Social Competence in Children With Chronic Illness

A Meta-analytic Review

William Martinez; MA; Jocelyn Smith Carter; PhD; Lauren Jennifer Legato; MA


J Pediatr Psychol. 2011;36(8):878-890. 

In This Article

Abstract and Introduction


Objective To conduct a meta-analysis of social competence in children with a chronic illness.
Methods The meta-analysis included 57 studies comparing levels of social competence in children with chronic illness to those of children without chronic illness. A random effects model was used to calculate overall effect, subgroup, and meta-regression analyses.
Results Overall, the meta-analysis calculated 90 unique outcomes, producing a summary standardized mean difference of d = −0.44, 95% confidence interval (95% CI) −0.52 to −0.36 indicating a medium overall effect for decrease social competence. Chronic illness, measure, and informant moderated social competence outcomes.
Conclusions The impact of chronic illness on youth varied by individual child factors (e.g., gender, chronic illness type) and by measurement features such as informant and measure type. The current study demonstrates a need for further research of the assessment of social competence and has implications for the development of social skills programs for children with chronic illness.


Chronic illness (CI) in childhood can be understood as a heterogeneous category encompassing diverse diseases with varying degrees of impact on children and their families (Newacheck & Taylor, 1992). Perrin and colleagues (1993) operationalized CI as a disease lasting, or expecting to last, at least three months and demonstrating some impact on the child, such as functional impairment or a greater than expected need for medical attention given a child's age. A disease implies "a condition of the body or one of its parts that impairs normal functioning and is typically manifested by signs and symptoms" (Disease, 2011). According to these definitions, examples of chronic childhood diseases include diabetes, asthma, and cancer. Obesity does not meet this definition because obesity is regarded as a chronic medical condition, not a disease. However, given the current epidemic status (Wang & Beydoun, 2007) and its impact on diseases in adolescence and adulthood (Baker, Olsen, & Sorensen, 2007; Nathan & Moran, 2008), obesity was also included in the current study.

Despite the differing definitions of CI, it is undeniable that chronic medical conditions affect many children. One out of two Americans suffer from a chronic illness (Centers for Disease Control and Prevention, 2010). Prevalence rates of CI in children vary greatly depending on definitions used, ranging from 3.5% to 35.3% (van der Lee, Mokkink, Grootenhuis, Heymans, & Offringa, 2007). Rates of childhood CI have steadily increased from 1.8% in 1960 to 7% in 2004, mostly as a result of advances in healthcare, which have allowed children to live longer, and increased incidences of obesity and asthma (Van Cleave, Gortmaker, & Perrin, 2010).

Children with CI may be at increased risk for developing social deficits compared to their healthy peers because of limitations associated with their illnesses, such as fewer social opportunities, restricted physical capabilities, or feelings of alienation from peers (La Greca, 1990). Establishing positive peer relationships is an important developmental task in childhood (Parker & Asher, 1993) with implications for later social adjustment. Studies have found high-quality friendships and peer acceptance to relate to higher levels of adjustment in children and adolescents (Ladd & Price, 1987; Waldrip, Malcolm, & Jensen Campbell, 2008). Emotional support from peers may serve as a protective factor against risk for social isolation in children with CI. For example, La Greca and colleagues (1992) found that peer emotional support for children with diabetes helped them feel more accepted. Therefore, understanding levels of social functioning in relation to pediatric CI is important for improving the outcomes of children who suffer from chronic medical conditions.

The quality of social interactions with other children has been broadly defined as social competence (Hops, 1983). Other definitions of social competence proposed in the literature include: an evaluation of a child's level of social functioning (Rose-Krasnor, 1997) and the relationship between social information-processing patterns and children's social behavior (Dodge, Pettit, McClaskey, Brown, & Gottman, 1986). Much like the term "chronic illness," social competence is a nebulous construct in the literature that lacks an agreed-upon operational definition. Several reviewers of the literature have proposed heuristics for organizing and understanding the disparate theoretical and operational views of social competence (Cavell, 1990; Dirks, Treat, & Robin Weersing, 2007; Rose-Krasnor, 1997).

Cavell (1990) proposed a tricomponent model of social competence comprised of social adjustment, social performance, and social skills. Later, Rose-Krasner (1997) incorporated Cavell's subconstructs into four operational approaches: social skills, sociometric status, relationship quality, and functional outcomes. These categories provide a useful method for comparing and contrasting the disparate constructs tapped by existing measures of social competence. More recently, in an attempt to integrate theoretical, measurement, and intervention models for social competence in youth, Dirks and colleagues (2007) proposed a four-factor model of social competence based on four predictors associated with social competence—child, behavior, situation, and judge. According to the model, each predictor would explain unique variance in social competence, and the total variance would also include interactions among the predictor variables. Given the complexity inherent in the conceptualization and measurement of social competence, numerous measures tapping different constructs of social competence have been used to date to assess children's social functioning.

Several comprehensive reviews of the literature on the relationship between CI and social competence in children have been written (Reiter-Purtill, Waller, & Noll, 2010; Spirito, DeLawyer, & Stark, 1991). In one such review, Spirito and colleagues (1991) concluded that some children with CI appeared to experience social difficulties as rated by teachers and classmates. However, studies showing deficits in social competence (Deasy-Spinetta, 1981; Sawyer, Crettenden, & Toogood, 1986) only included samples of children with cancer. The authors concluded there was a need for more research in order to better ascertain the impact of social competence on children with different types of CIs.

Since 1991, the pediatric psychology field has responded to Spirito et al.'s (1991) call for further research; however, the literature has narrowly focused on a select few CI categories (e.g., cancer, sickle cell) and includes many discrepant findings even within individual disease types. For example, one study of children with multiple types of cancer found children's social competence levels to be the same or higher than matched healthy controls (Deasy-Spinetta, 1981; Noll, et al., 1999). Conversely, other studies found poor social competence outcomes among child survivors of cancer (Barrera, Shaw, Speechley, Maunsell, & Pogany, 2005; Vannatta, Zeller, Noll, & Koontz, 1998). Studies investigating sickle cell disease found similar discrepancies (Lemanek, Horwitz, & Ohenefrempong, 1994; Noll, Reiter-Purtill, Vannatta, Gerhardt, & Short, 2007). These disparate findings within CIs demonstrate the need for further study of moderators, such as ethnicity, gender, and age, in order to examine whether they may account for some of the group differences.

Contrary to the previously discussed discrepant findings in the literature, studies investigating juvenile arthritis have demonstrated findings that are somewhat more consistent across studies. For example, Huygen, Kuis, and Sinnema (2000) found no differences on parent reports of social competence for children or adolescents with juvenile chronic arthritis (JCA) compared to healthy peers. In another study of children and adolescents with juvenile rheumatoid arthritis (JRA), children with JRA showed no differences on social competence compared to their matched peers, despite having participated in fewer reported social activities (Feldmann, Weglage, Roth, Foell, & Frosch, 2005). Despite the relative consistency across studies of children with arthritis, it is still difficult to compare results since each study employed varied types of social competence measures. Given the heterogeneous nature of children with CI as a group (van der Lee, et al., 2007) and the methodological differences among studies, results on differences in social competence between children with CI and healthy peers currently present discrepancies. A systematic review of the literature is necessary to synthesize such a large body of empirical research with so many heterogeneous factors. Meta-analytic techniques provide a robust measurement tool for assessing the impact of social competence on children with CI while also serving as a review on the advancements of the literature in a particular area of research. Meta-analysis allows for statistical testing of effect sizes and potential moderators in order to more fully interpret the empirical evidence provided by previous research studies (Borenstein, Hedges, Higgins, & Rothstein, 2009). In the current study, we sought to explore the following research questions:

  1. Is the overall social competence of children with CI different than that of healthy comparisons, and if so, how large is that difference?

  2. Does social competence vary by the category of CI?

  3. Does social competence in children with CI vary according to demographic features such as age, ethnicity, or gender?

  4. Does social competence in children with CI vary according to the type of informant (e.g., parent, self)?


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