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

Sylia Wilson, Lindsay A. Washington, Joyce M. Engel, Marcia A. Ciol, and Mark P. JensenUniversity of Washington

Objective:To examine the relationship between perceived social support and psychological adjustment

and functional ability in youths with physical disabilities. Participants: Thirty-seven youths with

neuromuscular disease and 33 with spina bifida. Measures: Demographic and disability-related ques-

tions, Child Health Questionnaire, Functional Disability Inventory, and Multidimensional Scale of

Perceived Social Support. Results: Social support from family, but not from friends, was significantly

associated with better psychological adjustment. Significant interactions emerged between family support

and age, as well as between friend support and gross motor functioning, in the prediction of functional

ability.Conclusions: Social support appears to play an important role in psychological adjustment and

functional ability in this population, and the nature of this role may be moderated, to some extent, by age

and gross motor functioning. Future research and clinical implications are discussed.

Keywords: social support, physical disabilities, psychological adjustment, functional ability

Youths living with physical disabilities face a variety of unique

stressors, including restrictions in routine daily activities and par-

ticipation, limited independence, and coping with differences be-

tween themselves and their peers (Varni, Setoguchi, Rappaport, &

Talbot, 1992). In addition to the demands associated with typical

development, these youths must also cope with disability-specific

stressors and, therefore, face increased psychological and physical

demands associated with their diagnosis (Patterson & Geber, 1991;

see also Appleton et al., 1997; Bennet, 1994; Holmbeck et al.,

2003; Lavigne & Faier-Routman, 1992; Wallander & Thompson,

1995).A number of factors that may be associated with the psycho-

logical adjustment of this population have been examined in pre-

vious research, including perceived social support and functional

ability. Both of these have emerged as significant predictors of

adjustment in youths with physical disabilities. Higher levels of

social support and higher functional status are each positively

associated with good psychological adjustment in youths with a

number of physical disabilities. Varni, Setoguchi, Rappaport, and

Talbot (1991), for example, found that low levels of social support

from classmates increased the risk of depression and low self-

esteem in youths with limb deficiencies. Furthermore, Witt, Riley,

and Coiro (2003) found, in a nationally representative sample, that

lower youth functional status, independent of physical limitation,

was associated with psychosocial maladjustment. Similar results

have been found for a number of other diagnoses, including

diabetes (La Greca et al., 1995), limb deficiencies (Varni & Se-

toguchi, 1991; Varni et al., 1992), juvenile rheumatoid arthritis

(JRA; Varni, Wilcox, & Hanson, 1988; von Weiss et al., 2002),

and spina bifida (SB; Hommeyer, Holmbeck, Wills, & Coers,

1999). For more detailed reviews of the effects of social support

and functional status on psychological adjustment in youths, seeLa Greca, Bearman, and Moore (2002), Lavigne and Faier-Rout-

man (1993), and Wallander and Varni (1995).

Although these studies focus on the role of social support in the

lives of youths with physical disabilities, there is a lack of research

investigating the relationship between social support and func-

tional ability. Given past research indicating that social support is

positively associated with psychological adjustment in youths with

physical disabilities and that physical disability often impacts

functional ability, the present study sought to specifically examine

the interaction between these factors.

A search of the relevant literature revealed a paucity of research

examining the relationship between social support and functional

ability in youths with physical disabilities, though a link may wellexist. Research with adults has examined the predictive effects of

social support on functional ability in persons with physical dis-

abilities and chronic illnesses. Evers, Kraaimaat, Geenen, Jacobs,

and Bijlsma (2003) and Travis, Lyness, Shields, King, and Cox

(2004) found that low levels of social support predicted poorer

functional ability in adults with rheumatoid arthritis and depres-

sion, respectively. This adult research suggests that it is likely that

youths with physical disabilities may also benefit from social

support. For example, youths who have mild-to-moderate gross

motor restrictions and who are able to participate in educational

and extracurricular activities may have more opportunity for in-

Sylia Wilson, Lindsay A. Washington, Joyce M. Engel, Marcia A. Ciol,

and Mark P. Jensen, Department of Rehabilitation Medicine, University of

Washington.

This research was supported by Grant PO1 HD33988 from the National

Institutes of Health and Child Health and Human Development, National

Center for Rehabilitation Research. We gratefully acknowledge the con-

tributions of Kristie Bjornson, Ciara Kim, Chiara LaRotonda, Kimberly

McKearnan, Laura Nishimura, and Emily Phelps, Department of Rehabil-

itation Medicine, University of Washington, in data collection and database

management.

Correspondence concerning this article should be addressed to Sylia Wil-

son, Department of Rehabilitation Medicine, University of Washington, Box

356490, Seattle, WA 98195-6490. E-mail: [email protected]

Rehabilitation Psychology2006, Vol. 51, No. 4, 322330

Copyright 2006 by the American Psychological Association0090-5550/06/$12.00 DOI: 10.1037/0090-5550.51.4.322

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teraction and friendship with peers compared with those with more

severe restrictions. This social interaction may, in turn, positively

influence these youths functional ability because it allows for

increased participation, encouragement from peers, and exposure

to extracurricular activities.

A number of studies have examined social support on a global

level (i.e., social support in general) and its association withfunctioning in youths. For example, Wallander and Varni (1989)

found that children with a variety of chronic illnesses who reported

high levels of support from both family and friends exhibited

fewer behavior problems than did children who reported support

from only one source. Research suggests, however, that the dif-

ferent types of social support (i.e., that from family vs. that from

friends or peers) experienced by youths may play differential roles

in predicting psychological adjustment and functional status. Varni

et al. (1988), for example, found that family, but not peer, support

significantly predicted both internalizing and externalizing behav-

ior problems in youths with JRA.

It is also possible that different types of social support may play

different roles in adjustment as youths age (Kashani, Canfield,

Borduin, Soltys, & Reid, 1994). In examining psychological ad-aptation in youths with diabetes, for example, Varni, Babani,

Wallander, Roe, and Frasier (1989) found that perceived family

support predicted adaptation in children whereas perceived friend

support predicted adaptation in adolescents. This suggests the

possibility that perceived social support from friends might in-

crease in importance as children move into adolescence.

To better understand the role that social support may play in

persons with physical disabilities, the present study investigated

the relationship between perceived social support and psycholog-

ical adjustment and functional ability in youths with neuromuscu-

lar disease (NMD) and SB. These two disability types were in-

cluded both because of their commonality in the general

population and because little is as yet known about them. Thepotentially moderating roles that age and gross motor functioning,

an indicator of functional ability, may play in the association

between social support and functioning are also examined. Given

previous research in this area, our primary hypothesis was that

higher perceived social support would be associated with better

psychological adjustment in the sample, as indicated by higher

scores on a mental health scale. On the basis of research with

adults with physical disabilities and chronic illnesses, we further

hypothesized that youths with higher perceived social support

would report higher functional status. Finally, our third hypothesis

was that age and gross motor functioning would moderate the

association between perceived social support and both psycholog-

ical adjustment and functional status of participants. Specifically,

we predicted that perceived friend support would be more impor-tant for psychological adjustment in older youths and that per-

ceived family support would be more important for younger

youths. Similarly, we predicted that perceived social support

would show a stronger association with functioning among youths

with higher gross motor functioning than among youths with lower

levels of gross motor functioning.

Method

The data for this study came from a larger ongoing study of youths with

physical disabilities on the nature and scope of pain in this population. The

present article is the first to examine data from this larger study. The

present analyses focus on a subset of the measures obtained during youth

interviews and from parent questionnaires that address issues related to

youth-reported perceived social support, psychological adjustment, and

functional ability, as well as parent/guardian-reported demographic infor-

mation and disability level.

Participants

Participants were a convenience sample of youths with NMD (n 37)

and SB (n 33), and their parents/guardians, from the greater Seattle,

Washington, metropolitan area. Inclusion criteria included (a) a primary

diagnosis of NMD or SB; (b) chronological age between 8 and 20 years; (c)

capacity for expressive communication using augmentative communica-

tion devices as needed, although, in fact, none of the participants in the

present study used such devices during the interview; (d) no more than

mild cognitive impairment as determined by a brief telephone screening

with the parent/guardian and a minimum passing score of 17/25 on a

modified Mini-Mental Status Examination (MMSE; Roccaforte, Burke,

Bayer, & Wengel, 1992); and (e) use of English as the primary language.

The MMSE has been successfully used in children as young as 4 years

(Ouvrier, Goldsmith, Ouvrier, & Williams, 1993). The minimum passingscore of 17/25 is the cutoff score suggested by Roccaforte et al. If the

MMSE was conducted over the telephone, as opposed to in person,

participants were not assessed on the motoric component of the examina-

tion and, therefore, required a passing score of 15/22. See Table 1 for

further demographic information.

Materials

Structured interviews for the youths and questionnaires for the parents/

guardians included questions and measures that assessed demographic

information; disability level; psychological adjustment; impact of pain,

illness, and disability on functioning; and perceived social support.

Demographic data. Descriptive demographic data collected from the

parent/guardian included the youths age and sex and the total family

household income.Disability level. To assess gross motor functioning, we asked parents/

guardians to respond to a modified version of the Gross Motor Functioning

Classification Scale (GMFCS; Palisano et al., 1997). The GMFCS was

developed for use with the cerebral palsy population. The items were

adapted slightly in the present study to accommodate for the multiple

physical disabilities represented in our sample. The specific items used in

the present study were the following: I walks without restrictions but has

limitations in more advanced gross motor skills; II walks without an

assistive device and has limitations walking outdoors and in the commu-

nity; III walks with an assistive mobility device and has limitations

walking outdoors and in the community; IV limited self-mobility with

assistance or device (e.g., another person, walker, wheelchair) and uses

power mobility outdoors and in community only; and V severely limited

self-mobility even with the use of assistive technology (e.g., power mo-

bility). Lower scores on the gross motor functioning scale indicate a higher

level of functioning.

Psychological adjustment. Youth participants answered questions

from the Mental Health (MH) Scale from the child form of the Child

Health Questionnaire (CHQCF87; Landgraf, Abetz, & Ware, 1996). The

CHQCF87 is an 87-item self-report measure designed to assess youths

physical and psychosocial well-being. The questionnaire is divided into 12

scales and includes a 16-item MH Scale, which measures the frequency of

negative and positive states and is designed to capture anxiety, depression,

and positive affect. Using this measure, participants rate how often they

experienced different moods and feelings in the past 4 weeks on a 5-point

Likert scale ranging from 1 (all of the time) to 5 (none of the time). A low

score on the CHQCF87 MH Scale indicates that the child feels anxious

323PERCEIVED SOCIAL SUPPORT IN YOUTHS

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and depressed all of the time, whereas a high score indicates that he or she

feels peaceful, happy, and calm all of the time. The CHQCF87 is scored

by first computing a raw score, then transforming raw scores to standard-

ized scores, using the method outlined by Landgraf et al. Standardized

scores range from 0 to 100. The CHQCF87 MH Scale has demonstrated

adequate internal consistency in samples of youths with psychological and

physical diagnoses (e.g., attention deficit hyperactivity disorder, asthma,

JRA, and epilepsy; Cronbachs .82.86; Landgraf et al., 1996). The

alpha for our sample was .88. The scale has also demonstrated substantial

validity for measuring youths psychosocial well-being (Landgraf et al.,

1996).

Impact of illness, pain, or disability. Youth participants reported the

impact of illness, pain, or disability on their physical and psychosocial

functioning in everyday social roles by answering questions from the

Functional Disability Inventory (FDI; Walker & Greene, 1991). The FDI is

used to provide information on disruption of typical physical and social

activities, including schoolwork, caused by illness, pain, or disability.

Though this measure does not isolate pain as the primary contributor to

functional impairment, it does provide insight into activity interference, an

important aspect of this study. The FDI is comprised of 15 behaviors

related to functioning in child-relevant settings, such as In the last fewdays, would you have had any physical trouble or difficulty doing these

activities (e.g., being at school all day)? Using the FDI, respondents rate

the amount of difficulty of each activity on a 5-point Likert scale ranging

from 0 (no trouble) to 4 (impossible). The FDI is scored as a total sum of

items. This score ranges from 0 to 60. We prorated FDI items left blank in

the present study by calculating means based on answered items. The FDI

is scored such that lower scores indicate a higher level of functional ability.

The FDI has demonstrated good internal consistency in samples of youths

with minor health complaints (e.g., dysmenorrhea, gastrointestinal upset,

upper respiratory infections) and pediatric abdominal pain (Cronbachs

.85.92; Walker & Greene, 1991). It has also been used in studies of

recurrent headache, juvenile idiopathic arthritis, and sickle cell disease

(Logan & Scharff, 2005; Peterson & Palermo, 2004). The alpha for our

sample was .82. Evidence for the validity of the FDI as a measure ofillness, pain, or disability comes from its significant correlation with scores

on other measures of physical and emotional health (Walker & Greene,

1991).

Perceived social support from family and friends. Youth participants

reported on perceived social support from family and friends by answering

8 items from the Multidimensional Scale of Perceived Social Support

(MSPSS; Zimet, Dahlem, Zimet, & Farley, 1988). The original MSPSS is

a 12-item self-report measure of perceived social support from family (4

items), friends (4 items), and a significant other (4 items). For the present

study, we used only those 8 items assessing perceived social support from

family and friends, as we did not anticipate that the majority of participants

in the present study would have a significant other. For each item,

participants rate their level of agreement on a 7-point Likert scale ranging

from 1 (very strongly disagree) to 7 (very strongly agree). The MSPSS is

scored as a total summed score for each of the subscores (family supportand friend support). These subscores can range from 4 to 28. Higher scores

on the MSPSS indicate a higher level of perceived social support. The

MSPSS was shown to have good internal consistency in a typically

developing adult sample (Cronbachs .88 for the global score; Zimet

et al., 1988). Our sample had similarly high alphas (.86 for the global score,

.80 for the family score, and .88 for the friend score). Validity of the

original MSPSS scale comes from research that demonstrates its significant

negative association with depression and anxiety (Zimet et al., 1988). To

our knowledge, the MSPSS has not yet been used to assess perceived social

support in samples of youths.

Procedure

The study participants were recruited through mailings from clinics atthe local regional childrens hospital, as well as through public postings,

word of mouth, and, for some of the participants with NMD, a local

summer camp for youths with muscular dystrophy. All of the participants

and participating parents/guardians gave written informed assent/consent,

and the study was approved by Childrens Hospital and Regional Medical

Centers Institutional Review Board (Seattle, WA). Youth participants

completed one-time, in-person interviews in the participants home, at the

University of Washington Medical Center, at a local summer camp, or over

the telephone. Youths were interviewed in a private setting whenever

possible to minimize potential response interference from family members

and to ensure privacy. Parents/guardians of participating youths also com-

pleted brief questionnaires, either during the youth interview or by mail.

Table 1

Demographic Characteristics

Variable n %

SexMale 42 60Female 28 40

EthnicityaCaucasian 57 81Asian 6 9African American 3 4Hispanic 3 4American Indian 1 1

Family incomeb

Under $10,000 3 6$10,000$20,000 3 6$20,000$30,000 5 10$30,000$40,000 10 20$40,000$50,000 5 10$50,000$60,000 4 8$60,000$70,000 3 6Over $70,000 17 34

Neuromuscular disease diagnosisa

Duchenne muscular dystrophy 11 30Myotonic muscular dystrophy 6 16Spinal muscular atrophy 6 16CharcotMarieTooth 5 14Becker muscular dystrophy 2 5Congenital muscular dystrophy 2 5Limb-girdle muscular dystrophy 2 5Facioscapulohumeral muscular dystrophy 1 3Other 2 5

Spina bifida diagnosisMyelomeningocele 24 73Meningocele 5 15Other 4 12Hydrocephalus 23 70

Gross motor functioningc

I 21 30II 18 26

III 3 4IV 14 20V 14 20

Note. N 70. Age: M 14.51, SD 3.06, range 920.a Percentages may not equal 100% because of rounding. b Total Nmaynot equal 70 because of missing data. c I walks without restrictions buthas limitations in more advanced gross motor skills; II walks without anassistive device and has limitations walking outdoors and in the commu-nity; III walks with an assistive mobility device and has limitationswalking outdoors and in the community; IV limited self-mobility withassistance or device (e.g., another person, walker, wheelchair) and usespower mobility outdoors and in community only; V severely limitedself-mobility even with the use of assistive technology (e.g., powermobility).

324 WILSON, WASHINGTON, ENGEL, CIOL, AND JENSEN

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Data Analysis

Correlation coefficients were computed between continuous measures of

demographic/descriptor variables (age and gross motor functioning), cri-

terion variables (psychological adjustment and functional disability), and

predictor variables (perceived family and friend support) to estimate the

strength of the associations between the variables used in this study. We

performedttests to determine if sex or ethnicity (coded as Caucasian/non-Caucasian) were associated with the criterion and predictor variables. A

series of chi-square and t-test analyses were conducted to determine

whether participants with NMD and SB differed on demographic/descrip-

tive (age, sex, ethnicity, and gross motor functioning), criterion (psycho-

logical adjustment and functional disability), or predictor (perceived family

and friend support) variables. Any significant differences on these variables

would suggest that the two groups were too dissimilar to collapse for

primary regression analyses and should, therefore, be analyzed separately.

Regression analyses were used to test the hypothesis that perceived

social support was significantly associated with psychological adjustment

and functional ability. In these analyses, the CHQCF87 MH Scale and the

FDI were the criterion measures, and the MSPSS Family and Friend

subscales were the primary predictors. We followed West, Aiken, and

Krulls (1996) suggestion that predictor variables be centered prior to

computing interaction terms by first subtracting the mean score from eachparticipants MSPSS family and friend score. Any significant univariate

associations between demographic control variables (sex and ethnicity)

would suggest the possibility that such variables might confound the

association between perceived social support and psychological adjustment

or functional ability, and, therefore, any such variable that showed a

significant univariate association with the criterion variables was entered as

control variables in the first step of the regression analyses. The primary

predictors (perceived family and friend support) were then entered as a

block in the next step. To determine the extent to which age or gross motor

functioning might act as moderators of the association between perceived

social support and psychological adjustment and functional ability, we

entered age and the participants gross motor functioning scores next in

separate regression analyses, and we entered, stepwise, a term representing

the interaction between age and the gross motor functioning score and each

primary predictor in a final step (Cohen & Cohen, 1983).

Results

Participants with NMD and SB did not differ significantly on

demographic/descriptive (age, sex, ethnicity, and gross motor

functioning), criterion (psychological adjustment and functional

disability), or predictor variables (perceived family and friend

support). The two groups were, therefore, collapsed for all further

analyses. In addition, neither of the potential demographic control

variables (sex and ethnicity) showed a significant univariate asso-

ciation with the criterion variables, so these variables were not

included in the regression models.

Table 2 provides descriptive statistics for each of the measuresused in the present study. Correlation analyses between demo-

graphic/descriptive (age and gross motor functioning), criterion

(psychological adjustment and functional disability), and predictor

variables (perceived family and friend support) revealed signifi-

cant associations between family support and psychological ad-

justment, friend support and family support, friend support and

functional disability, and gross motor functioning and functional

disability (see Table 3).Ttests examining the relationship between

sex or ethnicity and the criterion and predictor variables, however,

revealed no significant effects.

The regression analyses predicting psychological adjustment

indicated a significant effect for the perceived social support

measures, with 19% of the variance in the CHQCF87 MH Scale

accounted for by the MSPSS Family and Friend subscales. The

beta weights in the final equation of these models indicated that

perceived family support made a significant and positive indepen-

dent contribution to the prediction of participant mental health (see

Table 4), whereas friend support made a negative, but nonsignif-icant, contribution. Neither age nor gross motor functioning, nor

interactions between family or friend support and these terms,

contributed significantly to the models.

The regression analyses predicting functional ability indicated

that both perceived family and friend support showed significant

direct associations with functional ability. Higher perceived family

support predicted lower functional ability, as measured by higher

scores on the FDI, whereas higher perceived friend support pre-

dicted higher functional ability, as measured by lower scores on

the FDI. Furthermore, after controlling for age in the first model

predicting functional ability, a significant interaction between per-

ceived family support and age emerged (see Table 4). After con-

trolling for gross motor functioning in the second model predictingfunctional ability, and as might be expected, lower gross motor

functioning scores were significantly associated with lower func-

tional ability, as measured by higher scores on the FDI. In addition,

a significant interaction between perceived friend support and

gross motor functioning was found (see Table 4).

To plot these interactions as continuous data, we reran regres-

sion analyses predicting functional ability, including only family

support, age, and the interaction of these two terms, and friend

support, gross motor functioning, and the interaction of these two

terms (see Table 5). As would be expected, on the basis of the

omnibus analyses, the interactions were still significant.

The beta weights from these interactions were used to plot the

effects of these interactions (see Figures 1 and 2), as recommended

by Cohen and Cohen (1983). The three regression lines used inFigure 1 represent three levels of age and were created by substi-

tuting the age score representing one standard deviation below the

mean (11.45 years old), that representing the mean (14.51 years

old), and that representing one standard deviation above the mean

(17.57 years old) in the regression equation for the first model

predicting functional ability, and then solving for the criterion

variable, functional ability.

As is evident in Figure 1, the slopes of the regression lines for

younger, mid-range, and older youths indicate that, among rela-

tively older youths, higher levels of perceived family support were

associated with higher functional ability, whereas, among younger

Table 2

Descriptive Statistics for Each Measure

Measure n M SD Range

Mental health scale(CHQCF87) 70 76.54 14.44 32.81100.00 .88

FDI 70 11.38 8.95 032.00 .82

MSPSS family support 70 24.33 3.77 13.0028.00 .80MSPSS friend support 70 22.74 5.56 3.0028.00 .88

Note. CHQCF87 Child Health Questionnaire, child version; FDI Functional Disability Inventory; MSPSS Multidimensional Scale ofPerceived Social Support (family and friend subscores).


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youths, higher levels of perceived family support were actuallyweakly associated with lower functional ability. The three regres-

sion lines used in Figure 2 represent three levels of gross motor

functioning and were created in the same manner, but by substi-

tuting the three gross motor functioning scores (mild restriction

1.18, moderate restriction 2.74, and severe restriction 4.30) in

the regression equation for the second model predicting functional

ability, before solving for the criterion variable. The slopes of the

regression lines for the three gross motor functioning levels indi-

cate that, for those youths with severe ambulatory restrictions,

higher functional ability was strongly associated with higher per-ceived friend support.

Discussion

The present study investigated the relationship between per-

ceived social support and psychological adjustment and functional

ability in youths with NMD and SB, while also examining age and

gross motor functioning as potential moderating factors in this

relationship. The finding that higher perceived social support pre-

Table 3

Correlation Matrix Illustrating Relationship Between Demographic/Descriptive and Criterion

and Predictor Variables

Variable

Demographicvariable Criterion variable

Predictor variable

Age GMF MH FDI

MSPSS family

support

MSPSS friend

support

MSPSS friend support .05 .06 .12 .27* .51** MSPSS family support .12 .03 .42** .16 FDI .07 .40** .19 MH .19 .22 GMF .16 Age

Note. GMF gross motor functioning; MH Mental Health Scale of the Child Health Questionnaire, childversion; FDI Functional Disability Inventory; MSPSS Multidimensional Scale of Perceived Social Support(family and friend subscores).*p .05. **p .01.

Table 4

Multiple Regression Analyses Examining the Association of Perceived Social Support WithConcurrent Age, Gross Motor Functioning, Mental Health, and Functional Ability

Step and variable Total R2 R2 change FchangeFinal

unstandardized

Mental Health Scale (CHQCF87)1. Social support .19 .19 7.63**

Family support 1.74**Friend support 0.27

2. Age .20 .02 1.38 0.62Mental Health Scale (CHQCF87)

1. Social support .19 .19 7.63**Family support 1.78**Friend support 0.27

2. GMF .22 .04 3.17 1.80Functional ability (FDI) with age as controlled variable

1. Social support .07 .07 2.64Family support 3.51*Friend support 0.46*

2. Age .08 .01 0.45 0.523. Family Support Age .16 .08 6.57* 0.24*

Functional ability (FDI) with GMF as controlled variable1. Social support .07 .07 2.64

Family support 0.19Friend support 0.53

2. GMF .22 .15 12.20** 2.44**3. Friend Support GMF .27 .05 4.66* 0.29*

Note. CHQCF87 Child Health Questionnaire, child version; GMF gross motor functioning; FDI Functional Disability Inventory.*p .05. **p .01.


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dicted better psychological adjustment was consistent with our first

hypothesis. Specifically, perceived social support contributed sig-

nificantly to the prediction of participant mental health, explaining

19% of the variance in this criterion measure. This finding wasexplained primarily by the effect of perceived family support,

which showed a positive and significant association with psycho-

logical adjustment, whereas friend support showed a negative, but

nonsignificant, association with psychological adjustment.

The lack of significant association between perceived friend

support and psychological adjustment is inconsistent with Varni et

al.s (1989) finding that adaptation in adolescents with diabetes

was predicted by perceived social support from friends. One ex-

planation for this discrepancy may be the probable relative differ-

ence in the amount of time that youths with physical disabilities

spend with family members, in contrast to youths with chronic

illnesses that do not involve physical limitations. For example,

many youths who have physical disabilities may rely more on

family for assistance with everyday tasks, such as getting out of

bed, dressing, and transportation, including transportation to

school or social activities with friends. In addition, older adoles-

cents who use a wheelchair or have other mobility limitationsmight differ from peers in their capacity to participate indepen-

dently in activities with friends. Many adolescents who are typi-

cally developing experience greater independence when they turn

16 years old, as they often no longer need to rely on another person

for transportation. It is possible that youths with physical disabil-

ities, many of whom cannot drive themselves, either spend an

increased amount of time at home, presumably with family mem-

bers, or require a family members assistance to travel from place

to place.

The finding that higher perceived friend, but not family, support

predicted higher functional ability was partially consistent with our

second hypothesis. Findings were inconsistent with our specific

Low

High

Younger

FunctionalAbility(FDI)

Mid-Range

Older

Low Support High Support

Family Support (MSPSS)

Figure 1. Effect of age on the relationship between family support, as

measured by the Multidimensional Scale of Perceived Social Support

(MSPSS), and functional ability, as measured by the Functional Disability

Inventory (FDI). The regression lines were created by substituting three

levels of age in the regression equation and solving for functional ability.

Low

High

FunctionalAbility(FDI)

Mild Restriction

Moderate Restriction

Severe Restriction

Low Support High Support

Friend Support (MSPSS)

Figure 2. Effect of gross motor functioning on the relationship between

friend support, as measured by the Multidimensional Scale of Perceived

Social Support (MSPSS), and functional ability, as measured by the Func-

tional Disability Inventory (FDI). The regression lines were created by

substituting three levels of gross motor functioning in the regression

equation and solving for functional ability.

Table 5

Multiple Regression Analyses Examining the Association of Perceived Social Support With

Concurrent Age, Gross Motor Functioning, and Functional Ability

Step and variable Total R2 R2 change FchangeFinal

unstandardized

Functional ability (FDI) with age as controlled variable

1. Family support .03 .03 1.75 2.99*2. Age .03 .00 0.17 0.413. Family Support Age .10 .08 5.66* 0.23*

Functional ability (FDI) with GMF as controlled variable1. Friend support .07 .07 5.32* 0.452. GMF .22 .14 12.15** 2.41**3. Friend Support GMF .27 .05 4.55* 0.28*

Note. FDI Functional Disability Inventory; GMF gross motor functioning.*p .05. **p .01.


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hypotheses about the nature of the moderating effects of age and

gross motor functioning on the association between perceived

social support and psychological adjustment and functional ability,

although unanticipated moderating effects were found. In the first

model predicting functional ability, a significant interaction be-

tween perceived family support and age emerged, but follow-up

analyses revealed that higher levels of perceived social supportfrom the family were associated with higher functional ability

among olderyouths, not younger youths, as predicted. Although

conclusions about the reliability of these findings must await

further research and replication, the finding that, among younger

youths, higher levels of perceived family support were actually

weakly associated with lower functional ability was surprising. It

is possible that family support may, in fact, be expressed through

an excess of assistance, so that these younger youths are not given

the opportunity or are not motivated to perform at a level at which

they are actually capable. As these youths age, however, they may

experience improvements in their functional ability as a result of

the cumulative positive effect of family support while they were

young. Future research should explore this possibility through

longitudinal studies.In addition, if these results are replicated, these findings suggest

that family support may be particularly important in older youths

with disabilities. Perhaps, again, because older youths with dis-

abilities may be more dependent on their family than same-age

peers who do not have a disability, family support may be even

more important as children with disabilities age than when they are

younger. Although as children move into adolescence the signif-

icance of friendships increases and the presence of such relation-

ships is important for social maturity development (Frey & Roth-

lisberger, 1996), youths with physical disabilities may be limited

in their ability to forge and maintain strong relationships with

peers because of several factors. These may include physical

restrictions, cognitive impairments, rehabilitation and medical ob-ligations like physical therapy and checkups, and social stigma

toward people with disabilities (La Greca et al., 2002). As a result,

older youths may continue to find the social support they need for

high functional status primarily from family members.

In the second model predicting functional ability, a significant

interaction between perceived friend support and gross motor

functioning emerged. Further follow-up analyses of this interaction

indicated that the nature of the moderating effect of gross motor

functioning on the association between perceived social support

and functional ability was inconsistent with our prediction. We had

anticipated that perceived social support would show a stronger

association among participants with mild ambulatory restrictions.

Instead, we found that, among youths with severe ambulatory

restrictions, higher functional ability was associated with higherperceived social support from friends. As this is the first time that

such a moderating effect has been examined, its reliability cannot

be assumed. If reliable, however, this moderating effect could be

influenced by the positive effects of perceived social support. For

example, youths with severe ambulatory restrictions who nonethe-

less have strong friend support and frequent involvement with

peers might be invited or encouraged to do more physical activities

with and by their peers. This, in turn, may increase the likelihood

that these youths may both participate in these activities and

develop skills useful for independent functioning.

Certain limitations should be highlighted in the present study.

First, it is important to note that our study populations included

only youths with SB and NMD. Although youths with these

disabilities experience a number of complications and physical

restrictions that are common to other physical disabilities, it is

possible that our results may not generalize to youths with all types

of physical disabilities. Future research should, therefore, include

youths with other diagnoses.A second limitation concerns the measures used in the present

study, as well as the method used to administer the measures. The

exclusive use of self-report data to assess the primary predictor and

criterion variables has the potential to bias results with regard to

the ability of participants to accurately evaluate social support and

the capability of performing activities, as well as creating the

possibility of a general source bias. Given that there are few

previously published studies in this area, it is difficult to demon-

strate the validity of these self-reported results by comparison with

other research. Additional research on the impact of perceived

social support on psychological adjustment and functional disabil-

ity for youths is needed to determine the reliability of our findings.

Future research could potentially assess social support from other

sources, such as through parent and teacher reports, to supplementfindings from primary sources.

The use of the MSPSS to assess perceived social support is also

a limitation of the measures used in the present study. Although the

internal consistencies of the scores from this measure in our

sample were high, the MSPSS has at present only been validated

for use with adults. Furthermore, it measures perceived social

support by using only eight items and does not assess other

important aspects of social support, such as network size and

density. It is possible, for example, that the findings of the present

study are in fact a reflection of the fact that a significant number of

participants had few or no close friends, or had infrequent contact

with peers. The limitations of the MSPSS may account for the

unexpected finding that friend support was negatively, but notsignificantly, associated with psychological adjustment. Future

research would benefit from the use of measures that assess addi-

tional aspects of social support.

The measures used were originally developed and validated as

paper-and-pencil questionnaires but were interview-administered

in the present study. As participants indicated answers to each

question to an interviewer, instead of privately marking answers,

responses may reflect demand characteristics. This methodology

was used nevertheless because of the potential for restrictions in

fine motor functioning of the participants. Moreover, the strong

internal consistencies found for each of the measures supports their

reliability in the sample, even with this altered methodology.

A final limitation is the potential for selection bias in the study

sample. Owing to the nature of our recruitment sites, participantsin the present study had parents/guardians who were not only

involved in their childrens medical care and recreation but who

were also willing and able to contact researchers regarding enroll-

ment. In addition, the study did not include youths with more than

mild cognitive impairment. It is possible that the inclusion of

youths with moderate-to-severe cognitive impairment might have

affected the sample in terms of severity of physical disability, as

well as the presence and strength of peer relationships. The scales

used in this study, however, require the participants to reflect

accurately on recent emotions, as well as evaluate their physical

capabilities, therefore necessitating that the youths possess a cer-


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tain level of cognitive functioning. The use of multiple informants

in gathering future data may be a means of circumventing this

issue, as this would allow for the inclusion of youths with mod-

erate-to-severe cognitive impairment.

Despite the limitations of the present study, however, the find-

ings offer several important new contributions. First, the results are

consistent with previous research indicating that higher perceivedsocial support predicts better psychological adjustment. Further-

more, expanding on earlier studies, the present findings suggest

that perceived family and friend support play a particularly im-

portant role for youths with physical disabilities. Moreover, we

found that family and friend support interacted with age and gross

motor functioning, respectively, to predict participant psycholog-

ical adjustment and functional ability in the present sample. This

suggests the possibility that perceived social support may be

particularly important for functioning among older youths and

among youths with more severe gross motor limitations. To our

knowledge, this is the first study to examine the role of perceived

social support on functional ability of this population. Future social

support research should take into consideration the moderating

roles of age and gross motor functioning on the psychologicaladjustment and functional ability in youths with physical

disabilities.

If the findings from the present study replicate in future studies,

they would then argue for interventions to help families and

friends of youths with physical disabilities to provide more effec-

tive support to bolster psychological and physical functioning in

this population. Interventions could include social support training

programs and support groups for the parents/guardians and sib-

lings of these youths. Moreover, the finding that higher perceived

friend support is associated with higher functional ability in youths

with severe ambulatory restrictions has implications for academic

settings. Future research should examine the effects of supportive

interactions between youths who are typically developing andyouths with physical disabilities, particularly if the youths have

severe physical restrictions and are, therefore, less likely to have

opportunities for peer interactions. It is hoped that research of this

nature, and the development of interventions based on the findings

of such research, will help to continue to improve the quality of life

of youths with physical disabilities.

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Received August 4, 2005

Revision received December 1, 2005

Accepted February 7, 2006


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