCD were perceived as being less aggressive than comparison boys. Together, these studies provide limited support for the notion that chronic disease has a negative impact on youngsters peer relations or friendships. Nevertheless, the ndings do identify considerable variability in the peer relations of children and adolescents with chronic disease, and youth who have more severe illness may be more socially affected than other youth. In view of these ndings, it would be useful for school personnel to know how to identify youth with chronic pediatric conditions, and to be able to monitor their health and school adjustment on a regular basis. Children and adolescents who miss a substantial amount of school because of hospitalizations may be especially important to monitor and assist in their social adaptation. Cognitive Impairments. Pediatric conditions that are associated with cognitive impairments present a special challenge to social relations. Cognitive impairments occur with a variety of chronic conditions and treatments, and may range from mild learning disabilities to signicant impairment (e.g., mental retardation). Chronic health conditions that are associated with cognitive difculties include cerebral palsy, spina bida, epilepsy, congenital heart disease, SCD, and human immunodeciency virus (HIV) infection (Armstrong, Seidel, & Swales, 1993; Brouwers, Belman & Epstein, 1991; DeMaso, Beardslee, Silbert, & Fyler, 1990; Fabian & Peters, 1984; Gammal et al., 1988; Huttnelocher, Moohr, Johns, & Brown, 1984; Nassau & Drotar, 1997; Shepherd & Hosking, 1989; Wiznitzer et al., 1990). Cancers that involve brain tissue also can produce central nervous system (CNS) complications (Nassau & Drotar, 1997). Studies suggest that children with CNS-related health conditions may have trouble developing age-appropriate peer relations. Nassau and Drotar (1997) suggest that this linkage may be from: (1) cognitive impairments, such as below average intelligence or specic cognitive decits (e.g., memory or attention problems) associated with CNS-related conditions that interfere with social understanding and affect peer relations (Dodge & Price, 1994); (2) varying degrees of physical handicap (e.g., braces or wheelchairs) that limit childrens ability to participate in age-appropriate peer activities (La Greca, 1990) and lead to social isolation or
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peer rejection; and (3) limited opportunities for peer involvement for those who attend special education classes or participate in rehabilitation settings. Available evidence highlights problems in peer relations among children and adolescents with CNS-related conditions (see Nassau & Drotar, 1997). For example, studies have found that youth with CNS-related conditionssuch as spina bida, cerebral palsy, and other chronic physical disordersare rated as less socially competent than comparison control youth or normative samples (Ammerman, Van Hasselt, Hersen, & Moore, 1989; Apter et al., 1991; Wallander, Feldman, & Varni, 1989; Wallander, Hubert, & Varni, 1988; Wallander, Varni, Babini, Banis, & Wilcox, 1988). When peer-based sociometric ratings have been used (Center & Ward, 1984), children with spina bida have been found to be less socially accepted than their classmates. In addition, research suggests that children who survive brain tumors have more social problems, fewer friends (Vannatta, Gartstein, Short, & Noll, 1998), and are viewed as more sensitive and isolated than their healthy classmates (Noll, Ris, Davies, Bukowski, & Koontz, 1992; Vannatta et al., 1998). In addition, HIV-infected children with encephalopathy have been found to display less adaptive and appropriate behavior than those without encephalopathy (Moss, Wolters, Brouwers, Hendricks, & Pizzo, 1996). The social stigma associated with HIV infection also may contribute to problems in childrens social functioning. In summary, available evidence suggests that youngsters with physical conditions that involve cognitive difculties are at risk for problems in their peer relations and friendships. In their extensive review, the balance of studies cited by Nassau and Drotar (1997) support this observation. Implications for School Settings Although pediatric conditions do not necessarily have a negative impact on most youngsters peer relations, many children and adolescents express concern about this possibility. As a result, it may be important for school personnel to help children and adolescents communicate with teachers and peers about their disease or condition. In some circumstances, self-disclosure can be helpful, but this should not be done indiscriminately. For youth with CNS-related difculties, schools can be tremendously useful in helping children and adolescents to adapt to the social demands of school. Some suggestions for intervention are summarized herein. Self-disclosure of difcult or traumatic experiences has been associated with improved physiological health (e.g., Greenberg & Stone, 1992; Pennebaker & Beall, 1986). For children and adolescents, sharing intimate concerns, fears, and worries with peers is an essential part of friendships (La Greca, 1990). Children and adolescents who do not have close friends for condants may be missing a valuable mechanism for coping with their chronic illness. For example, Sherman, Bonanno, Wiener, and Battles (2000) found that children with HIV+ status who disclosed their diagnosis to friends had a signicantly larger increase in CD4% (a sign of improved immune functioning) than children who had not disclosed their status to friends. School personnel can help children and adolescents to nd appropriate ways to disclose disease information, while at the same time recognizing the potential social barriers that can arise when integrating children and adolescents with pediatric conditions into school settings. Studies have found that educating classmates about a childs medical condition may be helpful under some, but not all, circumstances. For example, Guite, Walker, Smith, and Garber (2000) found that when classmates were told that a child has somatic symptoms (recurrent abdominal pain) and these symptoms were illustrated as medically based, this information had little or no impact on the likeability of the child. Thus, disclosure did not appear to put children with recurrent abdominal pain at a social disadvantage (La Greca & Bearman, 2000). Similar ndings have been obtained for adolescents with cancer (Gray & Rodrigue, 2001).
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In contrast, when a child has a visible or stigmatizing condition (e.g., obesity, burns, physical handicap), giving the childs classmates a medical explanation for the childs condition may negatively inuence childrens attitudes or receptivity, instead of easing the transition into the classroom (Bell & Morgan, 2000; Morgan, Bieberich, Walker, & Schwerdtfeger, 1998). Thus, La Greca and Bearman (2000) suggest alternative ideas for enhancing childrens receptivity in the classroom. For example, providing information to classmates about the childs skills (e.g., sports, academics) may help to compensate for stigmatizing conditions. In addition, peerpairing and close friendships might be used to enhance a childs school integration. Overall peer likeability may not matter if children with medical conditions have supportive, close friendships (La Greca & Bearman, 2000). For youth with cognitive impairments, more specic guidance may be needed to ensure that children are well integrated into appropriate social networks at school, and that they are not left out. Such youth may benet from social skills training programs that explicitly teach age-appropriate social skills and ways to develop and maintain friendships (see La Greca & Prinstein, 1999). Friends as a Source of Support for Chronic or Life-Threatening Pediatric Conditions For youth with chronic or life-threatening conditions, social support is believed to be important for their disease adjustment and treatment management (e.g., Burroughs, Harris, Pontious, & Santiago, 1997; La Greca et al., 1995; Varni et al., 1989). Children and adolescents with pediatric conditions face a challenging array of stressors, including distress about their medical condition, teasing from peers, restrictions on activities, difcult or painful medical interventions, and chronic or demanding treatment regimens (Vessey, Swanson, & Hagedorn, 1995). In this context, support from friends may help to buffer stress reactions among children and adolescents with pediatric conditions, and thus may facilitate their psychosocial adaptation. Psychosocial Adaptation. Several studies have addressed the role of friends in facilitating the psychosocial adaptation of youth with chronic or life-threatening pediatric conditions. Specically, Wallander and Varni (1989) examined the contributions of family and friend support for children diagnosed with a variety of chronic illnesses. Children who reported high levels of both family and friend support exhibited lower levels of internalizing and externalizing behavior problems than children with support from only one source. Furthermore, Varni and colleagues (1989) demonstrated that perceptions of friend support predicted psychological adaptation among adolescents with diabetes whereas family support predicted adaptation in childhood. Their ndings suggested that friend support may become increasingly important during the adolescent years for youth with chronic illnesses. In subsequent studies, Varni, Setoguchi, Rappaport, and Talbot (1992) found that, among children with congenital and acquired limb deciencies, higher perceived classmate support was predictive of lower levels of depressive symptoms, lower trait anxiety, and higher selfesteem. Similarly, Varni, Katz, Colegrove, and Dolgin (1994) also found that, among children with cancer, higher perceived classmate support predicted fewer symptoms of depression and anxiety, and lower levels of internalizing and externalizing behavior problems. Overall, these studies suggest that classmates and friends are very important for the psychosocial adaptation of youth with chronic and life-threatening conditions. Studies of distinct and complementary roles of family and friend support for diabetes management have revealed that family members provide different types of disease-specic support. For example, La Greca and colleagues (1995) examined both family and friend support for adolescents with Type 1 diabetes and found that friends provided more emotional and
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companionship support than family members. Moreover, Bearman and La Greca (2002) found that adolescents friends provided more frequent emotional support than support for many other routine aspects of care. In addition, adolescents perceived their friends behaviors in certain areas of diabetes to be very supportive, with one such area being emotional support. Such ndings suggest that friends support is typically focused on emotional needs (e.g., acceptance, understanding) and companionship for youth with chronic disease. Gender differences in friends support have also emerged, with girls reporting more diseasespecic support from close friends than boys (e.g., Bearman & La Greca, 2002; La Greca et al., 1995). Thus far, however, very little attention has been directed to possible ethnic differences in friendship support. Some preliminary data suggest that Black males with diabetes receive less disease-specic support from their friends than do Black girls, or Hispanic boys and girls (Bearman, La Greca, Patino, & Delamater, 2001), although further study of this issue would be desirable. Implications for School Settings. School provides the opportunity for ongoing socialization and social support, and helps to normalize a difcult and stressful experience (Varni, Katz, Colegrove, & Dolgin, 1993; Varni et al., 1994). To facilitate the long-term adjustment to a chronic illness, children are encouraged to return to school and engage in social experiences as soon as medically possible (e.g., Katz, Varni, Rubenstein, Blew, & Hubert, 1992). However, some classmates may be nonsupportive, or may engage in potentially hurtful behaviors, such as teasing and name-calling (Varni et al., 1994). In a descriptive analysis of youth in school settings, Lightfoot, Wright, and Sloper (1999) illustrated that friends of youngsters with an illness or disability may help them deal with bullying and curiosity, crisis tasks, ongoing physical care, keeping up with school work, and keeping in touch with classmates during school absences. These ndings suggest that promoting childrens support from friends in the school setting is critical, and one strategy for accomplishing this is through formal school re-entry programs. Successful school re-entry focuses on addressing the unique needs of the individual child or adolescent, with an emphasis on academic and social skills (Madan-Swain, Fredrick, & Wallander, 1999) and on promoting social support from parents, teachers, and classmates. Several strategies have been suggested for strengthening social support from classmates in schools. For example, social skills training may enhance the self-efcacy and social competence of children with pediatric conditions, ultimately fostering positive social interactions (Varni et al., 1994), and leading to greater perceived support from classmates and close friends. As a specic example of this approach, Varni and colleagues (1993) developed a social skills intervention for children newly diagnosed with cancer. The intervention was organized into three individual 60-min sessions and two booster sessions, and included social-cognitive problem-solving training, assertiveness instruction, and coping with teasing and name-calling resulting from changes in physical appearance. A detailed treatment manual was developed that included videotape modeling, relaxation, and homework assignments; the assignments included activities for children and parents to promote generalization of the skills to the home and school settings. Compared with children receiving standard care, children in the social skills group reported greater classmate and teacher support at follow-up. Additionally, parents of the children in the social skills group reported a decrease in their childrens internalizing and externalizing behavior problems and an increase in school competence. The success of this program for improving social support and psychological adjustment for children and adolescents with pediatric conditions illustrates the importance and feasibility of strengthening friend support. Such interventions could be conducted in the school setting, directly involving teachers and classmates. With the collaborative efforts of health professionals, teachers, parents, and friends, children and adolescents with chronic illnesses may be able to
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continue normal social and academic activities without signicant disruption (Varni et al., 1993). Peers Inuence on Treatment Adherence Nonadherence to medical regimens is believed to contribute to increased morbidity, mortality, and health care utilization and costs (Rapoff, 1998). Disease management may be burdensome, especially for youth with complex disease maintenance regimens (e.g., diabetes, cystic brosis) and for older children who are increasingly responsible for their own disease management (La Greca, Follansbee, & Skyler, 1990). In particular, Rapoff (1998) has described adolescents as having poor adherence to medical regimens, such as cancer, cystic brosis, diabetes, and renal disease. If youth with chronic illnesses perceive that self-care behaviors (e.g., dietary and exercise restrictions) are supported and encouraged by their friends, they may be more likely to perform these behaviors when in the company of peers. In this manner, adolescents friends may play important roles in their disease management. Although friends may have a positive affect on youngsters treatment adherence, children and adolescents also may disregard their self-care so as not to call attention to themselves or appear different from peers (Schuman & LaGreca, 1999). For example, Christian and DAuria (1997) found that adolescents with cystic brosis reported not adhering to their treatment regimens for fear of being seen as different or of losing a romantic partner. La Greca and Hanna (1983) also found that, for youth with diabetes, social barriers played a role in poor regimen adherence and problems with metabolic control. Specically, children and adolescents reported that social interference represented a barrier to dietary adherence and blood glucose testing, mainly because youth with diabetes did not want to appear different or less socially competent than their friends (La Greca & Hanna, 1983). In an attempt to facilitate adherence, schools may be able to improve integration of children and adolescents with pediatric conditions in a way that would prevent them from feeling different or left out by peers. For adolescents with diabetes, friends have been identied as providing more frequent support for certain aspects of the diabetes regimen (e.g., exercise and helping out with reactions) than others (e.g., insulin injections and meals; Bearman & La Greca, 2002; La Greca et al., 1995). Furthermore, adolescents perceive friends behaviors in certain areas (e.g., meals) to be more supportive than behaviors in other areas of management (e.g., insulin injections, blood testing; Bearman & La Greca, 2002). Such ndings suggest the importance of identifying specic areas of disease management in which friends can be most supportive. This information would help to provide a focus for intervention programs designed to enhance friends support of treatment management. School Interventions Because peers play an important role in adherence, recognizing potential social barriers and enhancing friend support for children and adolescents with pediatric conditions are useful strategies for promoting positive health practices. Friendship support for treatment management may be enhanced in the school setting through peer group interventions. For example, Greco, Pendley, McDonell, and Reeves (2001) developed a group program for adolescents with diabetes and their best friends. This four-session intervention was structured to encourage friends to become involved with adolescents diabetes management. Each session included a review of homework, instruction on a particular topic, a game or exercise to practice the new concepts, and a homework assignment for the following week. The sessions covered topics such as descriptive information about diabetes, reective listening skills and problem-solving, the ways friends could be supportive and provide assistance with diabetes care, and stress
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management skills. After completing the intervention, adolescents and their friends reported higher levels of diabetes knowledge and support, and a higher ratio of friend to family support; and parents rated their adolescents as having less diabetes-related conict (Greco et al., 2001). Other strategies for enhancing friendship support among youngsters with pediatric conditions might include encouraging their close friends to maintain contact with them during hospitalizations (Sexson & Madan-Swain, 1995). Teachers, parents, and health professionals may need to make sure that childrens and adolescents close friendship ties are not disrupted during periods of extended treatment or hospitalization. The Role of Peers in the Promotion of Health Behaviors Peers not only affect children with current medical conditions, but also can have an impact on youngsters future medical conditions by inuencing health-related behaviors such as smoking, alcohol and drug use, diet, exercise, sexual behavior, and risky behaviors leading to injury. Together, these six behaviors are greatly responsible for the most serious mortality and morbidity-related health problems in the United States: heart disease, cancer, stroke, motor vehicle accidents, accidental deaths, HIV, other STDs, and teen pregnancy. According to the Centers for Disease Control and Prevention (CDC, 2000a, p. 1), these behaviors usually are established in youth; persist into adulthood; are interrelated; and are preventable. Children and adolescents health behaviors are inuenced both by the health behaviors of their closest friends and by perceptions of the behaviors and attitudes of the larger peer group. Close friends tend be similar in their health behaviors and these similarities increase with age. Tolson and Urberg (1993) found that adolescent best friends were more similar in their health behaviors than in their attitudes, family relationships, or school activities. Children and adolescents are also inuenced by perceived pressures from the larger peer group. Newman (1984) describes peer pressure as pressure to project a desirable image, rather than pressure for specic behaviors. These image-based pressures include pressure to appear independent, pressure for recognition, pressure to appear grown up, and pressure to have fun. Many healthrelated behaviors, such as smoking, drug and alcohol use, and sexual and risk-taking behaviors, may be perceived as easy ways to project these desired images. Membership in a peer crowd is one way for adolescents to establish and maintain a strong identity during a time when they are questioning and exploring who they are. Members of adolescent peer crowds tend to be very similar in behaviors. As discussed previously, this similarity increases through a bidirectional inuence: adolescents associate with similar peers through the process of selection and grow more similar to these peers through processes of socialization. Peer inuence does not always negatively affect health behaviors; Clasen and Brown (1985) found that peer pressure may also discourage unhealthy behaviors and encourage healthy ones. Understanding how peers inuence the development of health behaviors is extremely important, but has been understudied. Most of the research in this area has examined the impact of peers on the initiation, continuation, and cessation of smoking behaviors. Smoking. Researchers have examined adolescent smoking for several reasons: (1) tobacco use is the chief preventable cause of premature aging and death in the United States; (2) nearly all rst-time tobacco use and two thirds of new habitual tobacco use takes place in adolescence; (3) once smoking becomes habitual, it is extremely difcult to quit; and (4) cigarette smoking is often a gateway drug that leads to alcohol and drug use (Elders, 1994; Jessor & Jessor, 1977; National Center for Chronic Disease Prevention and Health Promotion, 2000). The consensus of this research is that peer smoking is the single best predictor of adolescent smoking (Flay, dAvernas, Best, Kersell, & Ryan, 1983; Petraitis, Flay, & Miller, 1995).
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However, the tendency for adolescents to form friendships based on shared characteristics has made it difcult to isolate the effect of peer inuence on smoking behaviors. For example, it is well known that adolescents who afliate with the Burnout crowd are more likely to smoke, but it is not clear whether selection or socialization processes are primarily responsible for these similarities (La Greca, et al., 2001; Moshbach & Leventhal, 1988; Sussman, et al., 1994). To control for the effects of selection, many researchers have used longitudinal designs to examine changes on smoking behavior over time. Using these methodologies, researchers have found strong evidence of both selection and socialization processes. Ary and Biglan (1988) found that peers were instrumental in the maintenance of smoking behaviors and increases from triers to habitual smokers. In one longitudinal study, the smoking behaviors of best friends was the only consistent and signicant factor in predicting adolescent smoking progression to a more advanced level of acquisition (Wang, Fitzhugh, Eddy, Fu, & Turner, 1997). Nonsmoking adolescents with at least one smoking friend are more likely to become smokers than nonsmokers who associate only with other nonsmokers (Ennett & Bauman, 1994). Researchers have found developmental differences in susceptibility to peer inuence; early adolescence appears to be a particularly vulnerable time, particularly for boys (Urberg, Cheng, & Shyu, 1991). Based on these ndings, it seems imperative that schools incorporate antismoking messages into their curriculum very early and teach students alternative ways of tting into a group. For example, involvement in sports or academics are good ways to gain membership in groups that discourage cigarette smoking. Because peers are also instrumental in the maintenance of smoking behaviors, it is important to teach refusal skills to teens who smoke, because they are much more likely than other adolescents to be offered cigarettes (Ary & Biglan, 1988). Adolescents who want to quit smoking may need to develop new interests to make new, nonsmoking friends. Research on school-based interventions has found that a social inuence resistance model is the most effective approach to reducing youth smoking. Such models focus on building skills to recognize and resist negative inuences, communication skills, decision-making skills, and assertiveness training (Institute of Medicine, 1994). Alcohol and Drug Use. Though alcohol consumption in the United States has declined in recent years, adolescents are drinking more at younger ages than ever before (Williams & Perry, 1998). A 1997 Monitoring the Future study found that 54% of eighth graders, 72% of tenth graders, and 82% of twelfth graders reported having consumed more than a few sips of alcohol (Johnston, OMalley, & Bachman, 1998). Adolescent alcohol use is associated with increases in a variety of risky behaviors, including sexual risk behavior and drunk driving (OMalley et al., 1998). In addition, early adolescent alcohol use puts adolescents at risk for later alcohol abuse, even when genetic factors are controlled for, and signicantly increases the chances that adolescents will try illegal drugs (Grant & Dawson, 1997; Kandel, 1980; OMalley et al., 1998). These sobering statistics have turned attention in recent years to the socialization factors associated with alcohol and drug use. Several recent longitudinal studies have found clear evidence of a strong peer inuence on alcohol and drug use. Wills and Cleary (1999) found more support for socialization than selection factors in the rate of change of substance use in middle schoolers. Two other large, longitudinal studies of adolescent alcohol use found similar results (Curran, Stice, & Chassin, 1997; Sieving, Perry, & Williams, 2000). Thus, unlike cigarette use that has both strong peer selection and peer socialization processes, alcohol use escalates primarily through peer socialization processes. Further research is needed to clarify the roles of gender, ethnicity, and individual differences in these processes (Farrell & Danish, 1993; Santor, Messervey, & Kusumakar, 2000).
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The strong evidence for socialization effects on adolescent alcohol use has led to the development of school and community-based interventions that heavily target peer inuence. One such intervention, Project Norland, has had some success in delaying the onset of alcohol use in middle school (Williams & Perry, 1998). School-based intervention techniques in Project Norland include interactive techniques, with peer leaders or role plays; normative education programs designed to change students misconceptions about the prevalence of underage drinking; resistance skills training, leadership skills training, and media-savvy training. Preliminary results show signicant reductions in the onset and prevalence of alcohol use among young adolescents (Williams & Perry, 1998). Sexual Risk Behaviors. High-risk sexual behavior includes lack of condom use, frequent sexual intercourse, and having sex with multiple partners, partners from high-risk groups (e.g., intravenous drug users, homosexual men, prostitutes), or partners of unknown status (Goedert, 1987). High-risk sexual behaviors are strongly related to other health-risk behaviors, such as cigarette, alcohol, and drug use, and are associated with friends engagement in problem behaviors (Biglan et al., 1990; Metzler, Noell, Biglan, Ary, & Smolkowski, 1994). Romer et al. (1994) found that perceived peer sexual behavior was associated with the rate at which sexual behavior progressed with age and with the degree to which condom use was maintained with age. However, there is a need for longitudinal studies of selection and socialization factors in similarities between peers sexual behaviors. There is some evidence of gender and ethnic differences in the inuence of peers on sexual behavior. Leland and Barth (1992) found that females perceived larger proportions of their peers as sexually active, were more likely to have used oral contraceptives instead of condoms, were less likely to have used protection during rst intercourse, and were less likely to always use protection. Billy and Undry (1985a, 1985b) found that the sexual behavior of male and female best friends inuenced the sexual behavior of White girls, but there were no inuence effects for White boys or for Black girls and boys. Similarly, Nathanson and Becker (1986) found that White girls, but not Black girls, were inuenced by the perceived contraceptive use of samesex friends. In a sample of Black adolescents, St. Lawrence, Braseld, Jefferson, Alyene, and Shirley (1994) found that those with less perceived social support reported higher sexual risk behaviors. These results suggest that effective intervention strategies may differ by gender and ethnicity. For example, interventions targeted to females should emphasize realistic appraisals of peer sexual activity and the importance of condom use for effective prevention of STDs. Diet and Exercise. The percentage of children and adolescents who are dened as overweight has more than doubled since the early 1970s (National Center for Chronic Disease Prevention and Health Promotion, 2001a). Childhood obesity is a public health concern both because of its immediate impact on physical health and because it places the child at risk for myriad health problems associated with adult obesity (Kanders, 1995). Physical inactivity and poor diet together account for at least 300,000 deaths in the United States each year (McGinnis & Foege, 1993). Peer inuence on childhood and adolescent obesity can be harmful or benecial. Children with obesity are often victims of peer teasing and rejection, which can lead to the development of psychological and social difculties on top of their medical difculties (Baum & Forehand, 1984; Strauss, Smith, Frame, & Forehand, 1985). Positive peer relationships may promote physical activity by boosting the mood and physical self-esteem of adolescents (Smith, 1999). One effective school-based obesity prevention program used older children as peer counselors (Foster, Wadden, & Brownell, 1985). Other programs encourage students to participate in physical activities together, such as walking to school (National Center for Chronic Disease Prevention and Health Promotion, 2001b).
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Although the percentage of children and adolescents who are overweight has dramatically increased in recent years, there has also been an increase in the numbers of children and adolescents whose efforts to reduce their weight lead to serious health problems, such as potentially fatal eating disorders (Fairburn, Hay, & Welch, 1993). Peers serve as a subculture that may enhance or diminish cultural pressures for thinness and engaging in weight loss strategies through modeling, verbal reinforcement, and teasing (Paxton, 1996). Although most of the literature examines these processes among adolescent girls, peer feedback also inuences the body images and body-changing methods of adolescent boys (Ricciardelli, McCabe, & Baneld, 2000). Adolescent girls who perceive that their peers go on diets are more likely to go on diets themselves (Huon, Lim, & Gunewardene, 2000; Huon & Walton, 1999). The body image concerns, dietary restraints, and extreme weight-loss behaviors of adolescent girls are most similar within friendship cliques, suggesting that this is the most effective level for intervention (Paxton, Schutz, Wertheim, & Muir, 1999). Summary of Suggestions for School Interventions. The Centers for Disease Control and Prevention recommend that schools incorporate health behavior information and skills into a sequential, comprehensive health education curriculum that begins in preschool and continues through secondary school (CDC, 2000b). Research suggests that such programs can be highly effective in reducing health risk behavior. For example, one such program reduced by 37% the onset of smoking in seventh graders (National Center for Chronic Disease Prevention and Health Promotion, 2001b). Understanding the precise mechanisms and levels of peer inuence on health behaviors can lead to the development and implementation of targeted, more effective interventions. For example, the impact of peers on alcohol and drug use is mainly through socialization, so effective interventions might focus on teaching children and adolescents refusal and moderation skills. In contrast, the inuence of peers on cigarette smoking has both selection and socialization components. Interventions should discourage children and adolescents who do not smoke from associating with smokers, whereas those who do smoke should be taught strong refusal skills. Interventions must also consider the level of peer inuence for a particular health behavior. For example, diet and exercise behaviors are most similar within peer cliques, so effective interventions should target adolescents within the same clique. In contrast, smoking inuence occurs at the peer crowd level and effective interventions must either target entire peer crowds or, perhaps more realistically, attempt to draw individuals away from these crowds.
CONCLUSIONS In summary, in this chapter, we have reviewed key developmental aspects of childrens and adolescents peer relations and friendships, with special attention to youth with chronic pediatric conditions. In general, the resilience of youth affected by medical conditions is remarkable, and the ndings suggest that most youth with pediatric conditions have peer relations and friendships that are comparable with those of their peers. Nevertheless, youth with visible and physically handicapping conditions and those with associated cognitive impairments may have an especially difcult time in social contexts. Special efforts to help such youth in the school setting are needed. One important aspect of friendships is the emotional support they provide. Social support from friends appears to be critical for youth with chronic pediatric conditions. Involving youngsters close friends in their disease management and making sure that friendships are not disrupted when children miss school or have an extended leave of absence from illness are
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ways that health care professionals and school personnel can facilitate the social adjustment and disease adaptation of youth with pediatric conditions. Another key theme of the chapter, most relevant to adolescents, is the importance of peer relations and peer crowd afliations for health behaviors. Peer crowds provide a context for encouraging health-risk or health-promoting behaviors. Given that proper diet, exercise, and restraint from using various substances (e.g., tobacco, alcohol, drugs) are especially important for adolescents with pediatric conditions, understanding these adolescents social contexts becomes a critical task for health care professionals and school personnel. In view of the aforementioned themes and the ndings reviewed in this chapter, future research efforts are needed that examine in a detailed manner the social challenges associated with childrens and adolescents pediatric conditions in the school setting. Much of the existing research has been done with children and adolescents who are seen in tertiary health care settings; it would be of interest to extend this work to the primary contexts in which children and youth spend their time on a daily basis. Further attention might also be directed toward developing pediatric interventions that are feasible to implement in school settings. Intervention programs that focus on issues such as school reentry, enhancing peer support and close friendships, and teaching peers how to accept those who are different, are especially appropriate for the interface between pediatric psychology and schools. It is hoped that the ideas and information provided in this chapter will provide an impetus to psychologists working in school settings with youth who have health-related problems.
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