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- Evaluating Body Image, Physical Activity, and Time since Disability Onset as Predictors of Psychological Adjustment to Mobility Impairments
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- BYRNES, ERICA L. ( Author, Primary )
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- 2008
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- Anxiety ( jstor )
Body image ( jstor )
Disabilities ( jstor )
Emotional adjustment ( jstor )
Exercise ( jstor )
Modeling ( jstor )
Psychological research ( jstor )
Psychology ( jstor )
Psychosociology ( jstor )
Self esteem ( jstor )
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- Copyright Erica L. Byrnes. Permission granted to University of Florida to digitize and display this item for non-profit research and educational purposes. Any reuse of this item in excess of fair use or other copyright exemptions requires permission of the copyright holder.
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EVALUATING BODY IMAGE, PHYSICAL ACTIVITY AND TIME SINCE
DISABILITY ONSET AS PREDICTORS OF PSYCHOLOGICAL ADJUSTMENT TO
MOBILITY IMPAIRMENTS
By
ERICA L. BYRNES
A MASTER'S THESIS PRESENTED TO THE GRADUATE SCHOOL
OF THE UNIVERSITY OF FLORIDA IN PARTIAL FULFILLMENT
OF THE REQUIREMENTS FOR THE DEGREE OF
MASTER OF ARTS IN EDUCATION
UNIVERSITY OF FLORIDA
2005
Copyright 2005
by
Erica L. Byrnes
This document is dedicated to the numerous participants who were willing to share their
time and personal experiences to make this research possible.
ACKNOWLEDGMENTS
I would like to gratefully acknowledge the many people that have been a part of my
graduate education: family, friends, teachers, mentors, colleagues and supervisors.
Without the amount of support that I received from these faculties, I surely would not
have reached such a milestone in my educational career. I am indebted to these people for
the opportunities that I have been afforded over the past few years to learn, grow,
challenge, discuss, experience and collaborate.
TABLE OF CONTENTS
A C K N O W L E D G M E N T S ................................................................................................. iv
LIST O F TA BLE S ......... ................... ... ............ .............. .. vii
LIST OF FIGURES ............. .. ..... ...... ........ ....... .......................... viii
ABSTRACT ........ .............. ............. ...... ...................... ix
CHAPTER
1 INTRODUCTION ............... ................. ........... ................. ... .... 1
2 REVIEW OF THE LITERATURE .................................................................. 8
Intro du action ................ .. ... ....... .. ........ .................... ... .... .......... ............... .. 8
Theoretical Models of Psychosocial Adjustment to Physical Disability....................9
Predictors of Psychosocial Adjustment to Disability .............................................. 12
Self-Esteem as a Predictor of Psychological Adjustment to Disability .............14
Body Image as a Predictor of Psychological Adjustment to Disability .............14
Physical Activity as a Predictor of Psychological Adjustment to Disability ......16
Time Since Disability Onset as a Predictor of Psychological Adjustment to
Disability ................. ............................. 17
C conclusion ................................................................................................ 19
3 M E T H O D O L O G Y ............................................................................ ................... 20
Research Questions and Hypotheses ........................................ ....... ............... 20
Procedures ............ ...... ......................................... .......... ...... 21
P a rtic ip a n ts ........................................................................................................... 2 3
M measures ........................................................................................................... 24
B ody-Cathexis Scale .................................... ................... ..... .... 24
D expression ..................................................................................................25
A n x iety ................................................................2 5
Self-Esteem ..................................................................................... .................... 26
Physical Activity ........................ ......................... 26
Demographic Data Questionnaire (DDQ) ................................27
D ata A n a ly se s ............. ..... ............ ....................................................................... 2 7
4 R E S U L T S ............................................................................................................. 2 8
D descriptive Statistics .............................................................28
Hypotheses Testing.......................................................... 31
5 DISCUSSION ............... ..................................................3 34
F in d in g s ................................................................ 3 5
G e n d e r ........................................................................................................... 3 5
D isab ility ....................................................... 3 6
Self-E steem ..................................................................... 36
B o d y Im a g e ................................................................................................... 3 7
P h y sical A ctiv ity ........................................................................................... 3 7
Tim e Since D disability O nset................................... .................. 38
Im plications for C counseling ................................................................................. 38
L im itatio n s .......................................................................................3 9
F utu re R research ................................................................ 39
APPENDIX
A INVITATION LETTER TO PARTICIPANTS............................ ...............41
B INFORMED CONSENT ................ ........ ....... ........ 42
C BODY CATHEXIS SCALE .............................................................. ............44
D CENTER FOR EPIDEMIOLOGIC STUDIES DEPRESSION SCALE (CES-D) ....46
E STATE TRAIT ANXIETY INVENTORY .................................. ....................47
F ROSENBERG SELF-ESTEEM SCALE ..............................48
G INTERNATIONAL PHYSICAL ACTIVITY QUESTIONNAIRE (IPAQ) .............49
H DEMOGRAPHIC DATA QUESTIONNAIRE (DDQ) ..........................................51
R E F E R E N C E S ............................................................................................................ 5 3
B IO G R A PH IC A L SK E T C H ....................................................................................... 58
LIST OF TABLES
Table page
4-1. Means, Standard Deviations, Ranges and Reliabilities of All Measures ...................28
4-2. Participant Characteristics .......................................................... ............... 29
4-3. C orrelation B etw een V ariables............................................................................... .. ..31
4-4. Multiple Regression Analyses Results for Depression.............................................32
4-5. Multiple Regression Analyses Results for Anxiety.................................................33
FIGURE
Figure page
2-1. Diagram of Wallander and Vami's theoretical adaptation model.............................13
Abstract of Thesis Presented to the Graduate School
of the University of Florida in Partial Fulfillment of the
Requirements for the Degree of Master of Arts in Education
EVALUATING BODY IMAGE, PHYSICAL ACTIVITY AND TIME SINCE
DISABILITY ONSET AS PREDICTORS OF PSYCHOLOGICAL ADJUSTMENT TO
MOBILITY IMPAIRMENTS
By
Erica L. Byrnes
December 2005
Chair: Sondra Smith-Adcock
Major Department: Counselor Education
Americans with disabilities are up to three times more likely to experience mental
health illness than their able-bodied counterparts. This increased risk is additionally
weighted with the dangers of comorbidity of mental health and disability. The
relationship between disability and mental illness is dangerously cyclical; symptoms
related to each illness are multiplied in the presence of symptoms of the opposing illness.
In order to appropriately understand psychological adjustment to mobility impairments,
this construct was examined through the lens of Wallander and Varni's multivariate
theoretical model of adjustment to disability.
The primary goal of this research was to evaluate type of disability, self-esteem,
body image, physical activity and time since disability onset as predictors of adjustment
to disability using the multivariate framework established by Wallander and Varni. The
relationship between each predictor variable and psychological adjustment outcome
measures (depression and anxiety) was assessed. A regression model including all of the
variables was utilized to assess the interaction of these variables in the process of
predicting psychological adjustment to disability.
Data were collected from 234 participants via an electronic questionnaire.
Participants were required to be 18 years of age or older, diagnosed with a disability that
requires the use of a wheelchair and able to respond to the instrument battery
electronically. The instrument battery consisted of the following measures: body cathexis
scale, Rosenberg's self-esteem scale, center for epidemiological studies depression scale,
state-trait anxiety inventory, international physical activity questionnaire and a
demographic data questionnaire.
The results of the hierarchical regression models revealed that the variables
explained a significant portion of the variance in both depression and anxiety.
Investigation of the independent variables (disability, self-esteem, body image, physical
activity and time since disability onset) indicated that self-esteem accounted for the most
variance in depression and anxiety.
CHAPTER 1
INTRODUCTION
Census 2000 delivered an astonishing figure to researchers in the field of health
sciences: 49.7 million Americans are diagnosed with at least one type of disability
(Waldrop & Stern, 2003). This sizeable figure accounts for 19.3% of the American
population over the age of five years. Thus, almost one in every five Americans is
currently affected by a disability, and as the population continues to age this figure will
rise. Based on the Census 2000 data, Waldrop and Stem indicated that of the 49.7 million
Americans living with a disability, 21.2 million (8.2% of the American population) have
a condition that limits basic physical activities. Given the magnitude of the population
living with a disability, the need for research centered on the well-being of this
population is critical.
Evidence suggests that people with disabilities are at a higher risk for mental health
illnesses as a result of chronic disability-related stressors (Turner & Beiser, 1990;
Wallander, Vami, Babani, Banis & Wilcox, 1988). Indeed, research findings support the
notion that the presence of a disability puts a person at a higher risk for depression (an
affective disorder), anxiety and substance use disorders (Polsky, Doshi, Marcus, Oslin,
Rothbard, Thomas & Thompson 2005; Turner & Noh, 1988; Wells, Golding & Burnam,
1988). In addition, the literature suggests that people with a disability experience
mitigated social interactions and relationships, which can further contribute to depressive
symptomatology (Fitzpatrick, Newman, Archer & Shipley, 1991). Effectively, the 21.2
million Americans with a physical disability have a risk for developing a comorbid
mental health disorder that is up to three times greater than their able-bodied American
counterparts.
Mental health illnesses such as depression, anxiety and substance use disorders
generate severe behavioral and health risks. Patients with these illnesses may experience
loss of energy, decrease in sleep patterns, decrease or increase in eating behaviors,
irritability, suicidality, panic attacks, dizziness and many other physical and mental health
implications (American Psychiatric Association, 2000). While the symptoms of mental
health illness are severe when experienced as a primary condition, the presence of both a
mental health illness and a physical disability may lead to unique negative health
outcomes only experienced by individuals with comorbid disorders. Individuals with a
disability and a comorbid mental health illness are at a heightened risk for negative health
and economic impacts that exceed the risks associated with disability or mental illness
alone.
Comorbidity of physical disability and mental health illness creates a counteractive
relationship in which each condition is uniquely worsened by the coexistence of
symptomatology of the other condition. The interaction of physical disability and mental
health illness has been correlated with further disability and activity impairment, as well
as higher rates of relapse for mental health illnesses (losifescu, Nierenberg, Alpert,
Papakostas, Perlis, Sonawalla & Fava, 2004; Vali & Walkup, 1998). The relationship
between disability and mental illness is dangerously cyclical; symptoms related to each
illness are multiplied in the presence of symptoms of the opposing illness.
In addition to increased experiences of poor mental health, Americans with a
disability will likely experience economic hardship, decreased levels of medical
treatment effectiveness, and decreased levels of treatment compliance. The prevalence of
such poor psychosocial adjustment outcomes demands research attention. According to
losifescu, Nierenberg, Alpert, Smith, Bitran, Dording and Fava (2005), patients who have
a disability and are diagnosed with major depressive disorder more frequently experience
negative clinical treatment outcomes for major depressive disorder than patients being
treated for major depressive disorder alone. Treatment effectiveness is further reduced by
patient non-compliance, which lead DiMatteo, Lepper and Croghan (2000) to indicate
that depression is a treatment compliance risk factor in patients under medical treatment
for a physical disability. Finally, comorbidity is attributed to increased utilization of
health care services (Manning & Wells, 1992), which can create negative economic
implications at an individual and societal level.
The number of persons with a disability is quickly growing and these people face
serious health implications; these facts illuminate the importance of making people with a
disability a research priority. Previous studies have examined factors that contribute to
the psychosocial adjustment outcomes of persons with a disability. In order to
appropriately understand psychological adjustment to disability, this construct must be
examined through the lens of a theoretical model. Researchers have produced theoretical
models that offer explanations of how variables work together to explain the process of
adjustment to disability. The present study utilized a model proposed by Wallander and
Varni (Wallander et al., 1988; Wallander, Varni, Babani, Banis, DeHaan & Wilcox 1989;
Wallander, Feldman & Varni, 1989; Wallander, Varni, Babani, Banis & Wilcox, 1989)
that offers insight into the process of mental health adjustment to disability and proposes
possible predictors of adjustment.
Wallander and Varni's model identifies a set of risk factors that directly influence
the mental health adjustment of persons with a disability. Further, they argue that the
relationship between the risk factors and the adjustment outcomes is moderated by a set
of resistance factors. There are three categories of risk factors: physical disease or
disability, chronic disability-related strain and psychosocial stress. Each category
includes a variety of variables: handicap severity, medical problems, bowel/bladder
control, visibility, cognitive functioning, brain involvement, functional independence,
major life events, handicap-related problems and daily hassles. The resistance factors are
also divided into three categories: intrapersonal factors, social-ecological factors and
coping ability. These categories consist of variables such as: temperament, competence,
effectance motivation, problem solving ability, family environment, social support,
family members' adaptation, utilitarian resources, cognitive appraisal and coping
strategies. Wallander and Varni initially selected the factors included in their model
based on current research findings at the time the model was developed. The selected
factors were subsequently evaluated in a series of studies with a variety of disabled
populations.
For the purposes of the present study, a specific risk and resistance factor were
identified as variables in the research. The risk factor assessed in the current research was
type of disability. This risk factor has been an established predictor of adjustment to
disability since the primary phases of Wallander and Varni's research which investigated
the differences in adjustment levels experienced by individuals with varying disabilities
(Wallander et al., 1988; Wallander et al., 1989; Wallander, Feldman & Vami, 1989;
Wallander, Varni, Babani, Banis & Wilcox, 1989). As a result of studies focused on
single disabilities or diseases, the adjustment model has rarely been evaluated across
multiple disabilities. The present study focused on disability as a risk factor to support
the application of the model across disabilities. Inclusion of multiple disabilities in the
present study will allow results to contribute to a comprehensive theoretical
understanding of the process of adjustment to disability. The resistance factor assessed in
the current research was self-esteem. Self-esteem has been found to play a significant role
in the process of adjustment to disability (Barnwell & Kavanagh, 1997; Li & Moore,
1998). As of yet, however, research has failed to determine the nature of the role that
self-esteem plays in the adjustment process. Consequently, the present research included
self-esteem in order to evaluate the resistance factor on a smaller scale.
Due to the increasing prevalence of disability related health concerns, recent
literature has continued to focus on identifying variables that play a role in adjustment
outcomes. Several studies have suggested significant relationships between adjustment
variables and body image (Fauerbach, Heinberg, Lawrence, Munster, Palombo, Richter,
Spence, Stevens, Ware & Muehlberger 2000; Breakey, 1997), physical activity
(Miilunpalo, 2001; Sands & Wettenhall, 2000) and time since disability onset (Elliott,
Witty, Herrick & Hoffman, 1991; Livneh & Martz, 2003).
While body image and physical activity have been positively correlated with high
levels of psychological adjustment to disability, research on time since disability offers
contrasting views of the role of time in the adjustment to disability process. Many of
these variables that have been correlated with psychological well-being in a sample of
persons with a disability have not been fully integrated into a model that offers insight
into the process of adjustment. In order to fully understand the process of adjustment, the
predictive potential of these variables must be investigated in a way that acknowledges
the influence of already established variables (e.g., disability and self-esteem). As with a
majority of the research on disability adjustment, psychological adjustment is
operationalized as depression and anxiety.
In order to design effective treatment and prevention strategies targeted at reducing
the prevalence of mental health illness among persons with a disability, important
variables that impact the adjustment process must be identified and comprehensively
understood. The overarching aim of this research is to produce information that will
further understanding of the process of psychological adjustment to mobility impairment,
ultimately leading to interventions with increased levels of efficacy. The present research
will build on the model of psychosocial adjustment to disability proposed by Wallander
and Varni (Wallander et al., 1988; Wallander et al., 1989; Wallander, Feldman & Varni,
1989; Wallander, Varni, Babani, Banis & Wilcox, 1989). Variables such as body image,
physical activity and time since disability that have demonstrated significant relationships
with psychological adjustment to disability have not yet been examined in the context of
this theoretical model. The primary goal of this research is to evaluate the inclusion of
these new variables into Wallander and Varni's theoretical model of adjustment. The
relationship between each established predictor variable (disability and self-esteem) and
psychological adjustment outcome measures (depression and anxiety) will be assessed.
Similarly, the relationship between each newly identified variable (body image, physical
activity and time since disability) and psychological adjustment outcome measures
(depression and anxiety) will be assessed. Finally, a regression model including all of the
variables will be utilized to assess the interaction of these variables in the process of
predicting psychological adjustment to disability.
Specifically, the research questions that were addressed by the study were:
(1) What is the relationship between self-esteem and psychological adjustment (i.e.,
depression and anxiety)?
(2) What is the relationship between disability type and psychological adjustment
(i.e., depression and anxiety)?
(3) What is the relationship between body image and psychological adjustment (i.e.,
depression and anxiety)?
(4) What is the relationship between physical activity level and psychological
adjustment (i.e., depression and anxiety)?
(5) What is the relationship between time since disability onset and psychological
adjustment (i.e., depression and anxiety)?
(6) Which predictor variable explains the most variance in psychological adjustment
(i.e., depression and anxiety)?
CHAPTER 2
REVIEW OF THE LITERATURE
Introduction
The number of persons with a disability is a rapidly growing figure, as is evidenced
by recent census data indicating that 19.3% of the American population has a disability
(Waldrop & Stern, 2003). Each disability brings a set of unique, immediate impacts to the
individual; moreover, having a disability puts a person at a greater risk for developing a
comorbid mental illness (Turner & Beiser, 1990; Wallander, Varni, Babani, Banis &
Wilcox, 1988). The cyclical relationship between disability and mental illness is wrought
with problems that range from economic hardships (Manning & Wells, 1992) to
decreased treatment effectiveness (losifescu, Nierenberg, Alpert, Smith et al., 2005).
Despite growing research interests in the relationship between physical and mental
health, there remains a lack of research focused on the 49.7 million Americans currently
living with a disability. Indeed, the impact of cutting-edge, health-promoting
interventions for persons with a disability is largely unknown due to the dearth of
research on this vulnerable population (Rimmer, Braddock & Pitetti, 1996). This
discrepancy leads to a lack of effective preventative measures and treatments, which
ultimately contributes to the lifetime of mental illness and reciprocal physical ailments
that many people with a disability face. The present study will address the lack of
information and understanding in the literature on the process of psychological
adjustment to disability by studying variables that contribute to the process of adjustment.
Early investigations into issues relating to persons with a disability focused on
psychological and social aspects of living with a disability. In an innovative study post
World War II, Dembo, Leviton and Wright (1956) interviewed 177 persons with a
disability or injury that impacted mobility. The study assessed acceptance of loss for both
the person with a disability and persons close to the person with a disability. Similarly,
Wright (1960) used qualitative research to identify broad psychological issues relevant to
persons with disabilities such as frustration, social skills, self-concept and acceptance of
physique. These seminal studies serve as the foundation of more recent research that
attempts to integrate these psychological and social themes into a comprehensive model.
Theoretical Models of Psychosocial Adjustment to Physical Disability
Literature has established that individuals with a disability experience varying
degrees of adjustment outcomes. Due to the severity of the impacts of negative
adjustment, it is paramount that mental health professionals understand the process of
psychological adjustment to disability in order to create appropriate interventions. As
such, several models have been proposed in the literature to facilitate understanding of
the process of adjustment to disability. However, theoretical models that have been
proposed thus far vary widely in their approach to adjustment (Livneh & Antonak, 1997).
One concept that has served as a foundation for many proposed models of
psychological adjustment to disability is based on the research of Lazarus (1993).
Lazarus reports that the concept of coping has been widely used in research on
adjustment, adaptation and well-being. The coping process presented by Lazarus involves
cognitive appraisal of the stress-causing situation and available resources that can assist
in the resolution of the stress. Indeed, the application of coping theory has widely
influenced models of disability adjustment presented in the literature. Early models
present disability adjustment as a series of linear stages (Fortier & Wanlass, 1984) similar
to the coping process (Lazarus & Folkman, 1984). In these models, the adjustment
process is marked by a series of psychosocial changes that are assumed to occur in
sequence. Stage models offer a simplified approach to understanding the nature of the
process of adjustment to disability, however, these models have been widely criticized in
the literature due to concerns regarding practical utility.
Charmaz (1995) presented a critique of linear adjustment models based on
qualitative data that suggested each person experiences a unique process of
transformation of the self in response to disability. This process of transformation
includes the core concepts of the generally accepted stages of adaptation, however,
Charmaz suggests that as opposed to occurring linearly, these stages "ebb and flow" (p.
658) as the individual works to reunify body and self following disability onset. This
sociological viewpoint highlights the complexity of the process of adjustment to
disability that is not captured in stage models. In order to understand the adjustment
process more thoroughly and to create effective interventions aimed at reducing poor
adjustment outcomes, researchers must establish a model of adjustment to disability that
offers more insight into the process.
Empirical support for similar arguments against a linear model of adjustment to
disability has emerged more prevalently in recent literature. Livneh and Antonak (1990)
conducted a study to investigate the non-linear structure of the process of adaptation to
disability. Based on the data collected in this study, Livneh and Antonak (1991)
suggested that the process of adapting to disability is multidimensional and non-linear.
Findings in this study produced clusters of participants demonstrating varying degrees of
adaptation across multiple dimensions. Recently, these researchers have presented further
empirical data that supports a multidimensional model of adaptation that proposes
adaptation patterns, or degrees of adaptation rather than traditional phases of adaptation
(Livneh, Lott & Antonak, 2004).
Similarly, Kendall and Buys (1998) acknowledged the presence of specific stages
of adjustment, yet argued that stage models were unable to address the recurrent nature of
the adjustment process. Thus, they presented a model of psychosocial adjustment that
incorporates concepts of schemas from cognitive theories of psychosocial well-being in
order to advocate that individuals faced with adjustment to disability often cycle through
different stages, or schemas, of adjustment and identity. Recurrent or degree-based
models of adjustment offer a more complex view of adjustment that have the potential to
account for individual differences in adjustment process. Neither linear nor recurrent
models, however, are able to explain the influence of different identified variables in
psychosocial adjustment. That is, none of these models account for the interaction of
human variables within the adjustment process a fact that has led to the development of
multivariate models.
Varni and Wallander (Wallander et al., 1988; Wallander et al., 1989; Wallander,
Feldman & Varni, 1989; Wallander, Thompson, & Alriksson-Schmidt, 1995; Wallander,
Varni, Babani, Banis & Wilcox, 1989) proposed a conceptual multivariate model for
psychological adjustment to disability based on research with chronically ill and disabled
children and their parents. The model was initially developed in an effort to explain the
differential adaptation to chronic illness and disability by children with different diseases,
such as chronic obesity, spina bifida and cerebral palsy. Early findings suggested that the
psychological adjustment to chronic illness varied widely across children with chronic
physical disorders (Wallander et al.). In this model, earlier research was used to generate
a set of adjustment risk factors which were then contrasted with hypothesized
intrapersonal factors to create predictive potential for psychosocial adjustment. Wallander
and Varni ultimately validated the model with a wide variety of disabled participants and
presented the model as applicable to all persons with disabilities (Wallander et al.).
The model of differential psychosocial adjustment proposed by Wallander and
Varni is a complex system of interrelated constructs. Primarily, there are two sets of
factors that interact to predict levels of adaptation or adjustment. The three risk factor
categories were outlined by Wallander, Varni, Babani, Banis and Wilcox (1989):
disease/disability parameters (e.g., diagnosis, handicap severity, medical problems,
bowel/bladder control, visibility of disability, cognitive functioning, brain involvement),
functional independence (i.e., how capable a person is in meeting daily living demands)
and psychosocial stressors (e.g., disability related problems, major life events, daily
hassles, social isolation). Wallander, Varni, Babani, Banis and Wilcox also presented the
following three resistance factor categories: intrapersonal factors (e.g., temperament,
competence, effectance motivation, problem solving ability), social-ecological factors
(e.g., family environment, social support, family members' adaptation, utilitarian
resources) and stress processing (i.e., cognitive appraisal, coping strategies). The model
presented in Figure 2-1 details how the identified risk and resistance factors interact to
predict psychosocial adjustment (i.e., mental health, social functioning, physical health).
Predictors of Psychosocial Adjustment to Disability
Findings in the literature support the multivariate components of the model
presented by Wallander and Vami. Due to the expanse and complexity of the model
proposed by Wallander and Varni, the model has been broken down at times and
investigated separately by individual variables (Wallander et al., 1989). Similarly, the
present study investigated newly proposed components independently. The predictor
variables selected for inclusion in this project were consistent with the theory and are
presented below.
RISK FACTORS
i I
Disease/Disability
Srsrea Psychosocial Stressors l m
: - - - -
RESISTANCE FACTORS
Intrapersonal Factors Social-Ecological Factors
Stress Processing
ADAPTATION 1111---
"Family resources as resistance factors for psychological maladjustment in
chronically ill and handicapped children," by J. L. Wallander, J. W. Varni, L.
Babani, H. T. Banis and K. T. Wilcox, 1989, Journal ofPediatric Psychology,
14(2), p.171. Copyright 1989 by Plenum Publishing Company.
Self-Esteem as a Predictor of Psychological Adjustment to Disability
Studies with a variety of participants with a disability have found that self-esteem
plays an important role in the process of adjustment to disability (Barnwell & Kavanagh,
1997; Li & Moore, 1998). Primarily, these findings indicate that self-esteem has a
significant relationship with mental health outcomes for specified populations. While
these findings support the inclusion of self-esteem as an intrapersonal resistance factor in
the model of adjustment proposed by Wallander and Vami, they lack the descriptive
ability to determine the role self-esteem plays in the adjustment process.
Recent research attempting to validate Wallander and Varni's model of disability
adjustment has produced discrepant data with regard to the role of self-esteem within the
overall model. Specifically, in a study conducted by Jarama and Belgrave (2002) with a
sample of African-Americans with disabilities, self-esteem was the only resistance factor
examined that failed to significantly predict mental health adjustment (i.e., depression
and anxiety) to disability. In fact, in the final regression model, self-esteem accounted for
.05 of the model variance for depression and -.11 of the model variance for anxiety, while
social support significantly accounted for -.17 and -.31, respectively. These findings
suggest that despite predictions based on previous findings in the literature regarding the
role of self-esteem on adjustment to disability, the predictive potential of self-esteem
within the framework of Wallander and Varni's multivariate model is not clear. Thus, the
present study further investigated the nature of this variable within the overall adjustment
model.
Body Image as a Predictor of Psychological Adjustment to Disability
Thompson, Heinberg, Altabe and Tantleff-Dunn extend a definition of body image
describing it as the internal representation of your outer appearance (as cited in
Hausenblas & Symons Downs, 2001). Through the act of defining body image, the innate
relationship between body image and self-esteem becomes evident. This relationship is
further supported in literature that reports positive relationships between self-esteem, an
internal representation of self, and body image. Further, body image is a natural
consideration for persons with disabilities, as outer appearances are often confounded by
the presence of disability.
Previous findings in the literature suggest the presence of a positive relationship
between body image and self-esteem. Keppel and Crowe (2000) reported data that
described the relationship between self-esteem and body image as inter-related. Indeed,
findings from their research on 40 young adult stroke patients produced evidence that
body image predicted physical and global self-esteem. Similarly, Breakey (1997)
reported data on 90 lower-limb amputees that indicated a significant, positive relationship
between self-esteem and body image. These findings indicate that body image may serve
a role similar to that of self-esteem in the process of adjustment to disability.
In addition to a positive relationship between self-esteem and body image, Breakey
(1997) also found a significant, positive relationship between body image and generalized
contentment. These findings suggest that in addition to positively correlating with self-
esteem, body image has a distinct relationship with psychosocial well-being. This finding
was again echoed by Fauerbach et al. (2000) in a study examining body image
dissatisfaction after disfiguring injury. In a sample of 86 patients recovering from severe
burn injury, Fauerbach et al. found body image dissatisfaction to be significantly related
to lower psychosocial adjustment. Clearly, evidence is mounting that body image has a
direct effect on psychosocial adjustment to disability. As such, for the present research,
body image will be explored and investigated as an independent predictor of
psychological adjustment in persons with a disability.
Physical Activity as a Predictor of Psychological Adjustment to Disability
Physical activity is believed to improve physical health and psychological well-
being (Miilunpalo, 2001). Indeed, data collected on disabled populations suggests that
persons with low levels of physical activity experience corresponding low levels of
physical health. Rimmer, Rubin and Braddock (1999) surveyed a sample of 50 African-
American women with physical disabilities. They found that extremely low levels of
physical activity exposed participants to higher risks of secondary health conditions.
Further, they reported findings of an overall low level of physical activity within the
sample. Studies such as this one suggest that physical activity plays a direct role in
overall health and well-being.
Extensive data suggests that persons with a disability have overall lower levels of
physical and mental health than their able-bodied counterparts. The psychosocial model
of adjustment to disability offered by Wallander and Varni explain this difference based
on the risk and resistance factors they have identified, however, research comparing
wheelchair athletes to their able-bodied counterparts offers an additional insight into the
established differences. Sands and Wettenhall (2000) conducted a study on female
wheelchair athletes in order to establish whether wheelchair athletes were more or less
satisfied with their body image than able-bodied athletes. The results revealed no
significant differences in the samples, suggesting that participation in physical activity
contributed to enhanced body image. The authors found support in earlier findings by
Brewer, Van Raalte and Linder (as cited in Sands & Wettenhall) for athletic participation
boosting the comfort level wheelchair athletes felt towards themselves. This theorization
is further supported by a meta-analytic review conducted by Hausenblas and Symons
Downs (2001) that reviewed the data from 78 studies and revealed a significant effect
indicating that able-bodied athletes have a more positive body image than able-bodied
persons who were non-athletes.
The relationship between physical and mental health has become a popular area of
research as Americans become more aware of the harmful implications of sedentary
behaviors. Despite the growing body of literature dedicated to physical activity and
fitness, there remains a void of research on physical activity in persons with disabilities.
Indeed, the scarcity of population specific research presently available leaves researchers
unable to make accurate conclusions regarding physical activity and disability (Rimmer
et al., 1996). Taylor, Baranowski, and Young (1998) found only four studies about
physical activity interventions that had been conducted on disabled populations within a
period of 14 years. Based on these findings, Taylor et al. propose several
recommendations for research priorities with disabled populations. One such
recommendation is to conduct theory-based research. Accordingly, in the present
research the impact of physical activity on psychological adjustment to disability will be
investigated within the context of the psychosocial model of adjustment to disability
proposed by Wallander and Varni.
Time Since Disability Onset as a Predictor of Psychological Adjustment to Disability
The historical development of models of adjustment to disability began with a
time-sensitive understanding of the process of adjustment. Linear models inherently
assumed that time played a role in the process of adjustment, as the progression to
advanced stages of acceptance was dependent upon the passage of time. Investigations of
the relationship between time since disability onset and psychological adjustment to
disability have yielded diverging results. While some research sets forth the notion that
the passage of time is related to higher levels of psychological adjustment (e.g., self-
efficacy, depression, anxiety), contrasting evidence can be found indicating that time
since disability onset and psychological adjustment have a non-significant relationship.
This dichotomy in the literature is fueled by findings that indirectly implicate a
relationship between psychological adjustment and time since disability onset, yet fail to
produce significant results. Elliott, Witty, Herrick and Hoffman (1991) conducted a study
on 57 persons with acquired severe physical disabilities. Despite expectations of a
moderating effect of time since onset of disability, the results indicated no significant
effect of time on psychological adjustment. However, the results did suggest that the
passage of time was related to how participants of varying degrees of hope experienced
psychological impairment.
Empirical research investigating a direct relationship between time since disability
onset and psychosocial adjustment has yielded insufficient findings. A recent study by
Attawong and Kovindha (2005) found no significant direct relationship between time
since injury and adjustment factors in a sample of 61 spinal cord injury patients. Further,
empirical data investigating the relationship between time since disability onset and body
image failed to produce significant results (Breakey, 1997). While extensive amounts of
literature address this variable, few studies offer insight into the role of time since
disability onset on the process of adjustment to disability.
In an exploratory study aimed to resolve such inconsistencies in the literature,
Livneh and Martz (2003) argued that empirical studies are unable to pinpoint a
relationship between time since disability onset and psychosocial adjustment because no
"pure" phases of adjustment exist. Instead, they offer an alternative explanation to the
thriving conflict in the literature on the role of time since disability onset. In their study
of 317 spinal cord injury patients, different patterns of adaptation emerged in patients
with short-term injuries (within the past four years) versus those with long-term injuries
(20 years ago or longer). This research suggested that while time may not play a direct
role in determining psychosocial adjustment to disability, patterns of adaptation vary over
time. As such, the present study sought to investigate the effectiveness of time since
disability onset as a predictor variable in the psychosocial model of adjustment by
Wallander and Varni.
Conclusion
Research aimed at improving the current mental health situation for Americans
with a disability must address the unique physical, psychological and social stressors
prominent for this population. The application of a multivariate model of understanding
the process of adjustment to disability creates an opportunity for researchers to identify
relevant influences on the adjustment process. In turn, identified variables can serve as
the foundation for prevention and treatment programs aimed at reducing the prevalence
of mental illness in persons with a disability.
Therefore, the major problem addressed in the present study was the investigation
of variables identified in the literature as predictors of psychological adjustment to
disability. As detailed previously, the research was conducted within the framework of a
multivariate model of psychosocial adjustment to disability in order to establish a clear
understanding of the influence of each variable.
CHAPTER 3
METHODOLOGY
In the preceding chapters, the importance and implications of the process of
psychosocial adjustment to disability were discussed. In addition, the research problems
were introduced and the pertinent literature related to these problems was reviewed. In
the first section of this chapter, the research hypotheses are presented. A presentation of
the research design, description of the population sample, review of the instrument
battery and an overview of the data analyses conducted in the present study follow the
first section.
Research Questions and Hypotheses
The fundamental goal of this study is to investigate possible predictors of
psychological adjustment to disability. This goal is operationalized within the context of
the multivariate model of psychosocial adjustment to disability outlined in the research of
Wallander and Varni (Wallander et al., 1988; Wallander et al., 1989; Wallander, Feldman
& Vami, 1989; Wallander, Vami, Babani, Banis & Wilcox, 1989). Wallander and Vami
identify two sets of variables risk and resistance factors. They propose that the
relationship between risk factors and psychosocial adjustment is moderated by the
resistance factors. Despite support in the literature for the multivariate model of
adjustment proposed by Wallander and Vami, current literature has suggested that the
relationship between disability and psychosocial adjustment is influenced by additional
variables that have not been formally included in the adjustment model. The present
research aimed to explore the inclusion of three additional variables in the adjustment
model proposed by Wallander and Varni body image, activity level, and time since
disability onset.
The primary research question addressed in the present research is: "What is the
relationship between risk factors, resistance factors and psychological adjustment?"
Which intrapersonal resistance factors explain the most variance in psychological
adjustment to disability?"
The hypotheses tested in the present study are set forth below:
(1) Self-esteem and disability type will account for significant variance in each
of the measures of psychological adjustment (i.e., depression and anxiety).
(2) Body image and physical activity will account for additional variance in the
predictive model of the measures of psychological adjustment (i.e.,
depression and anxiety).
(3) Time since disability onset will be non-significantly correlated with
measures of psychological adjustment (i.e., depression and anxiety).
(4) Self-esteem and body image will have the greatest beta weights, followed
by disability type, physical activity and time since disability onset.
Procedures
Participants were invited to participate in the study through an invitation that was
electronically mailed to several national electronic mail listservs that cater to disabled
populations and topics related to disability issues (e.g., DISAB-CON The DisAbility
Concerns Network, NDSU The National Disabled Students Union listserv, Disabled
Student Services in Higher Education, Disability Studies in the Humanities listserv).
Many members of these listservs forwarded the invitation to other listservs and national
discussion boards related to various disability topics, which resulted in a snowballed
participant pool. The invitation letter that was electronically mailed to potential
participants was based on a letter that had received prior approval from the Institutional
Review Board (See Appendix A). The invitation letter briefly described the purpose of
the study as being to learn more about the relationship between body image and
disability. Additionally, the invitation letter informed potential participants of the
confidentiality and anonymity ensured by the present study, and explained that
participation was voluntary and could be discontinued at any time. Finally, the letter
informed potential participants that the instrument battery was expected to take 20-30
minutes to complete.
If invited participants chose to participate in the present study, the invitation letter
instructed them to follow a hyperlink to an online survey. The first webpage that was
displayed to participants upon following the hyperlink was a welcome screen that briefly
described the process of informed consent. Once a participant clicked "continue" he/she
was routed to the second webpage, which contained the informed consent (See Appendix
B). The informed consent explained that there was no financial incentive for
participation, in addition to restating details about participation presented in the
invitation. Volunteer participants had to complete an electronic informed consent form
prior to responding to any of the survey items. Upon agreement to the informed consent,
the instrument battery was displayed to the participant and responses could be selected
electronically. Once a participant submitted electronic responses to the instrument
battery, participation was complete.
The entire instrument battery was administered online. Previous studies have
validated the use of psychological survey instruments in an internet format (Buchanan &
Smith, 1999; Krantz, Ballard & Scher, 1997). Furthermore, the population addressed in
this study fit two of the main criteria identified in the literature (Eysenbach & Wyatt,
2002; Wyatt, 2000) as populations who meet guidelines for online study: need for
respondents covering a wide geography due to disease/condition, respondents are avid
internet users.
The identity of volunteer participants was protected in two ways: (1) no identifying
information was requested from participants in the survey or consent process, and (2) the
IP address of the computer used to participate in the study was encrypted using a one-
way "hash" function that makes it impossible to determine the actual IP address of the
participant's computer.
Participants
A convenience sampling procedure was utilized to recruit 234 participants.
Participants were invited to participate in the study electronically via email, and informed
of the confidential nature of the data collection. All information provided by participants
was done so voluntarily, and all participants were treated in accordance with the "Ethical
Principles of Psychologists and Code of Conduct" (American Psychological Association,
1992).
Participants from the initial participant pool who met the inclusion criteria and who
completed the instrument battery entirely (regardless of whether particular questions were
skipped along the way) were selected for analysis in the present study. The inclusion
criteria were: (1) over 18 years of age; (2) diagnosed with a disability that requires the
use of either a manual wheelchair, electric wheelchair or both (as judged by the
participants); and (3) ability to respond to the instrument battery electronically. The final
participant pool consisted of 113 women and 106 men (15 participants failed to report
gender information, N= 234).
This sample size meets standard estimates of participants required to have
sufficient statistical power. Tabachnick and Fidell (2001) suggest calculating required
number of participants using this formula: 10 IV. This would require a minimum of 50
participants. Similarly, Stevens' (1996) formula is: 15 IV, which would require a
minimum of 75 participants. The present sample of 234 participants exceeds acceptable
sample size criteria for the analyses conducted, thus, results are assumed to be of
adequate effect size.
Measures
The following six instruments were utilized to measure independent and dependent
variables. The scales are presented here in the order in which they appeared on the
electronic instrument battery.
Body-Cathexis Scale
The Body-Cathexis scale was used to assess body image. Specifically, the scale
measures the degree of satisfaction or dissatisfaction with various parts of the body
(Secord & Jourard, 1953). Participants were asked to rate 46 items characteristic of
themselves (e.g., "hands", "appetite", "nose") on a five-point Likert scale that ranges in
polar responses from "have strong feelings and wish change could somehow be made" to
"consider myself fortunate". Secord and Jourard reported split half reliability coefficients
for men and women separately (men obtained a coefficient of .78 while women obtained
a coefficient of .83).
This scale was selected because it has been widely used with disabled populations.
Marcusson, List, Paulin, and Akerlind (2001) modified and used the body-cathexis scale
in treated cleft lip and palate patients. The modified scale contained 24 body regions
which were rated on a five-point Likert scale. The reliability of this modified instrument
ranged by question from 0.29 to 0.65, and the summary score of all regions assessed
produced a reliability coefficient of 0.41. The original scale, which was used in the
present study, has several reports of satisfactory reliability scores. Tucker (1981) reported
test-retest reliability as .87. Similarly, test-restest reliability has been reported as .90 by
Theodorakis, Doganis and Bagiatis (1991). Alpha coefficients have also been consistently
reported high; Riordan, Koff and Stubbs (1987) reported cronbach's alpha as .87 with a
sample of 585 girls. See Appendix C.
Depression
The Center for Epidemiological Studies Depression Scale (CES-D: Radloff, 1977)
was used to assess level of depression. The present research utilized the original scale
with 20 items that are used to assess depressive symptomatology. The instrument requires
respondents to select how often they have experienced certain feelings or behaviors over
the past week (e.g., "I talked less than usual", "I did not feel like eating: my appetite was
poor", "I felt sad"). Participants are asked to rate each item on a four-point scale that
ranges from "rarely or none of the time (less than 1 day)" to "most or all of the time (5-7
days". Radloff reported high scores for internal consistency, .85 for the general
population and .90 for the patient sample. See Appendix D.
Anxiety
The State-Trait Anxiety Inventory (STAI; Spielberger, Gorsuch, & Lushene,
1970) was used to assess anxiety. The STAI has two scales, the state anxiety scale ("S"
scale) and the trait anxiety scale ("T" scale). This research utilized the "T" scale, in order
to appropriately assess for the type of anxiety more commonly associated with mental
health diagnoses. The "T" scale contains 20 items (e.g., "I feel like a failure", "I have
disturbing thoughts", "I feel inadequate") rated on a 4-point Likert scale that ranges from
"almost never" to "almost always". Alpha coefficients have been consistently high (a =
.90; Spielberger, Gorsuch, Lushene, Vagg & Jacobs, 1983). See Appendix E.
Self-Esteem
The Rosenberg (1965) self-esteem scale (RSES) was selected to measure global
self-esteem. This measure has 10 items (e.g., "I feel that I have a number of good
qualities", "I feel that I am a person of worth, at least on an equal plane with others") that
ask participants to rate themselves on a four-point Likert scale ranging from "strongly
disagree" to "strongly agree". This scale has firmly established construct validity, and the
internal reliability has been high in samples of ethnic minorities with disabilities
(Belgrave & Walker, 1991). See Appendix F.
Physical Activity
The International Physical Activity Questionnaire (IPAQ: Craig, Marshall,
Sjostrom, Bauman, Booth, Ainsworth, Pratt, Ekelund, Yngve, Sallis & Oja 2003) was
used to assess level of physical activity. This research utilized the short form of the
instrument with a "last seven days" reference period, as recommended by the original
authors based on a sample of over 1,000 participants from 12 different countries. The
short form consists of seven items that ask participants to self-report information
regarding quantities of time spent on physical activity (e.g., "During the last 7 days, on
how many days did you do vigorous physical activities like heavy lifting, digging,
aerobics, or quickly pushing your wheelchair?").
Scores were reported as continuous measures of METS (multiples of resting
metabolic rate). Participants were then classified into one of three categories defined by
the authors of the IPAQ based on current public health guidelines for physical activity.
Category one is "inactive" and requires a MET score of 480 or below, category two is
"minimally active" and includes a range of MET scores from 481-1500, and category
three is "HEPA (health enhancing physical activity) active" and includes MET scores of
1501 and above. Reliability scores for the IPAQ (all forms) range from 0.65 0.88. The
self-administered short form with a seven-day reference period reports a reliability
coefficient of 0.75. See Appendix G.
Demographic Data Questionnaire (DDQ)
This questionnaire was used to obtain demographic and background information
about gender, ethnicity, age, age of disability onset, employment status, regular physical
activities, nature of disability and type of wheelchair used. The demographic questions
were placed last on the online instrument battery in an effort to mitigate the influence of
these questions on participant responses to other study questionnaires. See Appendix H.
Data Analyses
In order to test the stated hypotheses in the present study, two separate multiple
regression analyses were conducted on the data one for each dependent variable. In
both of the multiple regressions, the predictor variables were disability, self-esteem, body
image, physical activity, and age of onset while the criterion variable was either
depression or anxiety. In each regression, the first block consisted of gender, ethnicity
and age. These demographic variables were entered in the first block in order to control
for their effects on the dependent variables as it was important to investigate the
contribution of the variables of interest after the demographic variables were considered.
Therefore, the second block of both regressions included the various types of disabilities
self-reported by the participants. Finally, the remaining independent variables were
entered as the third block: self-esteem, body image, physical activity and time since
disability onset.
CHAPTER 4
RESULTS
This chapter presents the results of the statistical analyses described in the
methodology.
Descriptive Statistics
The distribution of body image, depression, anxiety and self-esteem was essentially
normal and unmarked by extreme scores skewnesss = -.78 +.64; kurtosis = .04 1.7).
However, initial descriptive statistics indicated a high level of skewness and kurtosis for
physical activity skewnesss = 7.10; kurtosis = 69.35). As such, the data was further
evaluated for outliers. Division of physical activity scores into 20 percentiles yielded
extreme scores (scores in the 95th percentile) beginning at 16933.50. The physical activity
scores were then recorded to include only scores that fell below 17000, which eliminated
8 scores. The final distribution of physical activity scores had a skewness statistic of 1.3
and a kurtosis statistic of .98. Table 4-1 presents the mean scores, standard deviations,
and ranges for the dependent variables (i.e., depression, anxiety) and independent
variables (i.e., physical activity, body image, self-esteem).
Table 4-1. Means, Standard Deviations and Ranges of All Measures
Variables M SD Range
Body Image 3.26 .66 .43 4.98
Depression 19.08 11.78 2.0 56.0
Anxiety 38.67 11.78 20.0 78.0
Self-Esteem 31.29 6.70 10.0 40.0
Physical Activity 3472.07 4441.67 0-16500.00
Age 38.07 11.57 18-71
Table 4-2 presents additional demographic information about the participants.
Table 4-2. Participant Characteristics
Variable N % of sample
Ethnicity
African-American/Black-American 5 2.1
Asian-American 4 1.7
Caucasian/White/European- 190 81.2
American
Hispanic/Latino(a) 12 5.1
Other 8 3.4
Unknown 15 6.4
Disability
Physical 159 67.9
Neuromuscular 41 17.5
Respiratory 2 0.9
Metabolic 2 0.9
Mental 1 0.4
Aging-Related 3 1.3
Other 2 0.9
Multiple Types of Disability 6 2.6
Unknown 18 7.7
Employment
Full Time 65 27.8
Part Time 37 15.8
Student 38 16.2
Does Not Work 76 32.5
Unknown 18 7.7
Age
0-20 11 4.7
21-40 118 50.4
41-60 83 35.5
61+ 3 1.3
Unknown 19 8.1
Physical Activity Level
Inactive 65 27.8
Minimally Active 14 6
HEPA Active 83 35.5
Unknown 72 30.8
Note: N = 234
Scores on the dependent measures of psychological adjustment (i.e., depression and
anxiety) suggest that the majority of the participants experience moderate levels of both
depression and anxiety. An independent samples t-test was conducted to contrast the
depression and anxiety scores of male participants against female participants. The effect
of gender was statistically significant at an alpha level ofp < .05 for depression, t(217) =
-2.35, p = .02 and for anxiety, t(217) = -2.05, p = .04. This data suggests that the
differences in depression and anxiety scores between male and female participants are
statistically different.
A one-way analysis of variance (ANOVA) was conducted to assess differences in
adjustment measures among ethnicity groups using an alpha level ofp < .05. Results of
this analysis indicated that there were no significant between group differences in
depression scores based on ethnicity, F [5,225] = 1.23, p = .29 nor were there significant
between group differences in anxiety scores based on ethnicity, F [5,225] = .81, p = .54.
This data suggests that there are no significant differences among the different ethnicity
groups for the two psychological adjustment measures (i.e., depression and anxiety).
A similar one-way analysis of variance (ANOVA) was conducted to assess
differences in adjustment measures based on participant age using an alpha level ofp <
.05. Results of this analysis indicated that there were no significant between group
differences in depression scores based on age, F [44,214] = .83, p = .77 nor were there
significant between group differences in anxiety scores based on ethnicity, F [44,214] =
.95, p = .57. This data suggests that there are no significant differences among the
participants based on age for the two psychological adjustment measures (i.e., depression
and anxiety).
Pearson product-moment correlation coefficients were computed to evaluate the
relationship between each risk and resistance factor variable (i.e., disability, self-esteem,
body image, physical activity and time since disability onset) and psychological
adjustment (i.e., depression and anxiety). The results of these analyses are presented in
table 4-3.
Table 4-3. Correlation Between Variables
1 2 3 4 5
Depression .12 -.77** -.56** -.20** -.01
Anxiety .07 -.88** -.60** -.23** .01
1. Disability Type -.09 -.22** -.08 .12
2. Self-Esteem -.56** .22** .00
3. Body Image .24** -.09
4. Physical Activity -.07
5. Time Since Disability Onset
Note: **p<.01
Depression and anxiety were both negatively and significantly correlated with self-
esteem, body image, and physical activity. These trends were echoed in the significant
relationships between self-esteem, body image and physical activity.
Hypotheses Testing
The hypotheses were tested using hierarchical regression analyses to examine the
impact of the variables on the psychological adjustment outcome variables (depression
and anxiety). The first model examined the impact of disability, self-esteem, body image,
physical activity and time since disability onset on depression. The variance accounted
for in this model was significant (r2 = .663, F[16,156] = 17.21, p = .00). The standardized
beta values for each variable are presented in table 4-4. The collinearity diagnostics
indicate that there is no significant collinearity problem. The condition indices are all
below or proximate to 15. The tolerance statistic is very close to 1, and the VIF statistic
is close to 0. The Durbin-Watson statistic is 1.96. Overall, the model does not seem
highly effected by collinearity.
Table 4-4. Multiple Regression Analyses Results for Depression
P F P
Depression
Step 1 3.162** .006
Gender .095 .076
Age .000 .996
Ethnicity
African-American/Black-American -.102 .179
Caucasian/White/European-American -.194 .096
Hispanic/Latino(a) -.036 .702
Other -.088
Step 2 2.869** .001
Disability
Physical -.399** .046
Neuromuscular -.349** .05
Respiratory -.015 .828
Aging-Related -.131 .065
Other -.203** .006
Multiple Types of Disability -.054 .591
Step 3 17.211** .000
Self-Esteem -.624** .000
Body Image -.168** .008
Physical Activity .012 .854
Time Since Disability Onset -.034 .535
Note: Standardized beta from final model (Step 3). **p < .05
The second model examined the impact of disability, self-esteem, body image,
physical activity and time since disability onset on anxiety. The variance accounted for in
this model was significant (r2 = .815, F[16,149] = 36.61, p = .00). The standardized beta
values for each variable are presented in table 4-5. The collinearity diagnostics indicate
that there is no significant collinearity problem. The condition indices are all below or
proximate to 15. The tolerance statistic is very close to 1, and the VIF statistic is close to
0. The Durbin-Watson statistic is 2.15. Overall, the model does not seem highly effected
by collinearity.
Table 4-5. Multiple Regression Analyses Results for Anxiety
P F P
Anxiety
Step 1 1.724** .119
Gender .034 .413
Age -.090** .039
Ethnicity
African-American/Black-American -.058 .190
Caucasian/White/European-American -.159 .067
Hispanic/Latino(a) -.104 .146
Other -.098 .119
Step 2 1.861** .044
Disability
Physical .096 .522
Neuromuscular .095 .472
Respiratory .098 .077
Aging-Related .091 .093
Other .020 .717
Multiple Types of Disability .132 .090
Step 3 36.608** .000
Self-Esteem -.772** .000
Body Image -.135** .006
Physical Activity -.050 .245
Time Since Disability Onset .021 .615
Note: Standardized beta from final model (Step 3). **p < .05
Recall that the researcher expected to find that self-esteem and disability type each
accounted for a significant portion of the variance in depression and anxiety. While self-
esteem was a significant predictor of both depression and anxiety, disability was only
predictive of depression. Further, body image and physical activity were expected to
further contribute to variance explained in the model. Body image was a significant
predictor of both depression and anxiety, while physical activity was non-significant for
either psychological outcome measure. Finally, time since disability onset was not found
to significantly predict depression or anxiety.
CHAPTER 5
DISCUSSION
The process of psychological adjustment to disability is influenced by numerous
variables. Wallander and Varni (Wallander et al., 1988; Wallander et al., 1989;
Wallander, Feldman & Varni, 1989; Wallander, Varni, Babani, Banis & Wilcox, 1989)
established a multivariate model that attempts to explain the adjustment process
described by Charmaz (1995) as "altering life and self to accommodate to physical losses
and to reunify body and self accordingly" (pg. 657). Their model describes the
adjustment process as the interaction of risk and resistance factors. Risk factors include
physical disease or disability, chronic disability-related strain and psychosocial stress.
Resistance factors are defined as intrapersonal factors, social-ecological factors and
coping ability. While this model has successfully identified and incorporated several
specific variables that predict adjustment, recent literature has identified additional
variables that play a role in the process.
Body image, physical activity and time since disability onset have been
investigated in recent literature and have demonstrated relationships with adjustment
outcomes. Body image has been positively correlated with contentment and psychosocial
adjustment in persons with a disability (Breakey, 1997; Fauerbach et al, 2000). Similarly,
physical activity levels have been positively correlated with overall health (Rimmer,
Rubin & Braddock, 1999). Finally, significant relationships between disability
adjustment and time since disability onset have been proposed in empirical studies of
persons with a disability (Livneh & Martz, 2003). While the relationship between these
variables and psychological adjustment to disability has been independently investigated,
these variables have not been tested in a multivariate model of disability adjustment.
This research evaluated disability, self-esteem, body image, physical activity and
time since disability onset as predictors of psychological adjustment. Psychological
adjustment was operationalized as depression and anxiety. The results of the hierarchical
regression models revealed that the variables explained a significant portion of the
variance in both depression and anxiety. Investigation of the independent variables
(disability, self-esteem, body image, physical activity and time since disability onset) in a
multivariate model can help to further explain the process of adjustment to disability.
Findings
Hypotheses were tested using two separate hierarchical regression models in which
the independent variables (disability, self-esteem, body image, physical activity and time
since disability onset) were regressed on the dependent variable (depression and anxiety).
It was hypothesized that both models would significantly predict psychological
adjustment based on previous findings using multivariate models by Wallander and Varni
(Wallander et al., 1988; Wallander et al., 1989; Wallander, Feldman & Vami, 1989;
Wallander, Vami, Babani, Banis & Wilcox, 1989). Results indicate that both models
significantly explained variance in depression and anxiety, yet the variables had a wide
range of influence on the models.
Gender
Significant differences were identified between males and females on depression
and anxiety scores. Although unexpected, this finding mirrors trends in the literature that
propose gender differences are vast enough to warrant separate consideration in
disability-related research (Nosek & Hughes, 2003). Gender may serve as a predictor of
psychological adjustment to some degree.
Disability
Disability was examined in block two in both models, and was found to account for
significant variance in both depression and anxiety. These results suggest that disability is
a significant predictor of depression and anxiety. For the outcome measure depression,
physical, neuromuscular and "other" disabilities produced significant beta values. For the
outcome measure anxiety, no category of disability produced significant beta values.
These findings are consistent with the data distribution that indicated lower levels of
probable anxiety than probable depression. This suggests that perhaps disability type is
more linked to depression than it is to anxiety.
Self-Esteem
There was a significant effect of self-esteem on both depression and anxiety. These
findings are consistent with literature that indicates a positive relationship between self-
esteem and psychological adjustment to disability (Bamwell & Kavanagh, 1997; Li &
Moore, 1998). In both models self-esteem carried the greatest beta weight; this indicates
that self-esteem accounts for a majority of the variance in depression and anxiety in the
population. It is important to note that self-esteem also had significant correlational
relationships with body image and physical activity. The presence of an interaction effect
between self-esteem and body image was examined and no significant interaction effect
was found. This suggests that although self-esteem and body image both have negative
effects on depression and anxiety (higher levels of self-esteem and body image
correspond to lower levels of depression and anxiety), the combined effect of these
variables does not significantly explain depression or anxiety levels.
Body Image
Body image was found to have a significant effect on both depression and anxiety.
While these findings are consistent with the literature, the variance in depression and
anxiety scores accounted for by body image was remarkably small in comparison to self-
esteem. The body cathexis instrument assesses an individuals' feelings regarding specific
body parts. Because self-esteem is an assessment of an individuals' internal
representation of self, body image may be encapsulated within this definition. The
discrepancy in variance explained between self-esteem and body image may indicate that
body image is a theoretical component of self-esteem, as Keppel and Crowe (2000) seem
to implicate.
Physical Activity
Physical activity was not found to be a significant predictor of depression or self-
esteem. Although this finding was unexpected, physical activity was significantly and
positively correlated with self-esteem and body image. The lack of significant effect of
physical activity on depression or self-esteem combined with the significant correlational
relationship between phsycial activity and self-esteem and body image suggests that
physical activity contributes directly to self-esteem and body image. This finding echoes
earlier findings in the literature that demonstrate physical activity contributes positively
to body image (Hausenblas & Symons Downs, 2001; Sands & Wettenhall, 2000). In the
context of the present study, physical activity may improve the comfort level that
individuals feel toward specific body parts, thus increasing their body image and self-
esteem.
Time Since Disability Onset
Time since disability onset did not yield significant effects on depression or self-
esteem. Similarly, this variable did not have a significant correlation with any other
variable. This finding further supports the divergent results in the literature regarding the
role of time in disability adjustment. The study design did not allow for isolation of this
variable or exploration of possible quadratic or curvilinear relationships. Perhaps, as is
suggested by Livneh and Martz (2003), the relationship between time since disability
onset and psychological adjustment variables is not linear. The lack of significant
relationships between time since disability onset and other predictor variables also
suggests that a linear trend may not be the best explanation of the involvement of this
variable in the adjustment process.
Implications for Counseling
Research investigating the multitude of variables that play a role in the process of
adjustment to disability establishes critical information for practicing professionals.
Knowledge of important variables within the adjustment process allows professionals to
appropriately adapt common therapeutic techniques and address core domains of
psychological adjustment that will facilitate the best outcomes for patients and clients.
Additionally, knowledge of core domains that influence the adjustment process
empowers professionals to further promote positive outcomes by creating unique
treatments and programs that address the unique needs of disabled persons.
Kendall and Terry (1996) emphasize the importance of establishing a model from
which professionals can work. They propose that administrative changes can be made to
standard procedures when professionals are informed about the process of adjustment.
For example, if a professional is treating a client who has depression and is also recently
injured, a self-esteem assessment may identify personal growth areas that can be further
developed through the course of therapy. Indeed, awareness of the process of adjustment
may guide counselors to more effective and change-enacting discussion points.
An equally important outcome of research dealing with variables that contribute to
the adjustment process is unique treatment and prevention programs specifically
developed to address key variables. Prevention programs designed for individuals with a
disability that address self-esteem through stimulation of physical activity might be
successful in decreasing levels of depression and anxiety within that population.
Limitations
Despite the significance of the predictor variables in both regression models, there
are limitations in this study. The convenience sampling method utilized the internet to
identify and recruit participants. This method creates incongruence in socioeconomic
status, as computer owners tend to be at one end of the socioeconomic status distribution.
The predominance in the sample of individuals who fall primarily in the middle and
higher SES range may inherently skew the data on some variables. Also, the data consists
of self-reported items that could permit individuals to misrepresent themselves, or cause
confusion in response. Either possibility would result in flawed data. The sample was not
representative to the population with respect to ethnicity or disability. This discrepancy
prevented further data analyses. Finally, the assessment battery was presented to each
participant in the same order of instrumentation, thus potentially falling susceptible to
ordering effects.
Future Research
Further research should be conducted using different formats (e.g., paper and pen)
in order to include a wider variety of individuals. The use of different formats would also
allow the researcher to randomize the order of assessments in an effort to prevent
ordering effects. Future research should also incorporate more exhaustive self-esteem
measures that entail sub-scales. This would create an opportunity for exploration of the
relationships between self-esteem and body image, as well as self-esteem and physical
activity. Similarly, future research should incorporate multiple body image assessments
in an effort to fully explore the theoretical construct of body image. Finally, it was noted
that there were differences in depression and anxiety based on gender. Future research is
needed to investigate the nature of the differences and whether separate models of
adjustment to disability occur between males and females. This research could also
explore the possibility of a quadratic or curvilinear effect of time since disability onset on
adjustment to disability.
APPENDIX A
INVITATION LETTER TO PARTICIPANTS
Dear
My name is Erica Byrnes and I am a disabled graduate student at the University of
Florida. I am conducting my thesis study on body image and disability, and I would like
to ask for your help. I am seeking participants in the study, and I am also seeking as many
places to distribute this message as possible. If you would be willing to help me in either
respect I would greatly appreciate it!
Participation in the study involves the completion of a survey online that takes
approximately 20-30 minutes. Participation is completely anonymous, and the website
will encrypt your internet address so that your location is not able to be traced. I am
recruiting any person over the age of 18, who has a physical disability that requires the
use of a wheelchair. My goal is to include at least 200 people in my study. I hope that the
findings can be used to inform health interventions designed specifically by and for
people who have a disability.
The survey can be accessed online at:
http://www.counselingsurveys.org/do.php?survey=sl51175
Please feel free to email me with any questions.
Thank you in advance for your time! Your help with this endeavor is truly appreciated!
Sincerely,
Erica Byrnes
APPENDIX B
INFORMED CONSENT
Protocol Title: Body image and disability: A study of the relationship between body
image and psychosocial well-being in a sample of physically disabled persons.
Please read this consent document carefully before you decide to participate in this
study.
Purpose of the research study: To investigate the relationship between body image and
psychosocial well-being in a sample of wheelchair users.
What you will be asked to do in the study: To respond to anonymous survey questions
online.
Time required: Approximately 20-30 minutes.
Risks and Benefits: No more than minimal risk. There is no direct benefit to the
participant in this research. The benefit of the research is to provide additional
information for understanding the relationship between body image and disability.
Compensation: There is no compensation for participating in the study.
Confidentiality: Your identity will be kept confidential to the extent provided by law.
The Principal Investigator will protect your identity in two ways: (1) no identifying
information will be requested from participants in the survey or consent process, and (2)
the IP address of the computer used to participate in the study will be encrypted using a
one-way "hash" function that makes it impossible to determine the actual IP address of
the participant's computer. The final results will be presented in a paper to education
journals and magazines for possible publication.
Voluntary participation: Your participation in this study is completely voluntary. There
is no penalty for not participating.
Right to withdraw from the study: You have the right to withdraw from the study at
anytime without consequence.
43
Whom to contact if you have questions about the study:
Erica L. Byrnes, B.S., B.A., Department of Counselor Education, 1215 Norman Hall,
(352) 392-0731, or, Sondra Smith, Ph.D., Department of Counselor Education, 1215
Norman Hall, (352) 392-0731.
Whom to contact about your rights as a research participant in the study:
UFIRB Office, Box 112250, University of Florida, Gainesville, FL 32611-2250; ph 392-
0433.
I have read the procedure outlined above. I voluntarily agree to participate in this
study and have received a copy of this description.
Participant's signature Principal investigator's signature
APPENDIX C
BODY CATHEXIS SCALE
In items 1-46, a number of things characteristic of yourself or related to you are
listed. You are asked to indicate which things you are satisfied with exactly as they are,
which things you worry about and would like to change if it were possible, and which
things you have no feelings about one way or the other.
Consider each item listed below and select the number which best represents your
feelings according to the following scale:
1. Have strong feelings and wish change could somehow be made.
2. Don't like, but can put up with.
3. Have no particular feelings one way or the other.
4. Am satisfied.
5. Consider myself fortunate.
Have
strong Have no
feelings Don't particular Co
S. Consider
and wish like, but feelings Am myse
change can put one way satisfied forty
fortunate
could up with or the
somehow other
be made
1. Hair 1 2 3 4 5
2. Facial complexion 1 2 3 4 5
3. Appetite 1 2 3 4 5
4. Hands 1 2 3 4 5
5. Distribution of hair over body 1 2 3 4 5
6. Nose 1 2 3 4 5
7. Fingers 1 2 3 4 5
8. Elimination 1 2 3 4 5
9. Wrists 1 2 3 4 5
10. Breathing 1 2 3 4 5
11. Waist 1 2 3 4 5
12. Energy level 1 2 3 4 5
13. Back 1 2 3 4 5
14. Ears 1 2 3 4 5
15. Chin 1 2 3 4 5
16. Exercise 1 2 3 4 5
17. Ankles 1 2 3 4 5
18. Neck 1 2 3 4 5
19. Shape of head 1 2 3 4 5
20. Body build 1 2 3 4 5
21. Profile 1 2 3 4 5
22. Height 1 2 3 4 5
23. Age 1 2 3 4 5
24. Width of shoulders 1 2 3 4 5
25. Arms 1 2 3 4 5
26. Chest 1 2 3 4 5
27. Eyes 1 2 3 4 5
28. Digestion 1 2 3 4 5
29. Hips 1 2 3 4 5
30. Skin texture 1 2 3 4 5
31. Lips 1 2 3 4 5
32. Legs 1 2 3 4 5
33. Teeth 1 2 3 4 5
34. Forehead 1 2 3 4 5
35. Feet 1 2 3 4 5
36. Sleep 1 2 3 4 5
37. Voice 1 2 3 4 5
38. Health 1 2 3 4 5
39. Sex activities 1 2 3 4 5
40. Knees 1 2 3 4 5
41. Posture 1 2 3 4 5
42. Face 1 2 3 4 5
43. Weight 1 2 3 4 5
44. Sex (male or female) 1 2 3 4 5
45. Back view of head 1 2 3 4 5
46. Trunk 1 2 3 4 5
APPENDIX D
CENTER FOR EPIDEMIOLOGIC STUDIES DEPRESSION SCALE (CES-D)
In items 47-66 there is a list of the ways you might have felt or behaved. Please tell
me how often you have felt this way DURING THE PAST WEEK.
-" a, -^ 0
2 3
2 3
people.2 3
47. I was bothered by things that usually don't 1 2 3 4
bother me.
48. I did not feel like eating; my appetite was 1 2 3 4
49. I felt that I could not shake off the blues 1 2 3 4
even55. I thought my life had been a family or friends.re. 1 2 3 4
50. I felt that I was just as good as other
58. I was happy. 1 2 3 4
people.
51. I had trouble keeping my mind on what I 1 2 3 4
was doing.
52. I felt depressed. 1 2 3 4
54. I enjoyehoful about the future.life. 1 2 3 4
55. I thad t my life had been a failure.spells. 1 2 3 4
56. I felt fearful. 1 2 3 4
57. My sleep was restless. 1 2 3 4
58.1 was happy. 1 2 3 4
59. Talked less than usual. 1 2 3 4
60. Felt lonely. 1 2 3 4
61. People were unfriendly. 1 2 3 4
62.1 enjoyed life. 1 2 3 4
63. Ihad crying spells. 1 2 3 4
64.1 felt sad. 1 2 3 4
65. I felt that people dislike me. 1 2 3 4
66. I could not get "going." 1 2 3 4
APPENDIX E
STATE TRAIT ANXIETY INVENTORY
In items 67-86, a number of statements which people have used to describe
themselves are given. Read each statement and then select the appropriate response
below the statement to indicate HOW YOU GENERALLY FEEL.
ALMOST SOMETIMES OFTEN ALMOST
NEVER ALWAYS
67. I feel pleasant. 1 2 3 4
68. I feel nervous and restless. 1 2 3 4
69. I feel satisfied with myself. 1 2 3 4
70. I wish I could be as happy as others 1 2 3 4
seem to be.
71.1 feel like a failure. 1 2 3 4
72.1 feel rested. 1 2 3 4
73. I am "calm, cool and collected." 1 2 3 4
74. I feel that difficulties are piling up so 1 2 3 4
that I cannot overcome them.
75. I worry too much over something 1 2 3 4
that doesn't really matter.
76.1 am happy. 1 2 3 4
77.I have disturbing thoughts. 1 2 3 4
78. I lack self-confidence. 1 2 3 4
79.1 feel secure. 1 2 3 4
80. I make decisions easily. 1 2 3 4
81. Feel inadequate. 1 2 3 4
82.1 am content. 1 2 3 4
83. Some unimportant thought runs 4
1 2 3 4
through my mind and bothers me.
84. I take disappointments so keenly
that I can't put them out of my 1 2 3 4
mind.
85. I am a steady person. 1 2 3 4
86. I get in a state of tension or turmoil
as I think over my recent concerns 1 2 3 4
and interests.
APPENDIX F
ROSENBERG SELF-ESTEEM SCALE
In items 87-96, please provide the requested information by selecting the response
that best applies to you.
87. On the whole, I am satisfied with myself. 1 2 3 4
At times I think I am no good at all. 1 2 3 4
89. I feel that I have a number of good qualities. 1 2 3 4
90. I am able to do things as well as most other people. 1 2 3 4
91. I feel I do not have much to be proud of. 1 2 3 4
92. I certainly feel useless as times. 1 2 3 4
93. I feel that I am a person of worth, at least on an equal 4
plane with others.
94. I wish I could have more respect for myself. 1 2 3 4
95. All in all, I am inclined to feel that I am a failure. 1 2 3 4
96. I take a positive attitude toward myself. 1 2 3 4
APPENDIX G
INTERNATIONAL PHYSICAL ACTIVITY QUESTIONNAIRE (IPAQ)
Questions 97-103 are aimed at finding out about what kind of physical activities
that people do as part of their everyday lives. The questions will ask you about the time
you spent being physically active in the last 7 days. Please answer each question even if
you do not consider yourself to be an active person. Please think about the activities you
do at work, school, as part of your house and yard work, to get from place to place, and in
your spare time for recreation, exercise or sport.
Think about all the vigorous activities that you did in the last 7 days. Vigorous
physical activities refer to activities that take hard physical effort and make you breathe
much harder than normal. Think only about those physical activities that you did for at
least 10 minutes at a time.
97. During the last 7 days, on how many days did you do vigorous physical activities like
heavy lifting, digging, aerobics, or quickly pushing your wheelchair? (please
provide answer in number of days) If no vigorous physical activities, please
record a zero and skip to question 99.
98. How much time did you usually spend doing vigorous physical activities on one of
those days?
Sample response: 1 hour, 15 minutes
If time is unknown, please type 'Don't know'.
Think about all the moderate activities that you did in the last 7 days. Moderate
activities refer to activities that take moderate physical effort and make you breathe
somewhat harder than normal. Think only about those physical activities that you did for
at least 10 minutes at a time.
99. During the last 7 days, on how many days did you do moderate physical activities like
carrying light loads, pushing your wheelchair above average distances, or
participating in a moderate intensity sport? Do not include your normal, daily
pushing of your wheelchair. (please provide answer in number of days) If no
vigorous physical activities, please record a zero and skip to question 101.
100. How much time did you usually spend doing moderate physical activities on one
of those days?
Sample response: 1 hour, 15 minutes
If time is unknown, please type 'Don't know'.
Think about the time you spent pushing your wheelchair in the last 7 days. This
includes at work and at home, pushing to travel from place to place, and any other
pushing that you might do solely for recreation, sport, exercise, or leisure.
101. During the last 7 days, on how many days did you do push your wheelchair for at
least 10 minutes at a time? (please provide answer in number of days) If no
pushing meets the criteria, please record a zero and skip to question 103.
102. How much time did you usually spend pushing your wheelchair on one of those
days?
Sample response: 1 hour, 15 minutes
If time is unknown, please type 'Don't know'.
This question is about the time you spent stationary on weekdays during the last 7
days. Include time spent at work, at home, while doing course work and during leisure
time. This may include time spent sitting at a desk, visiting friends, reading, or sitting or
lying down to watch television.
103. During the last 7 days, how much time did you spend stationary on a weekday?
(Please record your response in hours and minutes e.g., 3 hours, 20 minutes)
If time is unknown, please type 'Don't know/Not sure
APPENDIX H
DEMOGRAPHIC DATA QUESTIONNAIRE (DDQ)
104. What is your gender?
O Female
O Male
105. What is your Race/Ethnicity:
O African-American/Black-American
O Asian-American
O Caucasian/White/European-American
O Hispanic/Latino(a)
O Other (please specify:
106. What is your current age (in years)?
107. At what age did you become disabled (please list your age at the onset of
your disability)? If your disorder is genetic, please type zero.
108. Which physical activities do you participate in routinely?
O None
O Aerobics
O Weight lifting
O Fast-paced pushing in wheelchair/Running
O Collegiate level sports
O Swimming
O Quad Rugby
O Wheelchair Basketball
O Club sports (Which sport:)
O Recreational sports (Which sport:)
O Other
109. Employment Status:
O Work Full Time
O Work Part Time
O Student
O Do not work
110. Which of the following choices best describes your disability?
O Physical (for example, cerebral palsy, spina bifida, amputation, spinal cord
injury)
O Neuromuscular (for example, multiple sclerosis, myasthenia gravis, muscular
dystrophy)
52
O Respiratory (for example, asthma, chronic bronchitis, emphysema)
O Metabolic (for example, obesity, diabetes)
O Mental (for example, mental retardation, mental illness, autism, traumatic
brain injury)
O Aging-Related (for example, Parkinson's disease, stroke, arthritis,
fibromyalgia, osteoporosis)
O Other
111. Which type of wheelchair do you use most of the time?
O Manual Wheelchair
O Power/Electric Wheelchair or Scooter
O I use both equally
O Other (please specify: )
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BIOGRAPHICAL SKETCH
Erica L. Byrnes earned a Bachelor of Science degree in psychology and a Bachelor
of Arts degree in philosophy from the University of Florida in 2002. She is pursuing a
Master of Arts in Education degree in the Department of Counselor Education at the
University of Florida. Erica is currently employed as an Academic Advisor at the
Warrington College of Business at the University of Florida.
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EVALUATING BODY IMAGE, PHYSICAL ACTIVITY AND TIME SINCE DISABILITY ONSET AS PREDICTORS OF PSYCHOLOGICAL ADJUSTMENT TO MOBILITY IMPAIRMENTS By ERICA L. BYRNES A MASTERS THESIS PRESENTED TO THE GRADUATE SCHOOL OF THE UNIVERSITY OF FLORIDA IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF ARTS IN EDUCATION UNIVERSITY OF FLORIDA 2005
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Copyright 2005 by Erica L. Byrnes
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This document is dedicated to the numerous participants who were willing to share their time and personal experiences to make this research possible.
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ACKNOWLEDGMENTS I would like to gratefully acknowledge the many people that have been a part of my graduate education: family, friends, teachers, mentors, colleagues and supervisors. Without the amount of support that I received from these faculties, I surely would not have reached such a milestone in my educational career. I am indebted to these people for the opportunities that I have been afforded over the past few years to learn, grow, challenge, discuss, experience and collaborate. iv
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TABLE OF CONTENTS page ACKNOWLEDGMENTS.................................................................................................iv LIST OF TABLES............................................................................................................vii LIST OF FIGURES.........................................................................................................viii ABSTRACT.......................................................................................................................ix CHAPTER 1 INTRODUCTION........................................................................................................1 2 REVIEW OF THE LITERATURE..............................................................................8 Introduction...................................................................................................................8 Theoretical Models of Psychosocial Adjustment to Physical Disability......................9 Predictors of Psychosocial Adjustment to Disability.................................................12 Self-Esteem as a Predictor of Psychological Adjustment to Disability..............14 Body Image as a Predictor of Psychological Adjustment to Disability..............14 Physical Activity as a Predictor of Psychological Adjustment to Disability......16 Time Since Disability Onset as a Predictor of Psychological Adjustment to Disability..........................................................................................................17 Conclusion..................................................................................................................19 3 METHODOLOGY.....................................................................................................20 Research Questions and Hypotheses..........................................................................20 Procedures...................................................................................................................21 Participants.................................................................................................................23 Measures.....................................................................................................................24 Body-Cathexis Scale...........................................................................................24 Depression...........................................................................................................25 Anxiety................................................................................................................25 Self-Esteem..........................................................................................................26 Physical Activity.................................................................................................26 Demographic Data Questionnaire (DDQ)...........................................................27 Data Analyses.............................................................................................................27 v
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4 RESULTS...................................................................................................................28 Descriptive Statistics..................................................................................................28 Hypotheses Testing.....................................................................................................31 5 DISCUSSION.............................................................................................................34 Findings......................................................................................................................35 Gender.................................................................................................................35 Disability.............................................................................................................36 Self-Esteem..........................................................................................................36 Body Image.........................................................................................................37 Physical Activity.................................................................................................37 Time Since Disability Onset................................................................................38 Implications for Counseling.......................................................................................38 Limitations..................................................................................................................39 Future Research..........................................................................................................39 APPENDIX A INVITATION LETTER TO PARTICIPANTS..........................................................41 B INFORMED CONSENT............................................................................................42 C BODY CATHEXIS SCALE.......................................................................................44 D CENTER FOR EPIDEMIOLOGIC STUDIES DEPRESSION SCALE (CES-D)....46 E STATE TRAIT ANXIETY INVENTORY................................................................47 F ROSENBERG SELF-ESTEEM SCALE....................................................................48 G INTERNATIONAL PHYSICAL ACTIVITY QUESTIONNAIRE (IPAQ).............49 H DEMOGRAPHIC DATA QUESTIONNAIRE (DDQ).............................................51 REFERENCES..................................................................................................................53 BIOGRAPHICAL SKETCH.............................................................................................58 vi
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LIST OF TABLES Table page 4-1. Means, Standard Deviations, Ranges and Reliabilities of All Measures...................28 4-2. Participant Characteristics..........................................................................................29 4-3. Correlation Between Variables...................................................................................31 4-4. Multiple Regression Analyses Results for Depression...............................................32 4-5. Multiple Regression Analyses Results for Anxiety....................................................33 vii
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FIGURE Figure page 2-1. Diagram of Wallander and Varnis theoretical adaptation model..............................13 viii
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Abstract of Thesis Presented to the Graduate School of the University of Florida in Partial Fulfillment of the Requirements for the Degree of Master of Arts in Education EVALUATING BODY IMAGE, PHYSICAL ACTIVITY AND TIME SINCE DISABILITY ONSET AS PREDICTORS OF PSYCHOLOGICAL ADJUSTMENT TO MOBILITY IMPAIRMENTS By Erica L. Byrnes December 2005 Chair: Sondra Smith-Adcock Major Department: Counselor Education Americans with disabilities are up to three times more likely to experience mental health illness than their able-bodied counterparts. This increased risk is additionally weighted with the dangers of comorbidity of mental health and disability. The relationship between disability and mental illness is dangerously cyclical; symptoms related to each illness are multiplied in the presence of symptoms of the opposing illness. In order to appropriately understand psychological adjustment to mobility impairments, this construct was examined through the lens of Wallander and Varnis multivariate theoretical model of adjustment to disability. The primary goal of this research was to evaluate type of disability, self-esteem, body image, physical activity and time since disability onset as predictors of adjustment to disability using the multivariate framework established by Wallander and Varni. The relationship between each predictor variable and psychological adjustment outcome measures (depression and anxiety) was assessed. A regression model including all of the ix
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variables was utilized to assess the interaction of these variables in the process of predicting psychological adjustment to disability. Data were collected from 234 participants via an electronic questionnaire. Participants were required to be 18 years of age or older, diagnosed with a disability that requires the use of a wheelchair and able to respond to the instrument battery electronically. The instrument battery consisted of the following measures: body cathexis scale, Rosenbergs self-esteem scale, center for epidemiological studies depression scale, state-trait anxiety inventory, international physical activity questionnaire and a demographic data questionnaire. The results of the hierarchical regression models revealed that the variables explained a significant portion of the variance in both depression and anxiety. Investigation of the independent variables (disability, self-esteem, body image, physical activity and time since disability onset) indicated that self-esteem accounted for the most variance in depression and anxiety. x
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CHAPTER 1 INTRODUCTION Census 2000 delivered an astonishing figure to researchers in the field of health sciences: 49.7 million Americans are diagnosed with at least one type of disability (Waldrop & Stern, 2003). This sizeable figure accounts for 19.3% of the American population over the age of five years. Thus, almost one in every five Americans is currently affected by a disability, and as the population continues to age this figure will rise. Based on the Census 2000 data, Waldrop and Stern indicated that of the 49.7 million Americans living with a disability, 21.2 million (8.2% of the American population) have a condition that limits basic physical activities. Given the magnitude of the population living with a disability, the need for research centered on the well-being of this population is critical. Evidence suggests that people with disabilities are at a higher risk for mental health illnesses as a result of chronic disability-related stressors (Turner & Beiser, 1990; Wallander, Varni, Babani, Banis & Wilcox, 1988). Indeed, research findings support the notion that the presence of a disability puts a person at a higher risk for depression (an affective disorder), anxiety and substance use disorders (Polsky, Doshi, Marcus, Oslin, Rothbard, Thomas & Thompson 2005; Turner & Noh, 1988; Wells, Golding & Burnam, 1988). In addition, the literature suggests that people with a disability experience mitigated social interactions and relationships, which can further contribute to depressive symptomatology (Fitzpatrick, Newman, Archer & Shipley, 1991). Effectively, the 21.2 million Americans with a physical disability have a risk for developing a comorbid 1
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2 mental health disorder that is up to three times greater than their able-bodied American counterparts. Mental health illnesses such as depression, anxiety and substance use disorders generate severe behavioral and health risks. Patients with these illnesses may experience loss of energy, decrease in sleep patterns, decrease or increase in eating behaviors, irritability, suicidality, panic attacks, dizziness and many other physical and mental health implications (American Psychiatric Association, 2000). While the symptoms of mental health illness are severe when experienced as a primary condition, the presence of both a mental health illness and a physical disability may lead to unique negative health outcomes only experienced by individuals with comorbid disorders. Individuals with a disability and a comorbid mental health illness are at a heightened risk for negative health and economic impacts that exceed the risks associated with disability or mental illness alone. Comorbidity of physical disability and mental health illness creates a counteractive relationship in which each condition is uniquely worsened by the coexistence of symptomatology of the other condition. The interaction of physical disability and mental health illness has been correlated with further disability and activity impairment, as well as higher rates of relapse for mental health illnesses (Iosifescu, Nierenberg, Alpert, Papakostas, Perlis, Sonawalla & Fava, 2004; Vali & Walkup, 1998). The relationship between disability and mental illness is dangerously cyclical; symptoms related to each illness are multiplied in the presence of symptoms of the opposing illness. In addition to increased experiences of poor mental health, Americans with a disability will likely experience economic hardship, decreased levels of medical
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3 treatment effectiveness, and decreased levels of treatment compliance. The prevalence of such poor psychosocial adjustment outcomes demands research attention. According to Iosifescu, Nierenberg, Alpert, Smith, Bitran, Dording and Fava (2005), patients who have a disability and are diagnosed with major depressive disorder more frequently experience negative clinical treatment outcomes for major depressive disorder than patients being treated for major depressive disorder alone. Treatment effectiveness is further reduced by patient non-compliance, which lead DiMatteo, Lepper and Croghan (2000) to indicate that depression is a treatment compliance risk factor in patients under medical treatment for a physical disability. Finally, comorbidity is attributed to increased utilization of health care services (Manning & Wells, 1992), which can create negative economic implications at an individual and societal level. The number of persons with a disability is quickly growing and these people face serious health implications; these facts illuminate the importance of making people with a disability a research priority. Previous studies have examined factors that contribute to the psychosocial adjustment outcomes of persons with a disability. In order to appropriately understand psychological adjustment to disability, this construct must be examined through the lens of a theoretical model. Researchers have produced theoretical models that offer explanations of how variables work together to explain the process of adjustment to disability. The present study utilized a model proposed by Wallander and Varni (Wallander et al., 1988; Wallander, Varni, Babani, Banis, DeHaan & Wilcox 1989; Wallander, Feldman & Varni, 1989; Wallander, Varni, Babani, Banis & Wilcox, 1989) that offers insight into the process of mental health adjustment to disability and proposes possible predictors of adjustment.
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4 Wallander and Varnis model identifies a set of risk factors that directly influence the mental health adjustment of persons with a disability. Further, they argue that the relationship between the risk factors and the adjustment outcomes is moderated by a set of resistance factors. There are three categories of risk factors: physical disease or disability, chronic disability-related strain and psychosocial stress. Each category includes a variety of variables: handicap severity, medical problems, bowel/bladder control, visibility, cognitive functioning, brain involvement, functional independence, major life events, handicap-related problems and daily hassles. The resistance factors are also divided into three categories: intrapersonal factors, social-ecological factors and coping ability. These categories consist of variables such as: temperament, competence, effectance motivation, problem solving ability, family environment, social support, family members adaptation, utilitarian resources, cognitive appraisal and coping strategies. Wallander and Varni initially selected the factors included in their model based on current research findings at the time the model was developed. The selected factors were subsequently evaluated in a series of studies with a variety of disabled populations. For the purposes of the present study, a specific risk and resistance factor were identified as variables in the research. The risk factor assessed in the current research was type of disability. This risk factor has been an established predictor of adjustment to disability since the primary phases of Wallander and Varnis research which investigated the differences in adjustment levels experienced by individuals with varying disabilities (Wallander et al., 1988; Wallander et al., 1989; Wallander, Feldman & Varni, 1989; Wallander, Varni, Babani, Banis & Wilcox, 1989). As a result of studies focused on
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5 single disabilities or diseases, the adjustment model has rarely been evaluated across multiple disabilities. The present study focused on disability as a risk factor to support the application of the model across disabilities. Inclusion of multiple disabilities in the present study will allow results to contribute to a comprehensive theoretical understanding of the process of adjustment to disability. The resistance factor assessed in the current research was self-esteem. Self-esteem has been found to play a significant role in the process of adjustment to disability (Barnwell & Kavanagh, 1997; Li & Moore, 1998). As of yet, however, research has failed to determine the nature of the role that self-esteem plays in the adjustment process. Consequently, the present research included self-esteem in order to evaluate the resistance factor on a smaller scale. Due to the increasing prevalence of disability related health concerns, recent literature has continued to focus on identifying variables that play a role in adjustment outcomes. Several studies have suggested significant relationships between adjustment variables and body image (Fauerbach, Heinberg, Lawrence, Munster, Palombo, Richter, Spence, Stevens, Ware & Muehlberger 2000; Breakey, 1997), physical activity (Miilunpalo, 2001; Sands & Wettenhall, 2000) and time since disability onset (Elliott, Witty, Herrick & Hoffman, 1991; Livneh & Martz, 2003). While body image and physical activity have been positively correlated with high levels of psychological adjustment to disability, research on time since disability offers contrasting views of the role of time in the adjustment to disability process. Many of these variables that have been correlated with psychological well-being in a sample of persons with a disability have not been fully integrated into a model that offers insight into the process of adjustment. In order to fully understand the process of adjustment, the
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6 predictive potential of these variables must be investigated in a way that acknowledges the influence of already established variables (e.g., disablity and self-esteem). As with a majority of the research on disability adjustment, psychological adjustment is operationalized as depression and anxiety. In order to design effective treatment and prevention strategies targeted at reducing the prevalence of mental health illness among persons with a disability, important variables that impact the adjustment process must be identified and comprehensively understood. The overarching aim of this research is to produce information that will further understanding of the process of psychological adjustment to mobility impairment, ultimately leading to interventions with increased levels of efficacy. The present research will build on the model of psychosocial adjustment to disability proposed by Wallander and Varni (Wallander et al., 1988; Wallander et al., 1989; Wallander, Feldman & Varni, 1989; Wallander, Varni, Babani, Banis & Wilcox, 1989). Variables such as body image, physical activity and time since disability that have demonstrated significant relationships with psychological adjustment to disability have not yet been examined in the context of this theoretical model. The primary goal of this research is to evaluate the inclusion of these new variables into Wallander and Varnis theoretical model of adjustment. The relationship between each established predictor variable (disability and self-esteem) and psychological adjustment outcome measures (depression and anxiety) will be assessed. Similarly, the relationship between each newly identified variable (body image, physical activity and time since disability) and psychological adjustment outcome measures (depression and anxiety) will be assessed. Finally, a regression model including all of the
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7 variables will be utilized to assess the interaction of these variables in the process of predicting psychological adjustment to disability. Specifically, the research questions that were addressed by the study were: (1) What is the relationship between self-esteem and psychological adjustment (i.e., depression and anxiety)? (2) What is the relationship between disability type and psychological adjustment (i.e., depression and anxiety)? (3) What is the relationship between body image and psychological adjustment (i.e., depression and anxiety)? (4) What is the relationship between physical activity level and psychological adjustment (i.e., depression and anxiety)? (5) What is the relationship between time since disability onset and psychological adjustment (i.e., depression and anxiety)? (6) Which predictor variable explains the most variance in psychological adjustment (i.e., depression and anxiety)?
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CHAPTER 2 REVIEW OF THE LITERATURE Introduction The number of persons with a disability is a rapidly growing figure, as is evidenced by recent census data indicating that 19.3% of the American population has a disability (Waldrop & Stern, 2003). Each disability brings a set of unique, immediate impacts to the individual; moreover, having a disability puts a person at a greater risk for developing a comorbid mental illness (Turner & Beiser, 1990; Wallander, Varni, Babani, Banis & Wilcox, 1988). The cyclical relationship between disability and mental illness is wrought with problems that range from economic hardships (Manning & Wells, 1992) to decreased treatment effectiveness (Iosifescu, Nierenberg, Alpert, Smith et al., 2005). Despite growing research interests in the relationship between physical and mental health, there remains a lack of research focused on the 49.7 million Americans currently living with a disability. Indeed, the impact of cutting-edge, health-promoting interventions for persons with a disability is largely unknown due to the dearth of research on this vulnerable population (Rimmer, Braddock & Pitetti, 1996). This discrepancy leads to a lack of effective preventative measures and treatments, which ultimately contributes to the lifetime of mental illness and reciprocal physical ailments that many people with a disability face. The present study will address the lack of information and understanding in the literature on the process of psychological adjustment to disability by studying variables that contribute to the process of adjustment. 8
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9 Early investigations into issues relating to persons with a disability focused on psychological and social aspects of living with a disability. In an innovative study post World War II, Dembo, Leviton and Wright (1956) interviewed 177 persons with a disability or injury that impacted mobility. The study assessed acceptance of loss for both the person with a disability and persons close to the person with a disability. Similarly, Wright (1960) used qualitative research to identify broad psychological issues relevant to persons with disabilities such as frustration, social skills, self-concept and acceptance of physique. These seminal studies serve as the foundation of more recent research that attempts to integrate these psychological and social themes into a comprehensive model. Theoretical Models of Psychosocial Adjustment to Physical Disability Literature has established that individuals with a disability experience varying degrees of adjustment outcomes. Due to the severity of the impacts of negative adjustment, it is paramount that mental health professionals understand the process of psychological adjustment to disability in order to create appropriate interventions. As such, several models have been proposed in the literature to facilitate understanding of the process of adjustment to disability. However, theoretical models that have been proposed thus far vary widely in their approach to adjustment (Livneh & Antonak, 1997). One concept that has served as a foundation for many proposed models of psychological adjustment to disability is based on the research of Lazarus (1993). Lazarus reports that the concept of coping has been widely used in research on adjustment, adaptation and well-being. The coping process presented by Lazarus involves cognitive appraisal of the stress-causing situation and available resources that can assist in the resolution of the stress. Indeed, the application of coping theory has widely influenced models of disability adjustment presented in the literature. Early models
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10 present disability adjustment as a series of linear stages (Fortier & Wanlass, 1984) similar to the coping process (Lazarus & Folkman, 1984). In these models, the adjustment process is marked by a series of psychosocial changes that are assumed to occur in sequence. Stage models offer a simplified approach to understanding the nature of the process of adjustment to disability, however, these models have been widely criticized in the literature due to concerns regarding practical utility. Charmaz (1995) presented a critique of linear adjustment models based on qualitative data that suggested each person experiences a unique process of transformation of the self in response to disability. This process of transformation includes the core concepts of the generally accepted stages of adaptation, however, Charmaz suggests that as opposed to occurring linearly, these stages ebb and flow (p. 658) as the individual works to reunify body and self following disability onset. This sociological viewpoint highlights the complexity of the process of adjustment to disability that is not captured in stage models. In order to understand the adjustment process more thoroughly and to create effective interventions aimed at reducing poor adjustment outcomes, researchers must establish a model of adjustment to disability that offers more insight into the process. Empirical support for similar arguments against a linear model of adjustment to disability has emerged more prevalently in recent literature. Livneh and Antonak (1990) conducted a study to investigate the non-linear structure of the process of adaptation to disability. Based on the data collected in this study, Livneh and Antonak (1991) suggested that the process of adapting to disability is multidimensional and non-linear. Findings in this study produced clusters of participants demonstrating varying degrees of
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11 adaptation across multiple dimensions. Recently, these researchers have presented further empirical data that supports a multidimensional model of adaptation that proposes adaptation patterns, or degrees of adaptation rather than traditional phases of adaptation (Livneh, Lott & Antonak, 2004). Similarly, Kendall and Buys (1998) acknowledged the presence of specific stages of adjustment, yet argued that stage models were unable to address the recurrent nature of the adjustment process. Thus, they presented a model of psychosocial adjustment that incorporates concepts of schemas from cognitive theories of psychosocial well-being in order to advocate that individuals faced with adjustment to disability often cycle through different stages, or schemas, of adjustment and identity. Recurrent or degree-based models of adjustment offer a more complex view of adjustment that have the potential to account for individual differences in adjustment process. Neither linear nor recurrent models, however, are able to explain the influence of different identified variables in psychosocial adjustment. That is, none of these models account for the interaction of human variables within the adjustment process a fact that has led to the development of multivariate models. Varni and Wallander (Wallander et al., 1988; Wallander et al., 1989; Wallander, Feldman & Varni, 1989; Wallander, Thompson, & Alriksson-Schmidt, 1995; Wallander, Varni, Babani, Banis & Wilcox, 1989) proposed a conceptual multivariate model for psychological adjustment to disability based on research with chronically ill and disabled children and their parents. The model was initially developed in an effort to explain the differential adaptation to chronic illness and disability by children with different diseases, such as chronic obesity, spina bifida and cerebral palsy. Early findings suggested that the
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12 psychological adjustment to chronic illness varied widely across children with chronic physical disorders (Wallander et al.). In this model, earlier research was used to generate a set of adjustment risk factors which were then contrasted with hypothesized intrapersonal factors to create predictive potential for psychosocial adjustment. Wallander and Varni ultimately validated the model with a wide variety of disabled participants and presented the model as applicable to all persons with disabilities (Wallander et al.). The model of differential psychosocial adjustment proposed by Wallander and Varni is a complex system of interrelated constructs. Primarily, there are two sets of factors that interact to predict levels of adaptation or adjustment. The three risk factor categories were outlined by Wallander, Varni, Babani, Banis and Wilcox (1989): disease/disability parameters (e.g., diagnosis, handicap severity, medical problems, bowel/bladder control, visibility of disability, cognitive functioning, brain involvement), functional independence (i.e., how capable a person is in meeting daily living demands) and psychosocial stressors (e.g., disability related problems, major life events, daily hassles, social isolation). Wallander, Varni, Babani, Banis and Wilcox also presented the following three resistance factor categories: intrapersonal factors (e.g., temperament, competence, effectance motivation, problem solving ability), social-ecological factors (e.g., family environment, social support, family members adaptation, utilitarian resources) and stress processing (i.e., cognitive appraisal, coping strategies). The model presented in Figure 2-1 details how the identified risk and resistance factors interact to predict psychosocial adjustment (i.e., mental health, social functioning, physical health). Predictors of Psychosocial Adjustment to Disability Findings in the literature support the multivariate components of the model presented by Wallander and Varni. Due to the expanse and complexity of the model
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13 proposed by Wallander and Varni, the model has been broken down at times and investigated separately by individual variables (Wallander et al., 1989). Similarly, the present study investigated newly proposed components independently. The predictor variables selected for inclusion in this project were consistent with the theory and are presented below. Disease/Disability Parameters Functional Independence Psychosocial Stressors RESISTANCE FACTORS Intrapersonal Factors Social-Ecological Factors Stress Processing ADAPTATION RISK FACTORS Figure 2-1. Diagram of Wallander and Varnis theoretical adaptation model. Note. From Family resources as resistance factors for psychological maladjustment in chronically ill and handicapped children, by J. L. Wallander, J. W. Varni, L. Babani, H. T. Banis and K. T. Wilcox, 1989, Journal of Pediatric Psychology, 14(2), p.171. Copyright 1989 by Plenum Publishing Company.
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14 Self-Esteem as a Predictor of Psychological Adjustment to Disability Studies with a variety of participants with a disability have found that self-esteem plays an important role in the process of adjustment to disability (Barnwell & Kavanagh, 1997; Li & Moore, 1998). Primarily, these findings indicate that self-esteem has a significant relationship with mental health outcomes for specified populations. While these findings support the inclusion of self-esteem as an intrapersonal resistance factor in the model of adjustment proposed by Wallander and Varni, they lack the descriptive ability to determine the role self-esteem plays in the adjustment process. Recent research attempting to validate Wallander and Varnis model of disability adjustment has produced discrepant data with regard to the role of self-esteem within the overall model. Specifically, in a study conducted by Jarama and Belgrave (2002) with a sample of African-Americans with disabilities, self-esteem was the only resistance factor examined that failed to significantly predict mental health adjustment (i.e., depression and anxiety) to disability. In fact, in the final regression model, self-esteem accounted for .05 of the model variance for depression and -.11 of the model variance for anxiety, while social support significantly accounted for -.17 and -.31, respectively. These findings suggest that despite predictions based on previous findings in the literature regarding the role of self-esteem on adjustment to disability, the predictive potential of self-esteem within the framework of Wallander and Varnis multivariate model is not clear. Thus, the present study further investigated the nature of this variable within the overall adjustment model. Body Image as a Predictor of Psychological Adjustment to Disability Thompson, Heinberg, Altabe and Tantleff-Dunn extend a definition of body image describing it as the internal representation of your outer appearance (as cited in
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15 Hausenblas & Symons Downs, 2001). Through the act of defining body image, the innate relationship between body image and self-esteem becomes evident. This relationship is further supported in literature that reports positive relationships between self-esteem, an internal representation of self, and body image. Further, body image is a natural consideration for persons with disabilities, as outer appearances are often confounded by the presence of disability. Previous findings in the literature suggest the presence of a positive relationship between body image and self-esteem. Keppel and Crowe (2000) reported data that described the relationship between self-esteem and body image as inter-related. Indeed, findings from their research on 40 young adult stroke patients produced evidence that body image predicted physical and global self-esteem. Similarly, Breakey (1997) reported data on 90 lower-limb amputees that indicated a significant, positive relationship between self-esteem and body image. These findings indicate that body image may serve a role similar to that of self-esteem in the process of adjustment to disability. In addition to a positive relationship between self-esteem and body image, Breakey (1997) also found a significant, positive relationship between body image and generalized contentment. These findings suggest that in addition to positively correlating with self-esteem, body image has a distinct relationship with psychosocial well-being. This finding was again echoed by Fauerbach et al. (2000) in a study examining body image dissatisfaction after disfiguring injury. In a sample of 86 patients recovering from severe burn injury, Fauerbach et al. found body image dissatisfaction to be significantly related to lower psychosocial adjustment. Clearly, evidence is mounting that body image has a direct effect on psychosocial adjustment to disability. As such, for the present research,
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16 body image will be explored and investigated as an independent predictor of psychological adjustment in persons with a disability. Physical Activity as a Predictor of Psychological Adjustment to Disability Physical activity is believed to improve physical health and psychological well-being (Miilunpalo, 2001). Indeed, data collected on disabled populations suggests that persons with low levels of physical activity experience corresponding low levels of physical health. Rimmer, Rubin and Braddock (1999) surveyed a sample of 50 African-American women with physical disabilities. They found that extremely low levels of physical activity exposed participants to higher risks of secondary health conditions. Further, they reported findings of an overall low level of physical activity within the sample. Studies such as this one suggest that physical activity plays a direct role in overall health and well-being. Extensive data suggests that persons with a disability have overall lower levels of physical and mental health than their able-bodied counterparts. The psychosocial model of adjustment to disability offered by Wallander and Varni explain this difference based on the risk and resistance factors they have identified, however, research comparing wheelchair athletes to their able-bodied counterparts offers an additional insight into the established differences. Sands and Wettenhall (2000) conducted a study on female wheelchair athletes in order to establish whether wheelchair athletes were more or less satisfied with their body image than able-bodied athletes. The results revealed no significant differences in the samples, suggesting that participation in physical activity contributed to enhanced body image. The authors found support in earlier findings by Brewer, Van Raalte and Linder (as cited in Sands & Wettenhall) for athletic participation boosting the comfort level wheelchair athletes felt towards themselves. This theorization
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17 is further supported by a meta-analytic review conducted by Hausenblas and Symons Downs (2001) that reviewed the data from 78 studies and revealed a significant effect indicating that able-bodied athletes have a more positive body image than able-bodied persons who were non-athletes. The relationship between physical and mental health has become a popular area of research as Americans become more aware of the harmful implications of sedentary behaviors. Despite the growing body of literature dedicated to physical activity and fitness, there remains a void of research on physical activity in persons with disabilities. Indeed, the scarcity of population specific research presently available leaves researchers unable to make accurate conclusions regarding physical activity and disability (Rimmer et al., 1996). Taylor, Baranowski, and Young (1998) found only four studies about physical activity interventions that had been conducted on disabled populations within a period of 14 years. Based on these findings, Taylor et al. propose several recommendations for research priorities with disabled populations. One such recommendation is to conduct theory-based research. Accordingly, in the present research the impact of physical activity on psychological adjustment to disability will be investigated within the context of the psychosocial model of adjustment to disability proposed by Wallander and Varni. Time Since Disability Onset as a Predictor of Psychological Adjustment to Disability The historical development of models of adjustment to disability began with a time-sensitive understanding of the process of adjustment. Linear models inherently assumed that time played a role in the process of adjustment, as the progression to advanced stages of acceptance was dependent upon the passage of time. Investigations of the relationship between time since disability onset and psychological adjustment to
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18 disability have yielded diverging results. While some research sets forth the notion that the passage of time is related to higher levels of psychological adjustment (e.g., self-efficacy, depression, anxiety), contrasting evidence can be found indicating that time since disability onset and psychological adjustment have a non-significant relationship. This dichotomy in the literature is fueled by findings that indirectly implicate a relationship between psychological adjustment and time since disability onset, yet fail to produce significant results. Elliott, Witty, Herrick and Hoffman (1991) conducted a study on 57 persons with acquired severe physical disabilities. Despite expectations of a moderating effect of time since onset of disability, the results indicated no significant effect of time on psychological adjustment. However, the results did suggest that the passage of time was related to how participants of varying degrees of hope experienced psychological impairment. Empirical research investigating a direct relationship between time since disability onset and psychosocial adjustment has yielded insufficient findings. A recent study by Attawong and Kovindha (2005) found no significant direct relationship between time since injury and adjustment factors in a sample of 61 spinal cord injury patients. Further, empirical data investigating the relationship between time since disability onset and body image failed to produce significant results (Breakey, 1997). While extensive amounts of literature address this variable, few studies offer insight into the role of time since disability onset on the process of adjustment to disability. In an exploratory study aimed to resolve such inconsistencies in the literature, Livneh and Martz (2003) argued that empirical studies are unable to pinpoint a relationship between time since disability onset and psychosocial adjustment because no
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19 pure phases of adjustment exist. Instead, they offer an alternative explanation to the thriving conflict in the literature on the role of time since disability onset. In their study of 317 spinal cord injury patients, different patterns of adaptation emerged in patients with short-term injuries (within the past four years) versus those with long-term injuries (20 years ago or longer). This research suggested that while time may not play a direct role in determining psychosocial adjustment to disability, patterns of adaptation vary over time. As such, the present study sought to investigate the effectiveness of time since disability onset as a predictor variable in the psychosocial model of adjustment by Wallander and Varni. Conclusion Research aimed at improving the current mental health situation for Americans with a disability must address the unique physical, psychological and social stressors prominent for this population. The application of a multivariate model of understanding the process of adjustment to disability creates an opportunity for researchers to identify relevant influences on the adjustment process. In turn, identified variables can serve as the foundation for prevention and treatment programs aimed at reducing the prevalence of mental illness in persons with a disability. Therefore, the major problem addressed in the present study was the investigation of variables identified in the literature as predictors of psychological adjustment to disability. As detailed previously, the research was conducted within the framework of a multivariate model of psychosocial adjustment to disability in order to establish a clear understanding of the influence of each variable.
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CHAPTER 3 METHODOLOGY In the preceding chapters, the importance and implications of the process of psychosocial adjustment to disability were discussed. In addition, the research problems were introduced and the pertinent literature related to these problems was reviewed. In the first section of this chapter, the research hypotheses are presented. A presentation of the research design, description of the population sample, review of the instrument battery and an overview of the data analyses conducted in the present study follow the first section. Research Questions and Hypotheses The fundamental goal of this study is to investigate possible predictors of psychological adjustment to disability. This goal is operationalized within the context of the multivariate model of psychosocial adjustment to disability outlined in the research of Wallander and Varni (Wallander et al., 1988; Wallander et al., 1989; Wallander, Feldman & Varni, 1989; Wallander, Varni, Babani, Banis & Wilcox, 1989). Wallander and Varni identify two sets of variables risk and resistance factors. They propose that the relationship between risk factors and psychosocial adjustment is moderated by the resistance factors. Despite support in the literature for the multivariate model of adjustment proposed by Wallander and Varni, current literature has suggested that the relationship between disability and psychosocial adjustment is influenced by additional variables that have not been formally included in the adjustment model. The present research aimed to explore the inclusion of three additional variables in the adjustment 20
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21 model proposed by Wallander and Varni body image, activity level, and time since disability onset. The primary research question addressed in the present research is: What is the relationship between risk factors, resistance factors and psychological adjustment? Which intrapersonal resistance factors explain the most variance in psychological adjustment to disability? The hypotheses tested in the present study are set forth below: (1) Self-esteem and disability type will account for significant variance in each of the measures of psychological adjustment (i.e., depression and anxiety). (2) Body image and physical activity will account for additional variance in the predictive model of the measures of psychological adjustment (i.e., depression and anxiety). (3) Time since disability onset will be non-significantly correlated with measures of psychological adjustment (i.e., depression and anxiety). (4) Self-esteem and body image will have the greatest beta weights, followed by disability type, physical activity and time since disability onset. Procedures Participants were invited to participate in the study through an invitation that was electronically mailed to several national electronic mail listservs that cater to disabled populations and topics related to disability issues (e.g., DISAB-CON The DisAbility Concerns Network, NDSU The National Disabled Students Union listserv, Disabled Student Services in Higher Education, Disability Studies in the Humanities listserv). Many members of these listservs forwarded the invitation to other listservs and national discussion boards related to various disability topics, which resulted in a snowballed participant pool. The invitation letter that was electronically mailed to potential participants was based on a letter that had received prior approval from the Institutional Review Board (See Appendix A). The invitation letter briefly described the purpose of the study as being to learn more about the relationship between body image and
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22 disability. Additionally, the invitation letter informed potential participants of the confidentiality and anonymity ensured by the present study, and explained that participation was voluntary and could be discontinued at any time. Finally, the letter informed potential participants that the instrument battery was expected to take 20-30 minutes to complete. If invited participants chose to participate in the present study, the invitation letter instructed them to follow a hyperlink to an online survey. The first webpage that was displayed to participants upon following the hyperlink was a welcome screen that briefly described the process of informed consent. Once a participant clicked continue he/she was routed to the second webpage, which contained the informed consent (See Appendix B). The informed consent explained that there was no financial incentive for participation, in addition to restating details about participation presented in the invitation. Volunteer participants had to complete an electronic informed consent form prior to responding to any of the survey items. Upon agreement to the informed consent, the instrument battery was displayed to the participant and responses could be selected electronically. Once a participant submitted electronic responses to the instrument battery, participation was complete. The entire instrument battery was administered online. Previous studies have validated the use of psychological survey instruments in an internet format (Buchanan & Smith, 1999; Krantz, Ballard & Scher, 1997). Furthermore, the population addressed in this study fit two of the main criteria identified in the literature (Eysenbach & Wyatt, 2002; Wyatt, 2000) as populations who meet guidelines for online study: need for
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23 respondents covering a wide geography due to disease/condition, respondents are avid internet users. The identity of volunteer participants was protected in two ways: (1) no identifying information was requested from participants in the survey or consent process, and (2) the IP address of the computer used to participate in the study was encrypted using a one-way hash function that makes it impossible to determine the actual IP address of the participants computer. Participants A convenience sampling procedure was utilized to recruit 234 participants. Participants were invited to participate in the study electronically via email, and informed of the confidential nature of the data collection. All information provided by participants was done so voluntarily, and all participants were treated in accordance with the Ethical Principles of Psychologists and Code of Conduct (American Psychological Association, 1992). Participants from the initial participant pool who met the inclusion criteria and who completed the instrument battery entirely (regardless of whether particular questions were skipped along the way) were selected for analysis in the present study. The inclusion criteria were: (1) over 18 years of age; (2) diagnosed with a disability that requires the use of either a manual wheelchair, electric wheelchair or both (as judged by the participants); and (3) ability to respond to the instrument battery electronically. The final participant pool consisted of 113 women and 106 men (15 participants failed to report gender information, N = 234). This sample size meets standard estimates of participants required to have sufficient statistical power. Tabachnick and Fidell (2001) suggest calculating required
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24 number of participants using this formula: 10 IV. This would require a minimum of 50 participants. Similarly, Stevens (1996) formula is: 15 IV, which would require a minimum of 75 participants. The present sample of 234 participants exceeds acceptable sample size criteria for the analyses conducted, thus, results are assumed to be of adequate effect size. Measures The following six instruments were utilized to measure independent and dependent variables. The scales are presented here in the order in which they appeared on the electronic instrument battery. Body-Cathexis Scale The Body-Cathexis scale was used to assess body image. Specifically, the scale measures the degree of satisfaction or dissatisfaction with various parts of the body (Secord & Jourard, 1953). Participants were asked to rate 46 items characteristic of themselves (e.g., hands, appetite, nose) on a five-point Likert scale that ranges in polar responses from have strong feelings and wish change could somehow be made to consider myself fortunate. Secord and Jourard reported split half reliability coefficients for men and women separately (men obtained a coefficient of .78 while women obtained a coefficient of .83). This scale was selected because it has been widely used with disabled populations. Marcusson, List, Paulin, and Akerlind (2001) modified and used the body-cathexis scale in treated cleft lip and palate patients. The modified scale contained 24 body regions which were rated on a five-point Likert scale. The reliability of this modified instrument ranged by question from 0.29 to 0.65, and the summary score of all regions assessed produced a reliability coefficient of 0.41. The original scale, which was used in the
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25 present study, has several reports of satisfactory reliability scores. Tucker (1981) reported test-retest reliability as .87. Similarly, test-restest reliability has been reported as .90 by Theodorakis, Doganis and Bagiatis (1991). Alpha coefficients have also been consistently reported high; Riordan, Koff and Stubbs (1987) reported cronbachs alpha as .87 with a sample of 585 girls. See Appendix C. Depression The Center for Epidemiological Studies Depression Scale (CES-D: Radloff, 1977) was used to assess level of depression. The present research utilized the original scale with 20 items that are used to assess depressive symptomatology. The instrument requires respondents to select how often they have experienced certain feelings or behaviors over the past week (e.g., I talked less than usual, I did not feel like eating: my appetite was poor, I felt sad). Participants are asked to rate each item on a four-point scale that ranges from rarely or none of the time (less than 1 day) to most or all of the time (5-7 days. Radloff reported high scores for internal consistency, .85 for the general population and .90 for the patient sample. See Appendix D. Anxiety The State-Trait Anxiety Inventory (STAI; Spielberger, Gorsuch, & Lushene, 1970) was used to assess anxiety. The STAI has two scales, the state anxiety scale (S scale) and the trait anxiety scale (T scale). This research utilized the T scale, in order to appropriately assess for the type of anxiety more commonly associated with mental health diagnoses. The T scale contains 20 items (e.g., I feel like a failure, I have disturbing thoughts, I feel inadequate) rated on a 4-point Likert scale that ranges from almost never to almost always. Alpha coefficients have been consistently high ( = .90; Spielberger, Gorsuch, Lushene, Vagg & Jacobs, 1983). See Appendix E.
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26 Self-Esteem The Rosenberg (1965) self-esteem scale (RSES) was selected to measure global self-esteem. This measure has 10 items (e.g., I feel that I have a number of good qualities, I feel that I am a person of worth, at least on an equal plane with others) that ask participants to rate themselves on a four-point Likert scale ranging from strongly disagree to strongly agree. This scale has firmly established construct validity, and the internal reliability has been high in samples of ethnic minorities with disabilities (Belgrave & Walker, 1991). See Appendix F. Physical Activity The International Physical Activity Questionnaire (IPAQ: Craig, Marshall, Sjostrom, Bauman, Booth, Ainsworth, Pratt, Ekelund, Yngve, Sallis & Oja 2003) was used to assess level of physical activity. This research utilized the short form of the instrument with a last seven days reference period, as recommended by the original authors based on a sample of over 1,000 participants from 12 different countries. The short form consists of seven items that ask participants to self-report information regarding quantities of time spent on physical activity (e.g., During the last 7 days, on how many days did you do vigorous physical activities like heavy lifting, digging, aerobics, or quickly pushing your wheelchair?). Scores were reported as continuous measures of METS (multiples of resting metabolic rate). Participants were then classified into one of three categories defined by the authors of the IPAQ based on current public health guidelines for physical activity. Category one is inactive and requires a MET score of 480 or below, category two is minimally active and includes a range of MET scores from 481-1500, and category three is HEPA (health enhancing physical activity) active and includes MET scores of
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27 1501 and above. Reliability scores for the IPAQ (all forms) range from 0.65 0.88. The self-administered short form with a seven-day reference period reports a reliability coefficient of 0.75. See Appendix G. Demographic Data Questionnaire (DDQ) This questionnaire was used to obtain demographic and background information about gender, ethnicity, age, age of disability onset, employment status, regular physical activities, nature of disability and type of wheelchair used. The demographic questions were placed last on the online instrument battery in an effort to mitigate the influence of these questions on participant responses to other study questionnaires. See Appendix H. Data Analyses In order to test the stated hypotheses in the present study, two separate multiple regression analyses were conducted on the data one for each dependent variable. In both of the multiple regressions, the predictor variables were disability, self-esteem, body image, physical activity, and age of onset while the criterion variable was either depression or anxiety. In each regression, the first block consisted of gender, ethnicity and age. These demographic variables were entered in the first block in order to control for their effects on the dependent variables as it was important to investigate the contribution of the variables of interest after the demographic variables were considered. Therefore, the second block of both regressions included the various types of disabilities self-reported by the participants. Finally, the remaining independent variables were entered as the third block: self-esteem, body image, physical activity and time since disability onset.
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CHAPTER 4 RESULTS This chapter presents the results of the statistical analyses described in the methodology. Descriptive Statistics The distribution of body image, depression, anxiety and self-esteem was essentially normal and unmarked by extreme scores (skewness = -.78 +.64; kurtosis = .04 1.7). However, initial descriptive statistics indicated a high level of skewness and kurtosis for physical activity (skewness = 7.10; kurtosis = 69.35). As such, the data was further evaluated for outliers. Division of physical activity scores into 20 percentiles yielded extreme scores (scores in the 95 th percentile) beginning at 16933.50. The physical activity scores were then recoded to include only scores that fell below 17000, which eliminated 8 scores. The final distribution of physical activity scores had a skewness statistic of 1.3 and a kurtosis statistic of .98. Table 4-1 presents the mean scores, standard deviations, and ranges for the dependent variables (i.e., depression, anxiety) and independent variables (i.e., physical activity, body image, self-esteem). Table 4-1. Means, Standard Deviations and Ranges of All Measures Variables M SD Range Body Image 3.26 .66 .43 4.98 Depression 19.08 11.78 2.0 56.0 Anxiety 38.67 11.78 20.0 78.0 Self-Esteem 31.29 6.70 10.0 40.0 Physical Activity 3472.07 4441.67 0 16500.00 Age 38.07 11.57 18-71 28
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29 Table 4-2 presents additional demographic information about the participants. Table 4-2. Participant Characteristics Variable N % of sample Ethnicity African-American/Black-American 5 2.1 Asian-American 4 1.7 Caucasian/White/European-American 190 81.2 Hispanic/Latino(a) 12 5.1 Other 8 3.4 Unknown 15 6.4 Disability Physical 159 67.9 Neuromuscular 41 17.5 Respiratory 2 0.9 Metabolic 2 0.9 Mental 1 0.4 Aging-Related 3 1.3 Other 2 0.9 Multiple Types of Disability 6 2.6 Unknown 18 7.7 Employment Full Time 65 27.8 Part Time 37 15.8 Student 38 16.2 Does Not Work 76 32.5 Unknown 18 7.7 Age 0-20 11 4.7 21-40 118 50.4 41-60 83 35.5 61+ 3 1.3 Unknown 19 8.1 Physical Activity Level Inactive 65 27.8 Minimally Active 14 6 HEPA Active 83 35.5 Unknown 72 30.8 Note: N = 234 Scores on the dependent measures of psychological adjustment (i.e., depression and anxiety) suggest that the majority of the participants experience moderate levels of both depression and anxiety. An independent samples t-test was conducted to contrast the
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30 depression and anxiety scores of male participants against female participants. The effect of gender was statistically significant at an alpha level of p < .05 for depression, t(217) = -2.35, p = .02 and for anxiety, t(217) = -2.05, p = .04. This data suggests that the differences in depression and anxiety scores between male and female participants are statistically different. A one-way analysis of variance (ANOVA) was conducted to assess differences in adjustment measures among ethnicity groups using an alpha level of p < .05. Results of this analysis indicated that there were no significant between group differences in depression scores based on ethnicity, F [5,225] = 1.23, p = .29 nor were there significant between group differences in anxiety scores based on ethnicity, F [5,225] = .81, p = .54. This data suggests that there are no significant differences among the different ethnicity groups for the two psychological adjustment measures (i.e., depression and anxiety). A similar one-way analysis of variance (ANOVA) was conducted to assess differences in adjustment measures based on participant age using an alpha level of p < .05. Results of this analysis indicated that there were no significant between group differences in depression scores based on age, F [44,214] = .83, p = .77 nor were there significant between group differences in anxiety scores based on ethnicity, F [44,214] = .95, p = .57. This data suggests that there are no significant differences among the participants based on age for the two psychological adjustment measures (i.e., depression and anxiety). Pearson product-moment correlation coefficients were computed to evaluate the relationship between each risk and resistance factor variable (i.e., disability, self-esteem, body image, physical activity and time since disability onset) and psychological
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31 adjustment (i.e., depression and anxiety). The results of these analyses are presented in table 4-3. Table 4-3. Correlation Between Variables 1 2 3 4 5 Depression .12 -.77** -.56** -.20** -.01 Anxiety .07 -.88** -.60** -.23** .01 1. Disability Type -.09 -.22** -.08 .12 2. Self-Esteem -.56** .22** .00 3. Body Image .24** -.09 4. Physical Activity -.07 5. Time Since Disability Onset Note: **p < .01 Depression and anxiety were both negatively and significantly correlated with self-esteem, body image, and physical activity. These trends were echoed in the significant relationships between self-esteem, body image and physical activity. Hypotheses Testing The hypotheses were tested using hierarchical regression analyses to examine the impact of the variables on the psychological adjustment outcome variables (depression and anxiety). The first model examined the impact of disability, self-esteem, body image, physical activity and time since disability onset on depression. The variance accounted for in this model was significant (r 2 = .663, F[16,156] = 17.21, p = .00). The standardized beta values for each variable are presented in table 4-4. The collinearity diagnostics indicate that there is no significant collinearity problem. The condition indices are all below or proximate to 15. The tolerance statistic is very close to 1, and the VIF statistic is close to 0. The Durbin-Watson statistic is 1.96. Overall, the model does not seem highly effected by collinearity.
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32 Table 4-4. Multiple Regression Analyses Results for Depression F p Depression Step 1 3.162** .006 Gender .095 .076 Age .000 .996 Ethnicity African-American/Black-American -.102 .179 Caucasian/White/European-American -.194 .096 Hispanic/Latino(a) -.036 .702 Other -.088 Step 2 2.869** .001 Disability Physical -.399** .046 Neuromuscular -.349** .05 Respiratory -.015 .828 Aging-Related -.131 .065 Other -.203** .006 Multiple Types of Disability -.054 .591 Step 3 17.211** .000 Self-Esteem -.624** .000 Body Image -.168** .008 Physical Activity .012 .854 Time Since Disability Onset -.034 .535 Note: Standardized beta from final model (Step 3). ** p < .05 The second model examined the impact of disability, self-esteem, body image, physical activity and time since disability onset on anxiety. The variance accounted for in this model was significant (r 2 = .815, F[16,149] = 36.61, p = .00). The standardized beta values for each variable are presented in table 4-5. The collinearity diagnostics indicate that there is no significant collinearity problem. The condition indices are all below or proximate to 15. The tolerance statistic is very close to 1, and the VIF statistic is close to 0. The Durbin-Watson statistic is 2.15. Overall, the model does not seem highly effected by collinearity.
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33 Table 4-5. Multiple Regression Analyses Results for Anxiety F p Anxiety Step 1 1.724** .119 Gender .034 .413 Age -.090** .039 Ethnicity African-American/Black-American -.058 .190 Caucasian/White/European-American -.159 .067 Hispanic/Latino(a) -.104 .146 Other -.098 .119 Step 2 1.861** .044 Disability Physical .096 .522 Neuromuscular .095 .472 Respiratory .098 .077 Aging-Related .091 .093 Other .020 .717 Multiple Types of Disability .132 .090 Step 3 36.608** .000 Self-Esteem -.772** .000 Body Image -.135** .006 Physical Activity -.050 .245 Time Since Disability Onset .021 .615 Note: Standardized beta from final model (Step 3). ** p < .05 Recall that the researcher expected to find that self-esteem and disability type each accounted for a significant portion of the variance in depression and anxiety. While self-esteem was a significant predictor of both depression and anxiety, disability was only predictive of depression. Further, body image and physical activity were expected to further contribute to variance explained in the model. Body image was a significant predictor of both depression and anxiety, while physical activity was non-significant for either psychological outcome measure. Finally, time since disability onset was not found to significantly predict depression or anxiety.
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CHAPTER 5 DISCUSSION The process of psychological adjustment to disability is influenced by numerous variables. Wallander and Varni (Wallander et al., 1988; Wallander et al., 1989; Wallander, Feldman & Varni, 1989; Wallander, Varni, Babani, Banis & Wilcox, 1989) established a multivariate model that attempts to explain the adjustment process described by Charmaz (1995) as altering life and self to accommodate to physical losses and to reunify body and self accordingly (pg. 657). Their model describes the adjustment process as the interaction of risk and resistance factors. Risk factors include physical disease or disability, chronic disability-related strain and psychosocial stress. Resistance factors are defined as intrapersonal factors, social-ecological factors and coping ability. While this model has successfully identified and incorporated several specific variables that predict adjustment, recent literature has identified additional variables that play a role in the process. Body image, physical activity and time since disability onset have been investigated in recent literature and have demonstrated relationships with adjustment outcomes. Body image has been positively correlated with contentment and psychosocial adjustment in persons with a disability (Breakey, 1997; Fauerbach et al, 2000). Similarly, physical activity levels have been positively correlated with overall health (Rimmer, Rubin & Braddock, 1999). Finally, significant relationships between disability adjustment and time since disability onset have been proposed in empirical studies of persons with a disability (Livneh & Martz, 2003). While the relationship between these 34
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35 variables and psychological adjustment to disability has been independently investigated, these variables have not been tested in a multivariate model of disability adjustment. This research evaluated disability, self-esteem, body image, physical activity and time since disability onset as predictors of psychological adjustment. Psychological adjustment was operationalized as depression and anxiety. The results of the hierarchical regression models revealed that the variables explained a significant portion of the variance in both depression and anxiety. Investigation of the independent variables (disability, self-esteem, body image, physical activity and time since disability onset) in a multivariate model can help to further explain the process of adjustment to disability. Findings Hypotheses were tested using two separate hierarchical regression models in which the independent variables (disability, self-esteem, body image, physical activity and time since disability onset) were regressed on the dependent variable (depression and anxiety). It was hypothesized that both models would significantly predict psychological adjustment based on previous findings using multivariate models by Wallander and Varni (Wallander et al., 1988; Wallander et al., 1989; Wallander, Feldman & Varni, 1989; Wallander, Varni, Babani, Banis & Wilcox, 1989). Results indicate that both models significantly explained variance in depression and anxiety, yet the variables had a wide range of influence on the models. Gender Significant differences were identified between males and females on depression and anxiety scores. Although unexpected, this finding mirrors trends in the literature that propose gender differences are vast enough to warrant separate consideration in
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36 disability-related research (Nosek & Hughes, 2003). Gender may serve as a predictor of psychological adjustment to some degree. Disability Disability was examined in block two in both models, and was found to account for significant variance in both depression and anxiety. These results suggest that disability is a significant predictor of depression and anxiety. For the outcome measure depression, physical, neuromuscular and other disabilities produced significant beta values. For the outcome measure anxiety, no category of disability produced significant beta values. These findings are consistent with the data distribution that indicated lower levels of probable anxiety than probable depression. This suggests that perhaps disability type is more linked to depression than it is to anxiety. Self-Esteem There was a significant effect of self-esteem on both depression and anxiety. These findings are consistent with literature that indicates a positive relationship between self-esteem and psychological adjustment to disability (Barnwell & Kavanagh, 1997; Li & Moore, 1998). In both models self-esteem carried the greatest beta weight; this indicates that self-esteem accounts for a majority of the variance in depression and anxiety in the population. It is important to note that self-esteem also had significant correlational relationships with body image and physical activity. The presence of an interaction effect between self-esteem and body image was examined and no significant interaction effect was found. This suggests that although self-esteem and body image both have negative effects on depression and anxiety (higher levels of self-esteem and body image correspond to lower levels of depression and anxiety), the combined effect of these variables does not significantly explain depression or anxiety levels.
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37 Body Image Body image was found to have a significant effect on both depression and anxiety. While these findings are consistent with the literature, the variance in depression and anxiety scores accounted for by body image was remarkably small in comparison to self-esteem. The body cathexis instrument assesses an individuals feelings regarding specific body parts. Because self-esteem is an assessment of an individuals internal representation of self, body image may be encapsulated within this definition. The discrepancy in variance explained between self-esteem and body image may indicate that body image is a theoretical component of self-esteem, as Keppel and Crowe (2000) seem to implicate. Physical Activity Physical activity was not found to be a significant predictor of depression or self-esteem. Although this finding was unexpected, physical activity was significantly and positively correlated with self-esteem and body image. The lack of significant effect of physical activity on depression or self-esteem combined with the significant correlational relationship between phsycial activity and self-esteem and body image suggests that physical activity contributes directly to self-esteem and body image. This finding echoes earlier findings in the literature that demonstrate physical activity contributes positively to body image (Hausenblas & Symons Downs, 2001; Sands & Wettenhall, 2000). In the context of the present study, physical activity may improve the comfort level that individuals feel toward specific body parts, thus increasing their body image and self-esteem.
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38 Time Since Disability Onset Time since disability onset did not yield significant effects on depression or self-esteem. Similarly, this variable did not have a significant correlation with any other variable. This finding further supports the divergent results in the literature regarding the role of time in disability adjustment. The study design did not allow for isolation of this variable or exploration of possible quadratic or curvilinear relationships. Perhaps, as is suggested by Livneh and Martz (2003), the relationship between time since disability onset and psychological adjustment variables is not linear. The lack of significant relationships between time since disability onset and other predictor variables also suggests that a linear trend may not be the best explanation of the involvement of this variable in the adjustment process. Implications for Counseling Research investigating the multitude of variables that play a role in the process of adjustment to disability establishes critical information for practicing professionals. Knowledge of important variables within the adjustment process allows professionals to appropriately adapt common therapeutic techniques and address core domains of psychological adjustment that will facilitate the best outcomes for patients and clients. Additionally, knowledge of core domains that influence the adjustment process empowers professionals to further promote positive outcomes by creating unique treatments and programs that address the unique needs of disabled persons. Kendall and Terry (1996) emphasize the importance of establishing a model from which professionals can work. They propose that administrative changes can be made to standard procedures when professionals are informed about the process of adjustment. For example, if a professional is treating a client who has depression and is also recently
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39 injured, a self-esteem assessment may identify personal growth areas that can be further developed through the course of therapy. Indeed, awareness of the process of adjustment may guide counselors to more effective and change-enacting discussion points. An equally important outcome of research dealing with variables that contribute to the adjustment process is unique treatment and prevention programs specifically developed to address key variables. Prevention programs designed for individuals with a disability that address self-esteem through stimulation of physical activity might be successful in decreasing levels of depression and anxiety within that population. Limitations Despite the significance of the predictor variables in both regression models, there are limitations in this study. The convenience sampling method utilized the internet to identify and recruit participants. This method creates incongruence in socioeconomic status, as computer owners tend to be at one end of the socioeconomic status distribution. The predominance in the sample of individuals who fall primarily in the middle and higher SES range may inherently skew the data on some variables. Also, the data consists of self-reported items that could permit individuals to misrepresent themselves, or cause confusion in response. Either possibility would result in flawed data. The sample was not representative to the population with respect to ethnicity or disability. This discrepancy prevented further data analyses. Finally, the assessment battery was presented to each participant in the same order of instrumentation, thus potentially falling susceptible to ordering effects. Future Research Further research should be conducted using different formats (e.g., paper and pen) in order to include a wider variety of individuals. The use of different formats would also
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40 allow the researcher to randomize the order of assessments in an effort to prevent ordering effects. Future research should also incorporate more exhaustive self-esteem measures that entail sub-scales. This would create an opportunity for exploration of the relationships between self-esteem and body image, as well as self-esteem and physical activity. Similarly, future research should incorporate multiple body image assessments in an effort to fully explore the theoretical construct of body image. Finally, it was noted that there were differences in depression and anxiety based on gender. Future research is needed to investigate the nature of the differences and whether separate models of adjustment to disability occur between males and females. This research could also explore the possibility of a quadratic or curvilinear effect of time since disability onset on adjustment to disability.
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APPENDIX A INVITATION LETTER TO PARTICIPANTS Dear ____, My name is Erica Byrnes and I am a disabled graduate student at the University of Florida. I am conducting my thesis study on body image and disability, and I would like to ask for your help. I am seeking participants in the study, and I am also seeking as many places to distribute this message as possible. If you would be willing to help me in either respect I would greatly appreciate it! Participation in the study involves the completion of a survey online that takes approximately 20-30 minutes. Participation is completely anonymous, and the website will encrypt your internet address so that your location is not able to be traced. I am recruiting any person over the age of 18, who has a physical disability that requires the use of a wheelchair. My goal is to include at least 200 people in my study. I hope that the findings can be used to inform health interventions designed specifically by and for people who have a disability. The survey can be accessed online at: http://www.counselingsurveys.org/do.php?survey=s151175 Please feel free to email me with any questions. Thank you in advance for your time! Your help with this endeavor is truly appreciated! Sincerely, Erica Byrnes 41
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APPENDIX B INFORMED CONSENT Protocol Title: Body image and disability: A study of the relationship between body image and psychosocial well-being in a sample of physically disabled persons. Please read this consent document carefully before you decide to participate in this study. Purpose of the research study: To investigate the relationship between body image and psychosocial well-being in a sample of wheelchair users. What you will be asked to do in the study: To respond to anonymous survey questions online. Time required: Approximately 20-30 minutes. Risks and Benefits: No more than minimal risk. There is no direct benefit to the participant in this research. The benefit of the research is to provide additional information for understanding the relationship between body image and disability. Compensation: There is no compensation for participating in the study. Confidentiality: Your identity will be kept confidential to the extent provided by law. The Principal Investigator will protect your identity in two ways: (1) no identifying information will be requested from participants in the survey or consent process, and (2) the IP address of the computer used to participate in the study will be encrypted using a one-way hash function that makes it impossible to determine the actual IP address of the participants computer. The final results will be presented in a paper to education journals and magazines for possible publication. Voluntary participation: Your participation in this study is completely voluntary. There is no penalty for not participating. Right to withdraw from the study: You have the right to withdraw from the study at anytime without consequence. 42
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43 Whom to contact if you have questions about the study: Erica L. Byrnes, B.S., B.A., Department of Counselor Education, 1215 Norman Hall, (352) 392-0731, or, Sondra Smith, Ph.D., Department of Counselor Education, 1215 Norman Hall, (352) 392-0731. Whom to contact about your rights as a research participant in the study: UFIRB Office, Box 112250, University of Florida, Gainesville, FL 32611-2250; ph 392-0433. I have read the procedure outlined above. I voluntarily agree to participate in this study and have received a copy of this description. Participants signature Principal investigators signature _________________________________ _________________________________
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APPENDIX C BODY CATHEXIS SCALE In items 1-46, a number of things characteristic of yourself or related to you are listed. You are asked to indicate which things you are satisfied with exactly as they are, which things you worry about and would like to change if it were possible, and which things you have no feelings about one way or the other. Consider each item listed below and select the number which best represents your feelings according to the following scale: 1. Have strong feelings and wish change could somehow be made. 2. Don`t like, but can put up with. 3. Have no particular feelings one way or the other. 4. Am satisfied. 5. Consider myself fortunate. Have strong feelings and wish change could somehow be made Dont like, but can put up with Have no particular feelings one way or the other Am satisfied Consider myself fortunate 1. Hair 1 2 3 4 5 2. Facial complexion 1 2 3 4 5 3. Appetite 1 2 3 4 5 4. Hands 1 2 3 4 5 5. Distribution of hair over body 1 2 3 4 5 6. Nose 1 2 3 4 5 7. Fingers 1 2 3 4 5 8. Elimination 1 2 3 4 5 9. Wrists 1 2 3 4 5 44
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45 10. Breathing 1 2 3 4 5 11. Waist 1 2 3 4 5 12. Energy level 1 2 3 4 5 13. Back 1 2 3 4 5 14. Ears 1 2 3 4 5 15. Chin 1 2 3 4 5 16. Exercise 1 2 3 4 5 17. Ankles 1 2 3 4 5 18. Neck 1 2 3 4 5 19. Shape of head 1 2 3 4 5 20. Body build 1 2 3 4 5 21. Profile 1 2 3 4 5 22. Height 1 2 3 4 5 23. Age 1 2 3 4 5 24. Width of shoulders 1 2 3 4 5 25. Arms 1 2 3 4 5 26. Chest 1 2 3 4 5 27. Eyes 1 2 3 4 5 28. Digestion 1 2 3 4 5 29. Hips 1 2 3 4 5 30. Skin texture 1 2 3 4 5 31. Lips 1 2 3 4 5 32. Legs 1 2 3 4 5 33. Teeth 1 2 3 4 5 34. Forehead 1 2 3 4 5 35. Feet 1 2 3 4 5 36. Sleep 1 2 3 4 5 37. Voice 1 2 3 4 5 38. Health 1 2 3 4 5 39. Sex activities 1 2 3 4 5 40. Knees 1 2 3 4 5 41. Posture 1 2 3 4 5 42. Face 1 2 3 4 5 43. Weight 1 2 3 4 5 44. Sex (male or female) 1 2 3 4 5 45. Back view of head 1 2 3 4 5 46. Trunk 1 2 3 4 5
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APPENDIX D CENTER FOR EPIDEMIOLOGIC STUDIES DEPRESSION SCALE (CES-D) In items 47-66 there is a list of the ways you might have felt or behaved. Please tell me how often you have felt this way DURING THE PAST WEEK. Rarely or None of the Time (Less than 1 Day) Some or a Little of the Time (1-2 Days) Occasionally or a Moderate Amount of Time (3-4 Days) Most or All of the Time (5-7 Days) 47. I was bothered by things that usually dont bother me. 1 2 3 4 48. I did not feel like eating; my appetite was poor. 1 2 3 4 49. I felt that I could not shake off the blues even with help from my family or friends. 1 2 3 4 50. I felt that I was just as good as other people. 1 2 3 4 51. I had trouble keeping my mind on what I was doing. 1 2 3 4 52. I felt depressed. 1 2 3 4 53. I felt that everything I did was an effort. 1 2 3 4 54. I felt hopeful about the future. 1 2 3 4 55. I thought my life had been a failure. 1 2 3 4 56. I felt fearful. 1 2 3 4 57. My sleep was restless. 1 2 3 4 58. I was happy. 1 2 3 4 59. I talked less than usual. 1 2 3 4 60. I felt lonely. 1 2 3 4 61. People were unfriendly. 1 2 3 4 62. I enjoyed life. 1 2 3 4 63. I had crying spells. 1 2 3 4 64. I felt sad. 1 2 3 4 65. I felt that people dislike me. 1 2 3 4 66. I could not get going. 1 2 3 4 46
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APPENDIX E STATE TRAIT ANXIETY INVENTORY In items 67-86, a number of statements which people have used to describe themselves are given. Read each statement and then select the appropriate response below the statement to indicate HOW YOU GENERALLY FEEL. ALMOST NEVER SOMETIMES OFTEN ALMOST ALWAYS 67. I feel pleasant. 1 2 3 4 68. I feel nervous and restless. 1 2 3 4 69. I feel satisfied with myself. 1 2 3 4 70. I wish I could be as happy as others seem to be. 1 2 3 4 71. I feel like a failure. 1 2 3 4 72. I feel rested. 1 2 3 4 73. I am calm, cool and collected. 1 2 3 4 74. I feel that difficulties are piling up so that I cannot overcome them. 1 2 3 4 75. I worry too much over something that doesnt really matter. 1 2 3 4 76. I am happy. 1 2 3 4 77. I have disturbing thoughts. 1 2 3 4 78. I lack self-confidence. 1 2 3 4 79. I feel secure. 1 2 3 4 80. I make decisions easily. 1 2 3 4 81. I feel inadequate. 1 2 3 4 82. I am content. 1 2 3 4 83. Some unimportant thought runs through my mind and bothers me. 1 2 3 4 84. I take disappointments so keenly that I cant put them out of my mind. 1 2 3 4 85. I am a steady person. 1 2 3 4 86. I get in a state of tension or turmoil as I think over my recent concerns and interests. 1 2 3 4 47
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APPENDIX F ROSENBERG SELF-ESTEEM SCALE In items 87-96, please provide the requested information by selecting the response that best applies to you. Strongly D isagree Disagree Agree Strongly A gree 87. On the whole, I am satisfied with myself. 1 2 3 4 88. At times I think I am no good at all. 1 2 3 4 89. I feel that I have a number of good qualities. 1 2 3 4 90. I am able to do things as well as most other people. 1 2 3 4 91. I feel I do not have much to be proud of. 1 2 3 4 92. I certainly feel useless as times. 1 2 3 4 93. I feel that I am a person of worth, at least on an equal plane with others. 1 2 3 4 94. I wish I could have more respect for myself. 1 2 3 4 95. All in all, I am inclined to feel that I am a failure. 1 2 3 4 96. I take a positive attitude toward myself. 1 2 3 4 48
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APPENDIX G INTERNATIONAL PHYSICAL ACTIVITY QUESTIONNAIRE (IPAQ) Questions 97-103 are aimed at finding out about what kind of physical activities that people do as part of their everyday lives. The questions will ask you about the time you spent being physically active in the last 7 days. Please answer each question even if you do not consider yourself to be an active person. Please think about the activities you do at work, school, as part of your house and yard work, to get from place to place, and in your spare time for recreation, exercise or sport. Think about all the vigorous activities that you did in the last 7 days. Vigorous physical activities refer to activities that take hard physical effort and make you breathe much harder than normal. Think only about those physical activities that you did for at least 10 minutes at a time. 97. During the last 7 days, on how many days did you do vigorous physical activities like heavy lifting, digging, aerobics, or quickly pushing your wheelchair? (please provide answer in number of days) If no vigorous physical activities, please record a zero and skip to question 99. 98. How much time did you usually spend doing vigorous physical activities on one of those days? Sample response: 1 hour, 15 minutes If time is unknown, please type `Don`t know`. Think about all the moderate activities that you did in the last 7 days. Moderate activities refer to activities that take moderate physical effort and make you breathe somewhat harder than normal. Think only about those physical activities that you did for at least 10 minutes at a time. 49
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50 99. During the last 7 days, on how many days did you do moderate physical activities like carrying light loads, pushing your wheelchair above average distances, or participating in a moderate intensity sport? Do not include your normal, daily pushing of your wheelchair. (please provide answer in number of days) If no vigorous physical activities, please record a zero and skip to question 101. 100. How much time did you usually spend doing moderate physical activities on one of those days? Sample response: 1 hour, 15 minutes If time is unknown, please type `Don`t know`. Think about the time you spent pushing your wheelchair in the last 7 days. This includes at work and at home, pushing to travel from place to place, and any other pushing that you might do solely for recreation, sport, exercise, or leisure. 101. During the last 7 days, on how many days did you do push your wheelchair for at least 10 minutes at a time? (please provide answer in number of days) If no pushing meets the criteria, please record a zero and skip to question 103. 102. How much time did you usually spend pushing your wheelchair on one of those days? Sample response: 1 hour, 15 minutes If time is unknown, please type `Don`t know`. This question is about the time you spent stationary on weekdays during the last 7 days. Include time spent at work, at home, while doing course work and during leisure time. This may include time spent sitting at a desk, visiting friends, reading, or sitting or lying down to watch television. 103. During the last 7 days, how much time did you spend stationary on a weekday? (Please record your response in hours and minutes e.g., 3 hours, 20 minutes) If time is unknown, please type `Don`t know/Not sure`
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APPENDIX H DEMOGRAPHIC DATA QUESTIONNAIRE (DDQ) 104. What is your gender? O Female O Male 105. What is your Race/Ethnicity: O African-American/Black-American O Asian-American O Caucasian/White/European-American O Hispanic/Latino(a) O Other (please specify: _____________________) 106. What is your current age (in years)? _________ 107. At what age did you become disabled (please list your age at the onset of your disability)? If your disorder is genetic, please type zero. _________ 108. Which physical activities do you participate in routinely? O None O Aerobics O Weight lifting O Fast-paced pushing in wheelchair/Running O Collegiate level sports O Swimming O Quad Rugby O Wheelchair Basketball O Club sports (Which sport:______________) O Recreational sports (Which sport:______________) O Other __________________ 109. Employment Status: O Work Full Time O Work Part Time O Student O Do not work 110. Which of the following choices best describes your disability? O Physical (for example, cerebral palsy, spina bifida, amputation, spinal cord injury) O Neuromuscular (for example, multiple sclerosis, myasthenia gravis, muscular dystrophy) 51
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52 O Respiratory (for example, asthma, chronic bronchitis, emphysema) O Metabolic (for example, obesity, diabetes) O Mental (for example, mental retardation, mental illness, autism, traumatic brain injury) O Aging-Related (for example, Parkinson`s disease, stroke, arthritis, fibromyalgia, osteoporosis) O Other __________________ 111. Which type of wheelchair do you use most of the time? O Manual Wheelchair O Power/Electric Wheelchair or Scooter O I use both equally O Other (please specify: _____________________)
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55 Keppel, C. C., & Crowe, S. F. (2000). Changes to body image and self-esteem following stroke in young adults. Neuropsychological Rehabilitation, 10(1), 15-31. Krantz, J. H., Ballard, J., & Scher, J. (1997). Comparing the results of laboratory and world-wide web samples on the determinants of female attractiveness. Behavioural Research Methods in Instrumental Computing, 29, 264-269. Lazarus, R. (1993). Coping theory and research: Past, present and future. Psychosomatic Medicine, 55, 234-247. Lazarus, R., & Folkman, S. (1984). Stress, appraisal and coping. NY: Springer. Li, L., & Moore, D. (1998). Acceptance of disability and its correlates. Journal of Social Psychology, 138(1), 13-25. Livneh, H., & Antonak, R. F. (1990). Reactions to disability: An empirical investigation of their nature and structure. Journal of Applied Rehabilitation Counseling, 21, 13-21. Livneh, H., & Antonak, R. F. (1991). A hierarchy of reactions to disability. International Journal of Rehabilitation Research, 14(1), 13-24. Livneh, H., & Antonak, R. F. (1997). Psychosocial adaptation to chronic illness and disability. Maryland: Aspen Publishers, Inc. Livneh, H., Lott, S. M., & Antonak, R. F. (2004). Patterns of psychosocial adaptation to chronic illness and disability: A cluster analytic approach. Psychology, Health & Medicine, 9(4), 411-430. Livneh, H., & Martz, E. (2003). Psychosocial adaptation to spinal cord injury as a function of time since injury. International Journal of Rehabilitation Research, 26(3), 191-200. Manning, W. G., & Wells, K. B. (1992). The effects of psychological distress and psychological well-being on use of medical services. Medical Care, 30(6), 541-553. Marcusson, A., List, T., Paulin, G., & Akerlind, I. (2001). Reliability of a multidimensional questionnaire for adults with treated complete cleft lip and palate. Scandinavian Journal of Plastic Hand Surgery, 35, 271-278. Miilunpalo, S. (2001). Evidence and theory based promotion of health-enhancing physical activity. Public Health Nutrition, 4, 725-728. Nosek, M. A., & Hughes, R. B. (2003). Psychosocial issues of women with physical disabilities: The continuing gender debate. Rehabilitation Counseling Bulletin, 46(4), 224-233.
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56 Polsky, D., Doshi, J. A., Marcus, S., Oslin, D. Rothbard, A., Thomas, N., & Thompson, C. L. (2005). Long-term risk for depressive symptoms after a medical diagnosis. Archives of Internal Medicine, 165 (11), 1260-1266. Radloff, L. S. (1977). The CES-D scale: A self-report depression scale for research in the general population. Applied Psychological Measurement, 1, 385-401. Rimmer, J. H., Braddock, D., & Pitetti, K. H. (1996). Research on physical activity and disability: An emerging national priority. Medicine & Science in Sports & Exercise, 28, 1366-1372. Rimmer, J. H., Rubin, S. S., & Braddock, D. (1999). Physical activity patterns of African-American women with physical disabilities. Medicine and Science in Sports and Exercise, 31(4), 613-618. Riordan, J., Koff, E., & Stubbs, M. L. (1987). Depressive symptomlogy and body image in adolescent girls. Journal of Early Adolescence, 7, 205-216. Sands, R. T., & Wettenhall, R. S. (2000). Female wheelchair athletes and changes to body image. International Journal of Disability, 47(4), 413-426. Secord, P. F., & Jourard, S. M. (1953). The appraisal of body-cathexis: Body-Cathexis and the self. Journal of Consulting Psychology, 17, 343-347. Spielberger, C. D., Gorsuch, R. L., & Lushene, R. E. (1970). Manual for the State-Trait Anxiety Inventory (Self-Evaluation Questionnaire). Palo Alto, CA: Consulting Psychologists Press. Spielberger, C. D., Gorsuch, R. L., Lushene, R. E., Vagg, P. R., & Jacobs, G. A. (1983). Manual for the State-Trait Anxiety Inventory (Forms Y) (Self-Evaluation Questionnaire). Palo Alto, CA: Consulting Psychologists Press. Stevens, J. (1996). Applied multivariate statistics for the social sciences. NJ: Lawrence Erlbaum Associates. Tabachnick, B. G., & Fidell, L. S. (2001). Using multivariate statistics. Boston, MA: Allyn and Bacon. Taylor, W. C., Baranowski, T., & Young, D. R. (1998). Physical activity interventions in low-income, ethnic minority, and populations with disability. American Journal of Preventive Medicine, 15(4), 334-343. Theodorakis, Y., Doganis, G., & Bagiatis, K. (1991). Age differences and structural validity for the Greek version of the body cathexis scale. Psychological Reports, 68, 43-49. Tucker, L. A. (1981). Internal factor structure, satisfaction and reliability of the body cathexis scale. Perceptual and Motor Skills, 53, 891-896.
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57 Turner, R., & Beiser, M. (1990). Major depression and depressive symptomatology among the physically disabled: Assessing the role of chronic stress. Journal of Nervous and Mental Disease, 178(6), 343-350. Turner, R., & Noh, S. (1988). Physical disability and depression: A longitudinal analysis. Journal of Health and Social Behavior, 29, 23-37. Vali, F. M., & Walkup, J. (1998). Combined medical and psychological symptoms: Impact on disability and health care utilization of patients with arthritis. Medical Care, 36, 1073-1084. Waldrop, J., & Stern, S. M. (2003). Disability status: 2000, Census 2000 brief (C2KBR-17). U.S. Department of Commerce. Washington, D.C.: U.S. Government Printing Office. Wallander, J. L., Feldman, W. S., & Varni, J. W. (1989). Physical status and psychosocial adjustment in children with spina bifida. Journal of Pediatric Psychology, 14(1), 89-102. Wallander, J. L., Thompson, R. J., & Alriksson-Schmidt, A. (1995). Psychosocial adjustment of children with chronic physical conditions. In M. C. Roberts (Ed.), Handbook of pediatric psychology (pp. 141-158). New York: Guilford. Wallander, J. L., Varni, J. W., Babani, L., Banis, H. T., DeHaan, C. B., & Wilcox, K. T. (1989). Disability parameters, chronic strain, and adaptation of physically handicapped children and their mothers. Journal of Pediatric Psychology, 14(1), 23-42. Wallander, J. L., Varni, J. W., Babani, L., Banis, H. T., & Wilcox, K. T. (1988). Children with chronic physical disorders: Maternal reports of their psychological adjustment. Journal of Pediatric Psychology, 13(2), 197-212. Wallander, J. L., Varni, J. W., Babani, L., Banis, H. T., & Wilcox, K. T. (1989). Family resources as resistance factors for psychological maladjustment in chronically ill and handicapped children. Journal of Pediatric Psychology, 14(2), 157-173. Wells, K., Golding, J., & Burnam, M. (1988). Psychiatric disorder in a sample of the general population with and without chronic medical conditions. American Journal of Psychiatry, 145, 976-981. Wright, B. A. (1960). Physical disability A psychological approach. New York: Harper & Brothers. Wyatt, J. C. (2000). When to use web-based surveys. Journal of the American Medical Informatics Association, 7(4), 426-429.
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BIOGRAPHICAL SKETCH Erica L. Byrnes earned a Bachelor of Science degree in psychology and a Bachelor of Arts degree in philosophy from the University of Florida in 2002. She is pursuing a Master of Arts in Education degree in the Department of Counselor Education at the University of Florida. Erica is currently employed as an Academic Advisor at the Warrington College of Business at the University of Florida. 58
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