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The development of children's understanding of illness Kampman, Jacqueline Ida 1986

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THE DEVELOPMENT OF CHILDREN'S UNDERSTANDING OF ILLNESS By JACQUELINE IDA KAMPMAN B.Sc, The University of Br i t i s h Columbia, 1983 A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF ARTS in THE FACULTY OF GRADUATE STUDIES (Department of Psychology) We accept this thesis as conforming to the required standard THE UNIVERSITY OF BRITISH COLUMBIA August 1986 ©Jacqueline Ida Kampman, 1986 In presenting t h i s thesis i n p a r t i a l f u l f i l m e n t of the requirements for an advanced degree at the University of B r i t i s h Columbia, I agree that the Library s h a l l make i t f r e e l y available for reference and study. I further agree that permission for extensive copying of t h i s thesis for scholarly purposes may be granted by the head of my department or by his or her representatives. I t i s understood that copying or publication of t h i s thesis for f i n a n c i a l gain s h a l l not be allowed without my written permission. Department of Psychology  The University of B r i t i s h Columbia 1956 Main Mall Vancouver, Canada V6T 1Y3 Date September 2, 1986 A b s t r a c t This project addressed the issues of how children's understanding of i l l n e s s and i t s underlying dimensions might change over development as a function of age, cognitive l e v e l , or experience with p a r t i c u l a r i l l n e s s e s . Sixteen subjects at each of four age groups were r e c r u i t e d : kindergarten, grade 3, grade 7, and adults. The c h i l d groups were selected to correspond roughly to the preoperational, concrete operational, and beginning/basic formal operational l e v e l s of cognitive development. F i r s t l y , subjects were asked to give verbal d e f i n i t i o n s and diagnoses for i l l n e s s in general as well as for f i v e s p e c i f i c i l l n e s s e s (colds, chicken pox, a l l e r g i e s , diabetes, cancer) which were selected to vary on a hypothetical continuum of f a m i l i a r i t y , v i s i b i l i t y , s e v e r i t y , contagiousness, and the control one has over onset or healing. Secondly, subjects were asked to rate on a 7-point scale the dimensions of s e v e r i t y , s u s c e p t i b i l i t y , control over onset and control over healing for i l l n e s s in general, for the f i v e s p e c i f i c i l l n e s s e s , and for i l l persons of four d i f f e r e n t age groups (in f a n t s , c h i l d r e n , adults, e l d e r l y ) . In t h e i r descriptions of i l l n e s s in general, i t appears that subjects were more l i k e l y to focus on the i l l person rather than i l l n e s s i t s e l f ; whereas, subjects were more l i k e l y to focus on an i l l n e s s 1 s p e c i f i c symptoms and i t s e t i o l o g y in t h e i r descriptions of s p e c i f i c i l l n e s s e s . S i g n i f i c a n t developmental trends were apparent even in d e f i n i t i o n s and diagnoses of those i l l n e s s e s which are most f a m i l i a r and have the most v i s i b l e symptoms ( i e . colds, chicken pox); however, within i i i p a r t i c u l a r age groups, the l e v e l of s o p h i s t i c a t i o n in both d e f i n i t i o n s and diagnoses of s p e c i f i c i l l n e s s e s was dependent on the f a m i l i a r i t y / v i s i b i l i t y of the p a r t i c u l a r i l l n e s s under discussion. There were also age differences i n subjects' ratings of the i l l n e s s dimensions; these differences were most pronounced for s e v e r i t y and s u s c e p t i b i l i t y . I n t e r e s t i n g l y , a l l subjects appear capable of s i g n i f i c a n t l y and accurately ranking s p e c i f i c i l l n e s s e s on these four dimensions. With development, increasing d i f f e r e n t i a t i o n was made between s p e c i f i c i l l n e s s e s on the bases of these dimensions. As well, there were age differences in subjects' d i f f e r e n t i a t i o n between d i f f e r e n t aged i l l persons on the bases of these dimensions. These r e s u l t s suggest that young c h i l d r e n are aware of and understand ( a l b e i t in a l i m i t e d way) these four dimensions of i l l n e s s before they are able to convey t h i s information in t h e i r verbal descriptions of i l l n e s s . iv Table of Contents Introduction 1 Cognitive Development 1 Experience 4 Task Demands 7 Dimensions of Illness 9 Research Rationale 12 Ob jectives and Hypotheses 17 Method 20 Subjects 20 Cognitive Screening Tasks 20 Procedure 24 Ladder Diagram 26 Scoring of the Illness Interview 27 Definition of illness i n general 27 Diagnosis of illn e s s i n general 28 Prevention of illn e s s i n general 28 Experience with specific illnesses.. 29 Definitions of specific illnesses 29 Diagnoses of specific illnesses 30 Dimensions of illnesses.. 31 Results 32 Illness Experience and General Health of Subjects 32 Descriptions 32 Illness i n General 32 Definition 35 Diagnosis 35 Prevention 38 V Results Descriptions Specific Illnesses 38 Definitions 40 Diagnoses 43 Dimensions 46 Illness i n General 46 Age of 111 Person 48 Severity. 51 Susceptibility 52 Control-of-onset 52 Control-of-healing 54 Health Status 56 Specific Illnesses 58 Severity 58 Susceptibilty 61 Gontrol-of -onset 63 Control-of-healing 63 Rankings on the dimensions 67 Discussion 73 Verbal Descriptions of Illness 73 Illness i n general 73 Specific Illnesses .76 Dimensions of Illness 80 Illness i n general 81 Age of i l l person 82 Specific illnesses 86 Implications and Future Research 92 References. 94 v i v i i Table 1 -Table 2 -Table 3 -Table 4 -Table 5 -Table 6 -Table 7 -Table 8 -Table 9 -Table 10 -Table 11 -Table 12 -Table 13 -Table 14 -Table 15 -Table 16 -L i s t of Tables C h a r a c t e r i s t i c s of the Children P a r t i c i p a t i n g in t h i s Study 21 Level of Experience with S p e c i f i c Illnesses for Subjects of Each Age Group 33 Themes Used to Define I l l n e s s in General by Sub-jects of Each Age Group 36 Themes Used When Diagnosing I l l n e s s in General by Subjects of Each Age Group 37 Factors Considered in the Prevention of I l l n e s s in General by Subjects of Each Age Group 39 Level of De f i n i t i o n s for S p e c i f i c Illnesses by Sub-jects of Each Age Group 41 Level of Diagnoses for S p e c i f i c I l l n e s s e s by Sub-jects of Each Age Group 44 Mean Ratings of the Dimensions for I l l n e s s in General by Subjects of Each Age Group 47 Mean Ratings of the Dimensions for Persons of D i f -ferent Ages by Subjects of Each Age Group 49 S i g n i f i c a n t Differences in the Mean Ratings of Control-of-onset for Persons of D i f f e r e n t Ages by Subjects of Each Age Group 53 S i g n i f i c a n t Differences in the Mean Ratings of Control-of-healing for Persons of Dif f e r e n t Ages by Subjects of Each Age Group 55 Mean Ratings of Health Status for Persons of D i f -ferent Ages by Subjects of Each Age Group 57 Mean Ratings of the Dimensions for S p e c i f i c I l l -nesses by Subjects of Each Age Group 59 S i g n i f i c a n t Differences in the Mean Ratings of Severity for S p e c i f i c I l l n e s s e s by Subjects of Each Age Group 62 Mean Ratings of Medicine's Control-of-healing for S p e c i f i c Illnesses by Subjects of Each Age Group...66 Mean Rankings of the S p e c i f i c Illnesses on Each Dimensions by Subjects of Each Age Group 68 v i i i Table 17 - Degree of Intragroup Agreement for the Ordering of the S p e c i f i c Illnesses on Each Dimension by Sub-jects of Each Age Group 70 Acknowledgements I would l i k e to thank Janet Werker, Larry Walker, and Wolfgang Linden for t h e i r time commitment and i n t e r e s t shown in serving on my MA thesis committee. In addition, I would l i k e to thank Janet Werker for her advice on and help with a l l aspects of my MA t h e s i s , as well as her warmth, kindness, and moral support during d i f f i c u l t times. I would also l i k e to thank the s t a f f , parents, and students of the Abbotsford C h r i s t i a n Elementary School for t h e i r cooperation and p a r t i c i p a t i o n i n t h i s study. F i n a l l y , I would l i k e to give thanks to my parents, Leo and A l i d a Kampman; t h e i r b e l i e f i n my a b i l i t i e s and t h e i r encouragement have played a s i g n i f i c a n t role in helping me to reach my goals. Page 1 Children's and adults' understanding of the sick role (Parmelee, 1986) and th e i r attitudes towards the prevention and treatment of i l l n e s s (e.g., Burns & Zweig, 19 80; Leventhal, Meyer, & Nerenz, 1980) are related to t h e i r underlying b e l i e f s or concepts about i l l n e s s and health. These concepts may change in various ways over the l i f e time as a function of age, cognitive l e v e l , or experience with p a r t i c u l a r i l l n e s s e s . The goals of t h i s project were: (1) to consider healthy children's b e l i e f s about i l l n e s s within a s t r u c t u r a l i s t developmental framework, (2) to compare children's descriptions of i l l n e s s in general and of s p e c i f i c i l l n e s s e s which vary in t h e i r l e v e l of f a m i l i a r i t y and in the v i s i b i l i t y of t h e i r symptoms, (3) to spe c i f y children's understanding of the underlying dimensions of i l l n e s s and th e i r d i f f e r e n t i a t i o n between i l l persons of d i f f e r e n t ages as well as between s p e c i f i c i l l n e s s e s on the bases of these dimensions. Coqnitive Development Previous research has demonstrated that the c h i l d ' s concept of i l l n e s s develops in an orderly sequence which may be related to his/her cognitive developmental status. It has been claimed that as the c h i l d matures, his/her concepts of i l l n e s s become more sophisticated (Campbell, 1975; M i l l s t e i n , Adler, & Irwin, 1981) and more complex (Natapoff, 1978): With development, the c h i l d begins to focus on s p e c i f i c symptoms of disease (Campbell, 1975; M i l l s t e i n et a l . , 1981), and makes more frequent reference to in t e r n a l body cues (Natapoff, 1978; P a g e 2 N e u h a u s e r , A m s t e r d a m , H i n e s , & S t e w a r d , 1978) r a t h e r t h a n v a g u e s o m a t i c f e e l i n g s . A l s o t h e c a u s e s o f i l l n e s s c o n s i d e r e d b y t h e c h i l d become more d i f f e r e n t i a t e d a n d a b s t r a c t , a s w e l l a s more a c c u r a t e ( B i b a c e & W a l s h , 1 9 8 0 ; C a r a n d a n g , F o l k i n s , H i n e s , & S t e w a r d , 1 9 7 9 ) . T h e s e q u a l i t a t i v e a n d q u a n t i t a t i v e c h a n g e s w i t h a g e a r e c o n s i s t e n t w i t h t h e o r e t i c a l m o d e l s o f c o g n i t i v e d e v e l o p m e n t a n d s u g g e s t t h a t t h e more m a t u r e c h i l d h a s a t h i s / h e r d i s p o s a l a g r e a t e r number o f ways i n w h i c h t o d e f i n e a n d e x p l a i n h e a l t h o r i l l n e s s ( C a r a n d a n g e t a l . , 1 9 7 9 ; M i l l s t e i n e t a l . , 1 9 8 1 ; N a t a p o f f , 1 9 7 8 ) . T h e s e q u a l i t a t i v e c h a n g e s i n c o g n i t i v e a b i l i t y t h a t o c c u r w i t h d e v e l o p m e n t ( G i n s b u r g & O p p e r , 1979) a n d t h a t may a l s o i n f l u e n c e t h e c h i l d ' s d e v e l o p i n g i l l n e s s c o n c e p t s w i l l be b r i e f l y r e v i e w e d . One g e n e r a l c h a r a c t e r i s t i c o f t h e c h i l d ' s a b i l i t y i n t h e p r e o p e r a t i o n a l p e r i o d ( 4 - 7 y e a r s o f a g e ) o f d e v e l o p m e n t i s c e n t r a t i o n : T h e c h i l d t e n d s t o f o c u s on o n l y a v e r y l i m i t e d a m o u n t o f i n f o r m a t i o n a v a i l a b l e i n a s i t u a t i o n , p a r t i c u l a r l y on t h e s t a t i c s t a t e s o f r e a l i t y . A d d i t i o n a l l y , t h e p r e o p e r a t i o n a l c h i l d ' s t h o u g h t l a c k s r e v e r s i b i l i t y . In c o n t r a s t , t h e c o n c r e t e o p e r a t i o n a l c h i l d ( 7 - 1 1 y e a r s o f a g e ) i s c h a r a c t e r i z e d b y d e c e n t r a t i o n : s / h e c a n f o c u s on s e v e r a l d i m e n s i o n s o f a s i t u a t i o n s i m u l t a n e o u s l y , a n d c a n r e l a t e t h e s e d i m e n s i o n s . As w e l l , t h e c o n c r e t e o p e r a t i o n a l c h i l d i s s e n s i t i v e t o t r a n s f o r m a t i o n s a n d c a n r e v e r s e h i s / h e r d i r e c t i o n o f t h o u g h t . H o w e v e r , r e a s o n i n g r e m a i n s l i m i t e d t o t h e c h i l d ' s own c o n c r e t e e x p e r i e n c e s . I t i s w i t h t h e a t t a i n m e n t o f f o r m a l o p e r a t i o n s ( a t a b o u t 12 y e a r s o f a g e ) t h a t t h e c h i l d ' s t h i n k i n g b e c o m e s more a b s t r a c t a n d h y p o t h e t i c a l p r o p o s i t i o n s Page 3 can be dealt with by the c h i l d . The c h i l d ' s thought also becomes more f l e x i b l e and e f f e c t i v e : s/he begins to take into account a l l possible combinations of e v e n t u a l i t i e s in an exhaustive way. The c h i l d ' s conceptions of i l l n e s s at each of these periods in development appear to be characterized by s i m i l a r q u a l i t a t i v e differences (Perrin & G e r r i t y , 1981; Whitt, Dykstra, & Taylor, 1979). Whereas the preoperational c h i l d focuses on i s o l a t e d perceptual referents (or concrete physical symptoms) of i l l n e s s , the concrete operational c h i l d can consider d i f f e r e n t perceptual referents simultaneously. The concrete operational c h i l d also begins to understand that there is an underlying process of i l l n e s s and has some sense of causation. However, i t is only with the attainment of formal operations that the c h i l d has the a b i l i t y to f u l l y assimilate the more abstract processes of i l l n e s s , p a r t i c u l a r l y for diseases which have no (or less v i s i b l e ) external referents. This p a r a l l e l between children's understanding of i l l n e s s and general cognitive development is e s p e c i a l l y apparent for c a u s a l i t y . For instance, recent research by Bibace & Walsh (1980) indicates that the development of children's ideas about the causes of i l l n e s s very c l o s e l y p a r a l l e l s development of t h e i r understanding of physical concepts (and c a u s a l i t y within t h i s domain). In both areas, the least developmentally mature concepts of causation are phenomenistic: the cause which is offered may co-occur with the e f f e c t but i t i s s p a t i a l l y and/or temporally remote. However, with the Page 4 attainment of concrete operations, the c h i l d begins to accurately l i n k a cause and i t s e f f e c t ; and f i n a l l y with the attainment of formal operations, the c h i l d can off e r appropriate explanations for causation. In t h e i r exploration of stage-related developments of i l l n e s s concepts, Simeonsson, Buckley, & Monson (1979) make more d i r e c t l i n k s to general cognitive growth. They found children's performance on conservation and physical c a u s a l i t y tasks (which measure concrete operations) to be p o s i t i v e l y r e l a t e d to t h e i r understanding of i l l n e s s c a u s a l i t y . A d d i t i o n a l l y , a negative c o r r e l a t i o n was found between egocentrism (which was measured by a role-taking task, and is a c h a r a c t e r i s t i c of preoperational thinking) and understanding of i l l n e s s c a u s a l i t y . Exper ience As well as being re l a t e d to cognitive development, the c h i l d ' s understanding of i l l n e s s may be affected by experiences with i l l n e s s . Although t h i s has been suggested in the l i t e r a t u r e , there does not seem to be a consensus as to how experience exerts an influence. Does experience with i l l n e s s lead to a more or less mature understanding of health and i l l n e s s related concepts among children? One might predict that valuable knowledge w i l l be gained by the experience of i l l n e s s ; however, the experience of i l l n e s s may also cause i n h i b i t i o n or regression in the c h i l d ' s l e v e l of conceptualization due to i t s overwhelming emotional components, e s p e c i a l l y in the case of a chronic i l l n e s s (Bibace & Walsh, 1981). Page 5 In Investigating t h i s question, researchers have p r i m a r i l y focused on the influence of experience with chronic i l l n e s s . E i s e r , Patterson, & Tripp (1984) found that c h i l d r e n with diabetes did not d i f f e r from healthy childr e n in t h e i r d e f i n i t i o n s of health, or in t h e i r general knowledge about the cause and prevention of i l l n e s s . However d i a b e t i c c h i l d r e n did have a greater knowledge about the s p e c i f i c s of t h e i r own disease than did the healthy c h i l d r e n . From t h i s study one might conclude that generalized b e l i e f s and concepts are not affected by an i n d i v i d u a l ' s health stature. However, Carandang, Folkins, Hines, & Steward (1979) found that c h i l d r e n with d i a b e t i c s i b l i n g s performed at a lower conceptual l e v e l than did matched control c h i l d r e n with healthy s i b l i n g s on a i l l n e s s c a u s a l i t y and i l l n e s s treatment measure. (This phenomenon was p r i m a r i l y observed among formal operational thinkers.) They suggest t h i s may be due to stress acting as an intrusion factor to normal learning of t h i s general concept. As well, i t may be that s p e c i f i c symptoms and treatment of diabetes are discussed in the home at the expense of more broad i l l n e s s issues. Since the authors did not ask about diabetes in p a r t i c u l a r , we have no way of knowing whether these same chi l d r e n perform at a higher conceptual l e v e l with respect to t h e i r understanding of diabetes. In contrast to the above investigations of chronic i l l n e s s e s , Campbell (1975) examined the e f f e c t of children's recent general health h i s t o r i e s . He found that the way in which i l l n e s s experiences influenced the s o p h i s t i c a t i o n of Page 6 children's d e f i n i t i o n s of i l l n e s s was related to age. Children younger than 6-9, whose health was viewed as poor, had the least sophisticated concepts. However for the older c h i l d r e n the s i t u a t i o n was quite d i f f e r e n t ; s o p h i s t i c a t i o n of i l l n e s s concept was more evident among children whose health in recent years had been poor. Thus i t appears that cognitive l e v e l may determine the degree to which c h i l d r e n can u t i l i z e information obtained from experience with i l l n e s s . E i s e r , Patterson, & Eiser (1983) comment that although most c h i l d r e n develop a contagious disease such as chicken pox at some time, they do not seem to learn any generalized p r i n c i p l e s as a r e s u l t . As well, most ch i l d r e n receive preventative vaccinations, yet they do not learn about which diseases can be c o n t r o l l e d in t h i s way, or how the vaccine is e f f e c t i v e . They suggest that the many opportunities to educate c h i l d r e n are neglected. It i s possible that these experiences, when coupled with generalized information about c e r t a i n aspects of disease, could increase the c h i l d ' s understanding. In a d d i t i o n to the e f f e c t of d i r e c t experience, i t seems reasonable to expect that more i n d i r e c t experience with i l l n e s s (for instance, information and explanations provided in school or at home) may also influence the c h i l d ' s understanding of i l l n e s s . In support, recent work by Potter & Roberts (1984) suggests that both preoperational and concrete operational c h i l d r e n are capable of increased understanding of i l l n e s s e s when provided with appropriate information. The type of information necessary varies with age and cognitive Page 7 l e v e l . Their r e s u l t s Indicate that p r e o p e r a t i o n a l c h i l d r e n benefit most from a global nonspecific explanation of i l l n e s s , whereas concrete operational childr e n are more apt to comprehend de t a i l e d information. Task Demands The c h i l d ' s expressed concept of i l l n e s s may be affected by the content of the p a r t i c u l a r question asked in a test protocol (Bibace & Walsh, 1981). The d e t a i l and s p e c i f i c s of responses may vary depending on whether the c h i l d is asked to provide a general d e s c r i p t i o n of i l l n e s s or an explanation of the cause or cure of i l l n e s s . More importantly, i t seems that whether the c h i l d i s led to focus on i l l n e s s i n general or on s p e c i f i c i l l n e s s e s should a f f e c t the q u a l i t y of the c h i l d ' s response. Previous researchers have varied in t h e i r approach to assessing the c h i l d ' s concept of i l l n e s s . Some have simply assessed the c h i l d ' s concept of i l l n e s s in general ( i . e . , asked the c h i l d how s/he knows when s/he is " s i c k " or "not healthy"). However, i f the c h i l d spontaneously d i r e c t s his/her answers to a p a r t i c u l a r i l l n e s s , then the understanding of t h i s p a r t i c u l a r i l l n e s s has been further probed (Campbell, 1979; Carandang et a l . , 1979; M i l l s t e i n et a l . , 1981; Natapoff, 1978; Neuhauser et a l , 1978). Other researchers have asked c h i l d r e n to focus on s p e c i f i c i l l n e s s e s (Bibace & Walsh, 1980; E i s e r , Patterson, & Tripp, 1984) and used these s p e c i f i c responses to infer the c h i l d ' s concept of i l l n e s s in general. It i s l i k e l y that d i f f e r i n g focuses w i l l lead to d i f f e r e n t responses and should not necessarily be Page 8 treated as being equivalent. While a discussion of i l l n e s s in general may lend i t s e l f well to measuring the c h i l d ' s perception of what i t means to be sick ( i . e . , the sick r o l e ) , a discussion of more s p e c i f i c i l l n e s s e s may be necessary i f we want to f u l l y assess the c h i l d ' s understanding of i l l n e s s i t s e l f . It has been suggested that the abstractness of the concept involved needs to be considered when inv e s t i g a t i n g developmental differences in t h i s area (Neuhauser et a l . , 1978): the more abstract the concept, the more apparent these differences w i l l be. I l l n e s s in general appears to be quite an abstract concept for the c h i l d . Neuhauser and her colleagues (1978) compared children's responses to questions regarding s e l f - d i a g n o s i s and healing for either a cut or i l l n e s s . The developmental differences were more pronounced when chi l d r e n were asked about i l l n e s s than when they were asked about a cut. Both preoperational and concrete operational c h i l d r e n tended to respond s i m i l a r l y when asked about a cut: both groups r e l i e d more on external cues in t h i s s i t u a t i o n . However, when asked about i l l n e s s in general, concrete operational (as opposed to preoperational) c h i l d r e n more frequently used i n t e r n a l cues. It may also be that, i f the c h i l d i s asked to focus on a more s p e c i f i c i l l n e s s within th i s general i l l n e s s category, there w i l l be fewer developmental differences observed. As well, d i f f e r i n g developmental patterns might occur for i l l n e s s e s which are more v i s i b l e as compared to those which are less v i s i b l e . For the preoperational and concrete operational c h i l d , Page 9 the degree to which an i l l n e s s provides concrete p e r c e p t u a l referents may be an e s p e c i a l l y important variable i n t h e i r conceptualization of that i l l n e s s (Whitt et a l . , 1979). Questions which refer the c h i l d to i l l n e s s e s with less v i s i b l e symptoms appear to be more developmentally s e n s i t i v e than those with more v i s i b l e symptoms. Simmeonsson and colleagues (1979) found d i s t i n c t t r a n s i t i o n s between preoperational and concrete operational children's c a u s a l i t y conceptions when subjects were asked about a stomachache but only minimal and nonsignificant age differences when they were asked about bumps and spots. With these more v i s i b l e problems, the younger c h i l d r e n performed at a higher l e v e l of conceptualization whereas the older child r e n performed at a lower l e v e l than they had for the less v i s i b l e problem. Thus the way in which the c h i l d ' s concept of i l l n e s s i s probed is important to consider when looking at the r e s u l t s of any p a r t i c u l a r study. Asking about a set of s p e c i f i c i l l n e s s e s is very d i f f e r e n t from asking about i l l n e s s in general. Dimensions of I l l n e s s Researchers have also begun to systematically examine the c h i l d ' s understanding of some of the underlying dimensions of i l l n e s s . S p e c i f i c i l l n e s s e s vary in t h e i r v i s i b i l i t y , incidence, s e v e r i t y , and contagiousness, as well as in the amount of control one has over either the onset or healing of the i l l n e s s . The c h i l d ' s understanding of these dimensions may well influence his/her descriptions of i l l n e s s in s p e c i f i c ways . Page 10 For instance, Neuhauser and her colleagues (1978) found that the v i s i b i l i t y of a p a r t i c u l a r i l l n e s s / i n j u r y appears to influence the degree to which a c h i l d does or does not make reference to i n t e r n a l body cues in his/her. explanations. As well, Potter & Roberts (1984) report that t h i s dimension of v i s i b i l i t y also influences the perceived attractiveness of the d i s e a s e / i l l n e s s : the more observable symptoms of epilepsy (as compared to the less observable symptoms of diabetes) were perceived to be s i g n i f i c a n t l y less a t t r a c t i v e (acceptable) by ch i l d r e n 5-8 years of age. There i s also some speculation that the incidence of an i l l n e s s or one's f a m i l i a r i t y and experience with the i l l n e s s may be an important variable to consider. It i s possible that there are few developmental changes in the descriptions and explanations of some common i l l n e s s e s such as colds. Bibace & Walsh (1981), however, argue that such an absence of developmental differences may simply be due to i n s u f f i c i e n t probing. They report that, whereas i n i t i a l responses to c a u s a l i t y questions often appear very s i m i l a r and even i d e n t i c a l , further probing of these responses reveals s i g n i f i c a n t differences i n the q u a l i t y of reasoning underlying the responses even for common i l l n e s s e s (Bibace & Walsh, 1980 ) . Of more i n t e r e s t may be the c h i l d ' s understanding of the p a r t i c u l a r dimensions of i l l n e s s themselves. While a younger c h i l d may not f u l l y understand the symptoms and causes of s p e c i f i c i l l n e s s ( p a r t i c u l a r l y for an i l l n e s s with less v i s i b l e perceptual r e f e r e n t s ) , s/he may be more aware of some Page 11 of the dimensions of the i l l n e s s such as i t s sev e r i t y , and an i n d i v i d u a l ' s s u s c e p t i b i l i t y to the i l l n e s s or his/her control over i t s onset and healing r e l a t i v e to other i l l n e s s e s . The c h i l d ' s conceptualizations of i l l n e s s involve both cognitive and a f f e c t i v e components and there i s a complex inte r p l a y between these components. D i f f e r e n t trends i n development might occur for these a f f e c t i v e components. The circumstances and attitudes which surround a p a r t i c u l a r i l l n e s s may give the c h i l d quite accurate clues for a f f e c t i v e dimensions such as i t s s e v e r i t y (Whitt et a l . , 1979). Thus an understanding of the i l l n e s s ' r e l a t i v e rank on these dimensions may be apparent even before the c h i l d completely understands these dimensions. For example, even though the construct of contagion is not well understood u n t i l l a t e r In development, a c h i l d may have accurate perceptions of t h e i r r e l a t i v e v u l n e r a b i l i t y ( s u s c e p t i b i l i t y ) to s p e c i f i c i l l n e s s e s (Gochman, 1971; Gochman, Bagramian, & Sheiham, 1972). While l i t t l e work has addressed the issue of children's d i f f e r e n t i a t i o n of i l l n e s s e s on these dimensions, there is some work which has looked at age differences in children's ratings of these dimensions. The c h i l d ' s perceptions of v u l n e r a b i l i t y or s u s c e p t i b i l i t y ("What chance i s there of you catching ...?") and s e v e r i t y ("How bad do you think ... is?") have been investigated. While there was a s i g n i f i c a n t difference for perceived v u l n e r a b i l i t y to i l l n e s s as a function of cognitive l e v e l , with preoperational c h i l d r e n perceiving themselves as more vulnerable than concrete operational c h i l d r e n , there was not a s i g n i f i c a n t difference for perceived s e v e r i t y as a Page 12 function of cognitive l e v e l , although there was a trend for preoperational c h i l d r e n to perceive s e v e r i t y to be greater (Potter & Roberts, 1984). These dimensions of s e v e r i t y and v u l n e r a b i l i t y were investigated with respect to two s p e c i f i c i l l n e s s e s varying in the v i s i b i l i t y of t h e i r symptoms: epilepsy and diabetes. Children, regardless of t h e i r cognitive l e v e l , conceptualized epilepsy as being more severe than diabetes, and perceived themselves to be more vulnerable to epilepsy, although these differences were not s t a t i s t i c a l l y s i g n i f i c a n t . The amount of control a c h i l d perceives to have over the healing process may also be affected by his/her l e v e l of cognitive development. Neuhauser and her colleagues (1978) found that concrete operational c h i l d r e n f e l t they had more control over healing than did preoperational c h i l d r e n . This difference may r e f l e c t the fact that, r e a l i s t i c a l l y , older c h i l d r e n are able to do more for themselves than are c h i l d r e n 4-5 years younger. Although the perceived control over healing was assessed for both general i l l n e s s and a cut, whether or not the perceived control varies in these two s i t u a t i o n s i s not reported. The two s i t u a t i o n s vary in v i s i b i l i t y and abstractness; both of these dimensions may well exert some e f f e c t on the c h i l d ' s perception of c o n t r o l . Research Rationale This l i t e r a t u r e review shows that we have some idea of how children's descriptions/explanations of i l l n e s s are influenced by the dimensions of v i s i b i l i t y , incidence, s e v e r i t y , c h r o n i c i t y , contagiousness, and the amount of Page 13 control one can exert over either the onset or healing of i l l n e s s . However, we have very l i t t l e knowledge of children's actual understanding of the p a r t i c u l a r dimensions of i l l n e s s , or of how c h i l d r e n d i f f e r e n t i a t e between s p e c i f i c i l l n e s s e s according to these dimensions. For instance, Eiser and her colleagues (1983) assessed childrens' descriptions/explanations of several i l l n e s s e s . Although they concluded that accuracy among chi l d r e n matched for l e v e l of cognitive development was f a i r l y consistent regardless of the i l l n e s s under discussion, they do not report whether the children's responses for each i l l n e s s varied on the relevant dimensions of s e v e r i t y or one's s u s c e p t i b i l i t y to each i l l n e s s . The present i n v e s t i g a t i o n was designed to extend the e x i s t i n g research on children's understanding of i l l n e s s , by providing a coherent framework within which to investigate the various issues. Children (at three d i f f e r e n t ages corresponding to the preoperational, concrete operational, and formal operational stages of cognitive development) were asked to describe both i l l n e s s i n general and s p e c i f i c i l l n e s s e s . The c h i l d r e n were also asked to to relate t h e i r e x p e r i e n c e / f a m i l i a r i t y with the i l l n e s s e s . The s p e c i f i c i l l n e s s e s selected varied along a hypothetical continuum of f a m i l i a r i t y , v i s i b i l i t y of symptoms, se v e r i t y , contagiousness, and the amount of control one has over the onset or the healing process. This design allowed a f u l l e r i n v e s t i g a t i o n of the c h i l d ' s conceptualization of the dimensions of s e v e r i t y , one's s u s c e p t i b i l i t y to i l l n e s s and control over the Page 14 onset and healing of i l l n e s s . A group of adults also p a r t i c i p a t e d in the study so that we could also assess the mature understanding of these dimensions of i l l n e s s . Children were asked to give descriptions — d e f i n i t i o n s and diagnoses - for i l l n e s s in general as well as s p e c i f i c i l l n e s s e s so that a comparison might be made of the information obtained by these d i f f e r e n t interview approaches. It was believed that a discussion of i l l n e s s in general would best f a c i l i t a t e an understanding of the c h i l d ' s conceptualization of the sick r o l e . Thus, with development, i t was expected that there would be a trend towards increased reference to the psychosocial - emotional and behavioral -components of i l l n e s s in children's descriptions (both d e f i n i t i o n s and diagnoses) of i l l n e s s in general. In contrast, i t was believed that a discussion of s p e c i f i c i l l n e s s e s would best f a c i l i t a t e an understanding of the c h i l d ' s conceptualization of i l l n e s s i t s e l f . Since the i l l n e s s e s varied on a continuum, as previously described, i t was expected that the s o p h i s t i c a t i o n of both d e f i n i t i o n s and diagnoses would vary between i l l n e s s e s on the basis of the r e l a t i v e v i s i b i l i t y of the symptoms as well as the c h i l d ' s f a m i l i a r i t y with an i l l n e s s . These v a r i a t i o n s were expected to be most pronounced for the younger, less c o g n i t i v e l y advanced groups. Furthermore, i t was predicted that there would be fewer differences in the descriptions between age groups for the more common and v i s i b l e i l l n e s s e s . The major focus of the research project was to investigate children's understanding of the dimensions of Page 15 i l l n e s s . The p a r t i c u l a r dimensions under study - s e v e r i t y , s u s c e p t i b i l i t y , control over onset and control over healing -were selected because i t was f e l t that the c h i l d ' s understanding of these dimensions would influence t h e i r a t t i t u d e s and behaviors towards the prevention and treatment of i l l n e s s . As well, since previous researchers have considered these dimensions to some extent as discussed in the section t i t l e d "Dimensions of I l l n e s s " , we w i l l be able to compare our findings to past work in th i s area. Learning about the dimensions of i l l n e s s e s i s a c o g n i t i v e - a f f e c t i v e process. Conceptualizations of these dimensions involves both s p e c i f i c knowledge and emotional components. While perceptions of these dimensions for i l l n e s s In general may be most influenced by the emotional components, the perceptions of i l l n e s s may increasingly with age/development depend on the s p e c i f i c knowledge the i n d i v i d u a l has of i l l n e s s . As younger ch i l d r e n have the least s p e c i f i c knowledge of i l l n e s s , i t was expected that t h e i r perceptions of s e v e r i t y would be the greatest. Perception of s u s c e p t i b i l i t y was also expected to be the greatest for the younger ch i l d r e n due to the l i t t l e knowledge they have of i l l n e s s prevention (which was also assessed). For both control dimensions, i t was expected that there would be an increase in the ratings of personal control with age (as Neuhauser et a l . , 1978, have found). Previous work has not addressed the c h i l d ' s understanding of how age of an i n d i v i d u a l influences these dimensions of i l l n e s s . To address t h i s question, in the present study Page 16 childre n were asked for t h e i r general perceptions of these four dimensions with respect to indiv i d u a l s of four d i f f e r e n t age groups: infants, c h i l d r e n , adults, and the e l d e r l y . It has been suggested that, with development, sharper, more d i f f e r e n t i a t e d person concepts develop: Whereas young ch i l d r e n may only have broad, global impressions of persons which are formed on the basis of feelings that are highly egocentric and have l i t t l e cognitive content, older c h i l d r e n increasingly use information which more sharply d i f f e r e n t i a t e s one i n d i v i d u a l from another (Peevers & Secord, 1973). Li v e s l e y & Bromley (1973) also reported that child r e n are in general more l i k e l y to use psychological statements when describing adults than when describing other c h i l d r e n . These same age trends were expected i n the present study with respect to children's understanding of i l l n e s s . L a s t l y , we were also interested in addressing the c h i l d ' s understanding of how s p e c i f i c i l l n e s s e s might vary on these same dimensions of s e v e r i t y , s u s c e p t i b i l i t y , control over onset and control over healing. Age differences in children's a b i l i t y to d i f f e r e n t i a t e between i l l n e s s e s on these bases were expected due to the differences in the children's cognitive a b i l i t i e s . For instance, the concrete operational c h i l d can order items in a series when the r e l a t i o n s are presented v i s u a l l y ( i . e . , concrete s e r i a t i o n ) but not when the r e l a t i o n s are presented only v e r b a l l y ( i . e . , verbal s e r i a t i o n ) . This a b i l i t y only comes with the attainment of beginning formal operations (Piaget, 1924/1928; Walker, 1982). This increasing a b i l i t y to s e r i a t e may enable the c h i l d to also make greater Page 17 d i f f e r e n t i o n s . The s p e c i f i c i l l n e s s e s under discussion may have some obvious perceptual referents on which judgements of t h e i r dimensions might be made. However, refined judgements of an i l l n e s s ' dimensions, p a r t i c u l a r l y the dimensions of c o n t r o l , may depend on a d d i t i o n a l l y considering the less v i s u a l components of the i l l n e s s , such as i t s psychological e f f e c t s . As well, a f u l l understanding of how i l l n e s s e s vary on these dimensions must also include s p e c i f i c knowledge of the i l l n e s s e s under discussion. Thus, fewer developmental differences were expected in the judgements of i l l n e s s e s that are more common and have have more v i s i b l e symptoms (and treatments) as childr e n of a l l ages may equally consider these v i s u a l components. However, for judgements of the less v i s i b l e i l l n e s s e s , i t was thought that the developmental differences would be greater. With development, i t was believed that the d i s t i n c t i o n s between i l l n e s s e s on these dimensions would be perceived more sharply but that c h i l d r e n of a l l ages might well order the i l l n e s s e s on these dimensions in roughly in same way. Objectives and Hypotheses To summarize, the objectives of t h i s project and i t s s p e c i f i c hypotheses w i l l be b r i e f l y reviewed. The f i r s t objective was to consider children's b e l i e f s about i l l n e s s within a s t r u c t u r a l i s t developmental framework. It was expected that children's understanding of i l l n e s s , as r e f l e c t e d in t h e i r verbal d e f i n i t i o n s and diagnoses of i l l n e s s as well as in t h e i r ratings of the dimensions of i l l n e s s , Page 18 would p a r a l l e l t h e i r general cognitive development. The second objective of t h i s project was to investigate how task demands might a f f e c t the content of children's d e f i n i t i o n s and diagnoses of i l l n e s s . The themes used i n these descriptions for i l l n e s s in general were compared to those used to describe s p e c i f i c i l l n e s s e s . It was expected that children's descriptions of i l l n e s s in general would r e f l e c t t h e i r conceptualization of the i l l person whereas children's descriptions of s p e c i f i c i l l n e s s e s were expected to more c l o s e l y r e f l e c t t h e i r understanding of i l l n e s s i t s e l f . As a further examination of how task demands might a f f e c t the content of children's d e s c r i p t i o n s , t h e i r descriptions of the various s p e c i f i c i l l n e s s e s were compared. It was expected that the v i s i b i l i t y and/or f a m i l i a r i t y of the s p e c i f i c i l l n e s s under discussion would influence the l e v e l of knowledge/understanding demonstrated by the c h i l d in his/her d e f i n i t i o n and diagnosis of that i l l n e s s . For those i l l n e s s e s that are more f a m i l i a r / v i s i b l e , fewer developmental differences were expected than for those i l l n e s s e s that are less f a m i l i a r / v i s i b l e . F i n a l l y , the l a s t objective of t h i s project was to more f i n e l y s p e c i f y children's understanding of the dimensions of i l l n e s s - s e v e r i t y , s u s c e p t i b i l i t y , and control over the onset and healing of i l l n e s s - for i l l n e s s in general, for i l l persons of d i f f e r e n t ages, and for s p e c i f i c i l l n e s s e s . It was expected that these dimensions might be rated d i f f e r e n t l y by ch i l d r e n of d i f f e r e n t age/cognitive l e v e l s . A d d i t i o n a l l y , i t was expected that, with development, ch i l d r e n would more Page 19 f i n e l y and accurately d i f f e r e n t i a t e between d i f f e r e n t aged i l l persons as well as between s p e c i f i c i l l n e s s e s on the bases of these dimensions. Page 20 Method Subjects Sixty-four subjects p a r t i c i p a t e d in t h i s study. This included 16 c h i l d r e n at each of 3 grade l e v e l s : kindergarten, third-grade, and seventh-grade students were rec r u i t e d from a private school in Abbotsford, B.C. through l e t t e r s sent home to t h e i r parents (see Appendix A). These ages were chosen in an attempt to have c h i l d r e n at 3 l e v e l s of cognitive development: preoperations, concrete operations, and formal operations. A l l c h i l d r e n were given cognitive screening tasks to ascertain t h e i r l e v e l of cognitive development. Table 1 describes the c h a r a c t e r i s t i c s of the c h i l d r e n in more d e t a i l . A group of 16 of the children's mothers were rec r u i t e d to serve as adult c o n t r o l s . Cognitive Screeninq Tasks Seven tasks were used to assess cognitive development: conservation of number, conservation of area, and concrete s e r i a t i o n , which represent concrete operations; verbal s e r i a t i o n and conservation of volume, which represent beginning formal operations; i s o l a t i o n and combination of variables, which represent basic formal operations. Concrete operations were assessed by a conservation of number task, a conservation of area task, and a concrete-seriation task (Piaget, 1941/1952). In the conservation of number task, the c h i l d was f i r s t asked to construct a row of s i x squares that corresponded to a row constructed by the interviewer. The c h i l d was then asked whether the rows had the same number of squares. This Table 1 C h a r a c t e r i s t i c s of the Children P a r t i c i p a t i n g i n t h i s Study Cognitive Level Group n Males Females Mean Age Pre- Concrete B e g i n n i n g B a s i c (Yr-Mo) Operations Operations Formal Formal Operations Opera-. tions Kindergarten 16 7 9 5-9 15 1 0 0 Grade 3 16 8 8 8-9 0 13 3 0 Grade 7 16 8 8 12-9 0 0 13 3 Page 22 question was repeated a f t e r the interviewer had spread out the squares of one row so that t h i s row was longer than the other. The c h i l d was required to give correct answers to both questions i n order to pass t h i s task. In the conservation of area task, equal sized squares (2, 4 and 6 respectively, described to the c h i l d as "barns") were f i r s t placed in i d e n t i c a l arrangements on each of two i d e n t i c a l l y sized rectangles. These rectangles were described to the c h i l d as " f i e l d s " , and t h e i r i d e n t i c a l s i z e was demonstrated to the c h i l d . Then the squares on one rectangle were spread further apart. After each placement, c h i l d r e n were asked whether both " f i e l d s " had the same amount of grass for a cow to eat. Correct answers to f i v e of the s i x questions were required to pass t h i s task. In the concrete-seriation task, ten wooden s t i c k s were presented to the c h i l d ; the s t i c k s d i f f e r e d s l i g h t l y from each other in length (from 10.0 cm to 14.5 cm) in 0.5 cm increments. To pass the task, the c h i l d was required to c o r r e c t l y put the s t i c k s in order from shortest to longest. Beginning formal operations were assessed by a v e r b a l - s e r i a t i o n task (Piaget, 1924/1928) and conservation of volume task (Piaget & Inhelder, 1941/1974). The v e r b a l - s e r i a t i o n task consisted of three three-term ser i e s problems (eg. John has less than Tom. John has more than Bob. Who has the most?) typed on cards for the c h i l d to read. The c h i l d was required to c o r r e c t l y solve two of the three problems in order to pass t h i s task. In the conservation of volume task, the c h i l d was Page 23 presented with a beaker of water and a b a l l of p l a s t i c i n e . The c h i l d was shown that the l e v e l of water r i s e s when the b a l l i s placed in the beaker, and t h i s new l e v e l of water was marked. The b a l l was removed and flattened into a pancake shape and the c h i l d was asked to predict the l e v e l of water when the p l a s t i c i n e was again placed in i t . A correct p r e d i c t i o n and an appropriate explanation were required to pass t h i s task. Basic formal operations were assessed by a combinations task and an i s o l a t i o n s of variables task (Inhelder & Piaget, 1955/1958). In the combinations task (as adapted by F r i t z , 1974), the c h i l d was required to v e r b a l l y generate a l l combinations of four elements. The i s o l a t i o n of variables task used was designed by Kuhn & Brannock (1977). The c h i l d was shown drawings of two healthy and two unhealthy plants that also indicated the type of care each plant had been given. The c h i l d was required to i s o l a t e the variables that were responsible for making a plant healthy or unhealthy. Kuhn & Brannock's scoring was used to assess whether the c h i l d ' s performance was at a basic formal operations l e v e l . The c h i l d ' s l e v e l of cognitive functioning was judged as follows: preoperational i f the c h i l d f a i l e d to s u c c e s s f u l l y pass a l l concrete operations tasks; at least concrete operational only i f a l l tasks of t h i s l e v e l were passed; at least beginning formal operations only i f a l l tasks of t h i s l e v e l were passed; and basic formal operational only i f a l l tasks of t h i s l e v e l were passed. Those tasks which required only correct answers were scored by the interviewer during the P a g e 24 t e s t i n g s e s s i o n ; t h o s e t a s k s w h i c h a l s o r e q u i r e d c o r r e c t e x p l a n a t i o n s were s c o r e d a f t e r t h e t e s t i n g s e s s i o n P r o c e d u r e A l l c h i l d r e n w e r e s e e n on two s e p a r a t e o c c a s i o n s . On t h e f i r s t o c c a s i o n , t h e y were i n d i v i d u a l l y g i v e n t h e c o g n i t i v e t a s k s t o a s s e s s t h e i r l e v e l o f c o g n i t i v e d e v e l o p m e n t . A l l c h i l d r e n were g i v e n t h e c o n c r e t e o p e r a t i o n t a s k s , b u t o n l y i f c h i l d r e n c o u l d s u c c e s s f u l l y p e r f o r m t h e s e t a s k s were t h e y g i v e n t h e b e g i n n i n g f o r m a l o p e r a t i o n t a s k s . A g a i n , t h e b a s i c f o r m a l o p e r a t i o n t a s k s w e r e o n l y g i v e n t o c h i l d r e n who c o u l d s u c c e s s f u l l y p e r f o r m t a s k s o f t h e p r e v i o u s c o g n i t i v e l e v e l s . D u r i n g t h i s s e s s i o n , t h e c h i l d r e n a l s o became a c q u a i n t e d w i t h t h e i n t e r v i e w e r a n d t h e i n t e r v i e w s i t u a t i o n . On t h e s e c o n d o c c a s i o n , c h i l d r e n were g i v e n t h e i l l n e s s i n t e r v i e w . The i l l n e s s i n t e r v i e w c o n s i s t e d o f two m a i n p a r t s : G e n e r a l c o n c e p t s o f i l l n e s s a n d c o n c e p t s o f s p e c i f i c i l l n e s s e s . T h i s i n t e r v i e w was a d m i n i s t e r e d a t one t i m e f o r a l l b u t t h e k i n d e r g a r t e n g r o u p . F o r t h i s g r o u p , t h e two p a r t s were g i v e n a t d i f f e r e n t t i m e s b e c a u s e p i l o t t e s t i n g i n d i c a t e d t h a t t h e i r a t t e n t i o n c o u l d n o t be m a i n t a i n e d i n one l o n g s e s s i o n . C h i l d r e n were i n d i v i d u a l l y i n t e r v i e w e d i n a s e p a r a t e r o o m p r o v i d e d b y t h e s c h o o l . T h e a d u l t s w e r e i n t e r v i e w e d i n t h e i r homes a t a t i m e w h i c h was c o n v e n i e n t f o r t h e m . A l l i n t e r v i e w s w e r e t a p e r e c o r d e d a n d l a t e r t r a n s c r i b e d . In t h e f i r s t p a r t o f t h e i n t e r v i e w , t h e s u b j e c t s ' k n o w l e d g e o f i l l n e s s i n g e n e r a l was a s s e s s e d ( r e f e r t o s e c t i o n 1 o f t h e p r o t o c o l i n A p p e n d i x B ) . In t h i s a s s e s s m e n t , s u b j e c t s were a s k e d f o u r q u e s t i o n s w h i c h p r o b e d t h e i r Page 25 experience(s) with i l l n e s s , how they knew they were sick , how they f e l t sick i s d i f f e r e n t from being healthy, and what they f e l t one could do to keep from getting s i c k . The subjects were then asked to rate four dimensions of i l l n e s s on a 7 point s c a l e : s e v e r i t y , s u s c e p t i b i l i t y , control-of-onset, and control- o f - h e a l i n g . Because c h i l d r e n have d i f f i c u l t y with a scale, a 7-rung ladder diagram was used. This is described in the section which follows. They were also asked to rate t h e i r own state of health. At the beginning of the interview, subjects were asked to assess i l l n e s s in general according to these four dimensions. Following that, they were asked to rate infants, c h i l d r e n , adults, and the e l d e r l y according to these four dimensions (refer to section 1 of the protocol). As well, they were asked to rate the health status of ind i v i d u a l s of these age groups. To help i n t h i s task, small photos of persons of the various ages (infant - e l d e r l y ) were provided for the subjects to place d i r e c t l y on the ladder rung of t h e i r choice. The photos were l e f t on the ladder u n t i l a l l age comparisons were made for a p a r t i c u l a r dimension of i l l n e s s . This allowed the subjects to make d i r e c t comparisons. In the second part of the interview, the subjects' knowledge of s p e c i f i c i l l n e s s e s was assessed (refer to section 2 of the pro t o c o l ) . The subjects were asked the same kinds of questions as above for f i v e s p e c i f i c i l l n e s s e s : colds, chicken pox, a l l e r g i e s , diabetes, and cancer. These i l l n e s s e s are ranked on a hypothetical continuum based on factors such as f a m i l i a r i t y , v i s i b i l i t y of symptoms, sev e r i t y , c h r o n i c i t y , Page 26 contagiousness, and the amount of control one has over the onset or healing process. There were f i v e d i f f e r e n t sequences in which the i l l n e s s e s were presented to control for order of presentation. Subjects were given an opportunity to comment on the factors they considered when they made t h e i r ratings of these i l l n e s s e s . At the end of the interview, subjects were asked to rank the i l l n e s s e s : f i r s t in order of th e i r s e v e r i t y , then t h e i r s u s c e p t i b i l i t y , the amount of control one has over onset and the amount of control one has over healing of i l l n e s s (refer to section 3 of the pro t o c o l ) . To f a c i l i t a t e t h i s ranking, each i l l n e s s was assigned an abbreviated name (C=cold; CP=chicken pox; A=allergy; D=diabetes; CAN=cancer) on a separate cardboard c i r c l e . These symbols were previously introduced as the dimensions of each i l l n e s s were discussed. Ladder Diaqram A 7-rung ladder diagram (each rung was numbered, l=bottom rung - 7=top rung) was used to help the subjects rate s e v e r i t y , s u c e p t i b i l i t y , control-of-onset and control-of-healing for i l l n e s s . Symbols for i l l n e s s in general and s p e c i f i c i l l n e s s e s were provided so that these could be placed on the rungs when r a t i n g the dimensions for these i l l n e s s e s . P r i o r to the i l l n e s s interview, the interviewer f i r s t ensured that subjects knew how to use t h i s scale by giving a b r i e f explanation and then probing to see i f the subjects understood. This included d e t a i l e d t r a i n i n g in the use of the scale, p a r t i c u l a r l y for the younger c h i l d r e n . F i r s t each Page 27 ch i l d ' s attention was directed to d e t a i l s of the ladder. (For instance, the kindergarten c h i l d r e n were asked: What i s on the ladder that you don't usually see on a ladder? "Numbers." Show/tell me which numbers they are. Which i s the biggest number? Which is the smallest number? Which is the middle number?) The interviewer then explained to the c h i l d how the ladder could be used to answer questions. The c h i l d was then shown figures of climbing boys and asked where s/he would put a boy on the ladder i f he was a very good climber ( i.e,} rung 7), i f he couldn't climb at a l l (Le^ rung 1), and i f he was an average climber ( Le .; rung 4 ) . Comparisons using the other rungs of the ladder were also made. Two var i a t i o n s on t h i s t r a i n i n g task were used when required: how much d i f f e r e n t persons l i k e d ice cream and music. Training continued u n t i l i t was evident that the c h i l d could use the enti r e 7-point scale as well as make i d e n t i c a l ratings for d i f f e r e n t persons when appropriate. Scor inq of the IIlness Interview Def i n i t i o n of i l l n e s s in qenera1. Each subjects's response to the question about the difference between being sick and healthy (for a reminder, re f e r to section 1 of the protocol) was examined to determine the themes which were present. The themes l i s t e d below were derived from Campbell's (1975) l i s t of p r i n c i p a l themes defining i l l n e s s : 1. General somatic f e e l i n g states (e.g., " f e e l bad", "hurt", "stomach aches", " f e e l weak/tired"). 2. Objectively detectable indicators (e.g., fever, vomitting, coughing). Page 2 8 Psychosocial i n d i c a t o r s : 3. Behavior of a sick i n d i v i d u a l . This included both increases in s i c k - r o l e behavior and decreases in usual d a i l y a c t i v i t i e s (e.g., "stay in bed", "don't go to school", "can't play", "don't do your work"). 4. Mood, a t t i t u d i n a l or motivational states (e.g., " i r r i t a b l e " , "don't enjoy yourself", "have no energy/pep/get up and go"). Each theme was scored as either mentioned or not mentioned by a subject. Diagnosis of i l l n e s s in qenera1. Each subject's response to the question of how an i n d i v i d u a l knows s/he i s sick was also examined using the same set of themes from Campbell's (1975) l i s t of p r i n c i p a l themes def i n i n g i l l n e s s . Again, each theme was scored as either mentioned or not mentioned by a subject. Prevention of i l l n e s s i n general. Each subject's response to the question probing what an i n d i v i d u a l can do to keep from getting sick was examined to determine which factors were considered important in the maintenance of good health. Each of the following means of maintaining good health was scored as either mentioned or not mentioned by the subject: proper n u t r i t i o n , exercise, sleep, no v i c e s , p o s i t i v e mental a t t i t u d e s , keeping warm when outdoors, vaccinations, medical checkups, and avoiding sick people. Means of r e s t o r i n g one's good health (medicine; other treatments of i l l n e s s ) were also mentioned by the subjects and scored in the same manner. Page 29 Exper ience with speci f i c i l l n e s s e s . For each i l l n e s s , a score was assigned to the subject according to the degree to which s/he reported personal experience with the i l l n e s s as shown below: LEVEL 1: No experience. The subject has never had the i l l n e s s and does not know anyone who has. Includes "I don't know" responses to t h i s question. LEVEL 2: Vicarious experience. The subject knows someone with the p a r t i c u l a r i l l n e s s . LEVEL 3: Self-experience. The subject has or has had the p a r t i c u l a r i l l n e s s . Def i n i t i o n s of s p e c i f i c i l l n e s s e s . Each subject's responses to questions about what a p a r t i c u l a r i l l n e s s i s were scored according to the following scheme. This scheme i s ordered from lowest to highest l e v e l of understanding: LEVEL 1: An "I don't know" answer, even a f t e r probing; vague answers such as "a bad sickness". LEVEL 2: Answers li m i t e d to highly v i s i b l e treatment features of the i l l n e s s (e.g., i n j e c t i o n s , r e s t r i c t e d d i e t , h o s p i t a l i z a t i o n , amputation) or associated features(events) that are contiguous with the onset of the i l l n e s s (e.g., going outside without a coat, "catch i t from other people", contact with allergens, high sugar intake, smoking). An understanding of the i l l n e s s ' symptomatology or et i o l o g y i s not demonstrated. LEVEL 3: Answers include knowledge of the i l l n e s s ' s p e c i f i c symptoms. Page 30 LEVEL 4: Answers include appeals to or searches for an i n t e r n a l explanation of the i l l n e s s . The i n t e r n a l mechanism or cause of the i l l n e s s is described. The score assigned r e f l e c t s the highest l e v e l of d e s c r i p t i o n given by the subject. A l l responses were scored by the interviewer. Sixteen protocols (four from each age group), selected at random, were subsequently scored independently by a second r a t e r . Interrater agreement was found to be 91%. Diagnoses of s p e c i f i c i l l n e s s e s . Each subject's responses to the questions about how an i n d i v i d u a l knows s/he has a s p e c i f i c i l l n e s s were scored according to the degree to which a subject could personally use cues to d i s t i n g u i s h that s p e c i f i c i l l n e s s from general i l l n e s s : LEVEL 1: An "I don't know answer, even a f t e r probing; vague answers such as "you f e e l s i c k " . LEVEL 2: Reports that another i n d i v i d u a l makes the diagnosis (includes doctors, parents, and medical t e s t s ) . LEVEL 3: Reports the use of general symptoms of i l l n e s s (e.g., malaise, lethargy, fever, mood and behavior changes) that do not c l e a r l y d i s t i n g u i s h the p a r t i c u l a r i l l n e s s from i l l n e s s in general. LEVEL 4: Reports the use of s p e c i f i c symptoms (dis t i n g u i s h i n g features) of the p a r t i c u l a r i l l n e s s under discussion. The s p e c i f i c symptoms of each i l l n e s s that subjects were required to give in t h e i r diagnoses were obtained from common layman sources of i l l n e s s information (Pomeranz & Schultz, 1977; Spock & Rothenberg, 1985). Page 31 In the case of multiple means of diagnosis being given by the subject, the score assigned r e f l e c t s the highest level/means of diagnosis used by the subject. A l l responses were scored by the interviewer. Sixteen protocols (four from each age group), selected at random, were subsequently scored independently by a second r a t e r . Interrater agreement was found to by 97%. Dimens ions of i l l n e s s . As outlined previously, subjects' perceptions of sev e r i t y , s u c e p t i b i l i t y , control-of-onset and control-of-healing (personal) for i l l n e s s i n general, s p e c i f i c i l l n e s s e s , and for i l l persons of d i f f e r e n t ages was assessed on a 7-point s c a l e . A d d i t i o n a l l y parental control-of-healing and medicine's control-of-healing for i l l n e s s in general and s p e c i f i c i l l n e s s e s were assessed on t h i s s c a l e . For subjects in the three c h i l d groups, difference scores between the personal and parental control-of-healing ratings of i l l n e s s i n general and s p e c i f i c i l l n e s s e s were computed so that measures of control might be compared to those found by Neuhauser et a l . (1978). The subjects' comments on the factors they considered when making these ratings were not analyzed since not a l l subjects offered these comments. However, these comments did help give some insight into the age differences in the ratings for s p e c i f i c i l l n e s s e s . Page 32 Results I llness Experience and General Health of Subjects Information with respect to the subjects' experience with the fiv e s p e c i f i c i l l n e s s e s is given for each age group in Table 2. As can be seen from the table, f a m i l i a r i t y with a l l e r g i e s , diabetes and cancer increased with age whereas f a m i l i a r i t y with colds and chicken pox was sim i l a r across a l l age groups. As might be expected, subjects in a l l age groups reported the most experience for colds, then chicken pox, a l l e r g i e s , cancer and diabetes in descending order. Subjects also gave ratings of the i r own general health status. Individuals in a l l age groups perceived themselves to be very healthy, although the kindergarten (M=6.44) and adult (M=6.36) groups rated t h e i r health higher than did the grade 3 (M=5.94) or grade 7 groups (M=5.50) groups. Descr i p t i ons 111 ness in Ge ne ra 1 The subjects' verbal descriptions - d e f i n i t i o n s , diagnoses, and means of prevention - of i l l n e s s in general allowed an examination of qu a l i t a t i v e differences across development in the understanding of i l l n e s s . As there is a high c o r r e l a t i o n between the age groups selected and the levels of cognitive development, i t was decided to analyze the data according to the age of the subjects. These descriptions were examined for possible developmental differences in the use of i l l n e s s themes and preventative measures by the subjects (as has been described in the scoring section). The findings for the d e f i n i t i o n of i l l n e s s w i l l be presented f i r s t , Page 33 Table 2 Level of Experience with S p e c i f i c Illnesses  f o r Subjects of Each Age Group Level of Experience Ill n e s s 1 2 3 Kindergarten Colds 0 0 16 Chicken Pox 3 4 9 Allergy- 6 6 4 Diabetes 15 1 0 Cancer 13 3 0 Grade 3 Colds 0 0 16 Chicken Pox 1 2 13 Allergy 1 9 6 Diabetes 15 1 0 Cancer 3 13 0 (table continues) A Page 34 Table 2 (cont.) Level of Experience I l l n e s s 1 2 3 Grade 7 Colds 0 0 16 Chicken Pox 2 2 12 A l l e r g y 0 11 c Diabetes 7 9 0 Cancer 1 15 0 Adults Colds 0 0 16 Chicken Pox 1 11 A l l e r g y 1 12 3 Diabetes 0 16 0 Cancer 0 16 0 Note. Each table entry indicates the number of respondents within each group whose experience with a s p e c i f i c i l l n e s s (as indicated by the row Label) was at the l e v e l indicated by the column l a b e l . Page 35 f o l l o w e d by the d i a g n o s i s of i l l n e s s , and f i n a l l y the p r e v e n t i o n of i l l n e s s . D e f i n i t i o n . I n f o r m a t i o n w i t h r e s p e c t t o the f r e q u e n c y w i t h which d i f f e r e n t themes were i n c l u d e d by each age group i n t h e i r d e f i n i t i o n of i l l n e s s i n g e n e r a l i s g i v e n i n T a b l e 3. To look a t the r e l a t i o n s h i p between age group and the use of a p a r t i c u l a r theme, K e n d a l l ' s c o r r e l a t i o n c o e f f i c i e n t (T*), c o r r e c t e d f o r t i e s on r a n k s , was c a l c u l a t e d . As might be e x p e c t e d , t h e r e were s i g n i f i c a n t p o s i t i v e r e l a t i o n s h i p s between age and the f r e q u e n c y w i t h which p s y c h o s o c i a l i n d i c a t o r s were r e f e r r e d t o : b e h a v i o r o£ a s i c k i n d i v i d u a l , f = .31, p_<.005; and mood, a t t i t u d i n a l or m o t i v a t i o n a l s t a t e s , .64, p_<.001. For the use of g e n e r a l s o m a t i c f e e l i n g s t a t e s , t h e r e was a s i g n i f i c a n t n e g a t i v e r e l a t i o n s h i p t h a t o c c u r r e d from c h i l d h o o d t o a d u l t h o o d , T* = -.25, p_<.03. (For t h i s c o r r e l a t i o n , the k i n d e r g a r t e n , grade 3 and grade 7 groups formed a s i n g l e c h i l d h o o d group.) For the use of o b j e c t i v e l y d e t e c t a b l e i n d i c a t o r s , t h e r e was no s i g n i f i c a n t r e l a t i o n s h i p w i t h age, *T = .12, p_>.05. D iaqnos i s . I n f o r m a t i o n w i t h r e s p e c t t o the f r e q u e n c y w i t h which d i f f e r e n t themes were i n c l u d e d by each age group i n t h e i r d i a g n o s i s of i l l n e s s i n g e n e r a l i s g i v e n i n T a b l e 4. To look a t the r e l a t i o n s h i p between age group and the use of a p a r t i c u l a r theme, K e n d a l l ' s c o r r e l a t i o n c o e f f i c i e n t (T'), c o r r e c t e d f o r t i e s , was c a l c u l a t e d . As might be e x p e c t e d , t h e r e were s i g n i f i c a n t p o s i t i v e r e l a t i o n s h i p s between age and the use of g e n e r a l s o m a t i c s t a t e s , T* = .19, p_<.05; and f o r age and the use of mood, a t t i t u d i n a l or m o t i v a t i o n a l s t a t e s , Page 36 Table 3 Themes Used to Define I l l n e s s i n General by Subjects of  Each Age Group Subject Group Theme Kinder- 3 garten ifo) Grade 3 (%) Grade 7 (#) Adult (?>) General somatic f e e l i n g states 44 63 56 25 Objectively detectable indicators 6 13 38 13 Behavior of a s i c k i n d i v i d u a l 31 56 69 75 Mood, a t t i t u d i n a l or motivational states 0 6 3 8 " 88 Note. Each table entry indicates the percentage of subjects within the group i d e n t i f i e d by the column whose d e f i n i t i o n included themes described by the row l a b e l . Column t o t a l s add to more than 100$ since more than one theme per respondent was t y p i c a l l y the case ( p a r t i c u l a r l y f o r the older subjects). a F i v e of the subjects i n this group could only give vague or "I don't kno^'" answers. Page 37 Table 4 Themes Used When Diagnosing: I l l n e s s i n General by Subjects of  Each Age Group Subject Group Theme Kinder- 3 garten (*) Grade 3 (%) Grade b 7 (*) Adult General somatic f e e l i n g states 50 81 56 88 Objectively detectable indicators 69 63 81 50 Behavior of a sick i n d i v i d u a l 6 19 19 19 Mood, a t t i t u d i n a l or motivational states 0 6 25 44 Note» Each table entry indicates the percentage of subjects within the group i d e n t i f i e d by the column whose diagnosis included themes described by the row l a b e l . Column t o t a l s add to more than 100% since more than one theme per respondent was t y p i c a l l y the case ( p a r t i c u l a r l y f o r the older subjects). aTwo of the subjects i n thi s group could only give vague answers. ^One subject i n this group could only give a vague answer. P a g e 38 f = .39, p_<.001. H o w e v e r , t h e r e l a t i o n s h i p b e t w e e n age and t h e u s e o f t h e b e h a v i o r s o f a s i c k i n d i v i d u a l was n o n s i g n i f i c a n t , "t' = . 1 0 , p_>.05. As w e l l t h e r e a p p e a r s t o be no s i g n i f i c a n t d i f f e r e n c e s w i t h age i n t h e u s e o f o b j e c t i v e l y d e t e c t a b l e i n d i c a t o r s , T* = - . 0 8 , £ > . 0 5 . P r e v e n t i o n . I n f o r m a t i o n w i t h r e s p e c t t o t h e f r e q u e n c y w i t h w h i c h d i f f e r e n t f a c t o r s were c o n s i d e r e d by e a c h age g r o u p i s g i v e n i n T a b l e 5 . As m i g h t be e x p e c t e d , t h e r e were s i g n i f i c a n t p o s i t i v e r e l a t i o n s h i p s b e t w e e n age and t h e f r e q u e n c y w i t h w h i c h f a c t o r s i m p o r t a n t i n t h e m a i n t a i n a n c e of g o o d h e a l t h were m e n t i o n e d by s u b j e c t s : n u t r i t i o n , T " = . 4 6 , p_<.001; e x e r c i s e , Y - . 3 0 , p_<.005; a n d s l e e p , Y = . 4 2 , p_<.001. K e e p i n g warm when o u t d o o r s was o n l y m e n t i o n e d by t h e c h i l d g r o u p s ( k i n d e r g a r t e n , g r a d e 3 a n d g r a d e 7 ) ; w i t h i n t h e s e g r o u p s , t h e r e was a g a i n a s i g n i f i c a n t p o s i t i v e r e l a t i o n s h i p w i t h age f o r t h i s f a c t o r , T " = .37, p_<.005. As c a n be s e e n f r o m - t h e t a b l e , no v i c e s a n d p o s i t i v e m e n t a l a t t i t u d e s were o n l y m e n t i o n e d by t h e a d u l t g r o u p ; h o w e v e r , t h i s t r e n d was n o t s i g n i f i c a n t . In c o n t r a s t t o t h e a b o v e c o r r e l a t i o n s , a s i g n i f i c a n t n e g a t i v e r e l a t i o n s h i p was f o u n d b e t w e e n age and t h e f r e q u e n c y w i t h w h i c h f a c t o r s i m p o r t a n t i n t h e r e s t o r a t i o n o f g o o d h e a l t h were m e n t i o n e d by t h e s u b j e c t s : p a r t i c u l a r l y f o r t h e m e n t i o n of m e d i c i n e , T " = -.39, p_<.001. S p e c i f i c I l l n e s s e s The s u b j e c t s ' v e r b a l d e s c r i p t i o n s w i t h r e g a r d t o t h e s p e c i f i c i l l n e s s e s were a l s o e x a m i n e d f o r b o t h age and i l l n e s s d i f f e r e n c e s . A l l s u b j e c t s p r o v i d e d d e f i n i t i o n s and means of d i a g n o s i s f o r e a c h i l l n e s s . The d e f i n i t i o n s of s p e c i f i c Table 5 Factors Considered i n the Prevention of I l l n e s s i n General  by Subjects of Each Age Group Subject Group Factors Kinder-garten {%) Grade 3 {%) Grade 7 (%) Adult {%) Maintenance of Good Health: Proper n u t r i t i o n 19 81 69 94 Exercise 0 19 25 38 Sleep 6 6 0 63 No vices ( i e . smoking, drinking) 0 0 0 13 Mental attitudes 0 0 0 19 Keep warm when outdoors 13 19 56 0 Vaccinations 6 6 0 0 Medical check-ups 0 13 0 0 Avoid sick people 6 0 19 6 Restoration of Good Health: Medicine 50 13 13 0 Other treatments of i l l n e s s 19 0 6 0 Note. Each table entry indicates the percentage of subject within the group i d e n t i f i e d by the column whose i l l n e s s prevention descriptions included the factors described by the row l a b e l . Column t o t a l s add to more than 100% since more than one f a c t o r per respondent was t y p i c a l l y the case ( p a r t i c u l a r l y f o r the older subjects). Page 40 w i l l be presented f i r s t , followed by the diagnoses of s p e c i f i c i l l n e s s e s . Def in i t ions. Frequency data with respect to the highest le v e l of understanding for s p e c i f i c i l l n e s s e s demonstrated by subjects of each age group i s given in Table 6. To examine whether developmental trends might in part be due to the l e v e l of f a m i l i a r i t y , incidence and/or v i s i b i l i t y of the i l l n e s s under discussion, Kendall correlations (T*) between age group and l e v e l of understanding were calculated for each s p e c i f i c i l l n e s s . It was expected that for common i l l n e s s e s such as colds or chicken pox, the correlations would be nonsignificant, with age-related trends only apparent for the less common i l l n e s s e s . In contrast to what was expected, s i g n i f i c a n t positive correlations were found for a l l i l l n e s s e s : colds, T*= .45, p_<.001; chicken pox, .33, p_<.003; a l l e r g i e s , T'= -74, p_<.001; diabetes, *f= -78, p_<.001; and cancer, T" = .61, p_<.001. As can be seen, however, the correlations were higher for the less common i l l n e s s e s . To examine whether subjects within each age group demonstrated varying levels of understanding as a function of the s p e c i f i c i l l n e s s under discussion, Friedman's 2-way (Illn e s s x Level of Definition) ANOVA was performed for each age group. It was expected that, for younger groups, there would be greater differences between demonstrated levels of understanding for the s p e c i f i c i l l n e s s e s ; but that even for the older groups, the demonstrated l e v e l of understanding would vary as a function of the pa r t i c u l a r i l l n e s s under discussion. A d d i t i o n a l l y , i t was expected that younger groups Page 41 Table 6 Level of Definitions for Specific Illnesses by Subjects  of Each Age Group Level of Definition Illness 1 2 3 Kindergarten Colds 0 12 0 Chicken Pox 3 0 13 0 Allergy 8 6 2 0 Diabetes 16 0 0 0 Cancer 11 5 0 0 Grade 3 Colds 1 0 15 0 Chicken Pox 1 0 15 0 Allergy 0 10 6 0 Diabetes 11 5 0 0 Cancer 3 10 0 3 (table continues) Table 6 (cont.) Level of D e f i n i t i o n I l l n e s s 1 2 3 4 Grade 7 Colds 0 0 12 4 Chicken Pox 0 0 15 1 A l l e r g y 0 0 15 1 Diabetes 4 6 0 6 Cancer 3 6 0 7 Adults Colds 0 1 8 7 Chicken Pox 0 1 11 4 All e r g y 0 0 10 6 Diabetes 0 0 0 16 Cancer 0 3 0 13 Note. Each table entry indicates the number of respondents within each group whose d e f i n i t i o n of a s p e c i f i c i l l n e s s (as indicated by the row label) was at the l e v e l indicated by the column l a b e l . Page 43 would demonstrate a higher l e v e l of understanding for the more common and v i s i b l e i l l n e s s e s ( i e . colds, chicken pox, and a l l e r g i e s ) and that older groups would demonstrate a higher l e v e l of understanding for the less common and less v i s i b l e i l l n e s s e s ( i e . diabetes and cancer). The Friedman 2-way ANOVA supported such differences for the kindergarten, Ocf(4) = 27.51, p_<.0001; grade 3, X L ( 4 ) = 31.64, p_<.0001; and adult groups, X a ( 4 ) = 12.66, p_<.02; but not for the grade 7 groups, %*"( 4) = 4.13, p_>.05. As can be seen in Table 6, the trends in mean l e v e l of understanding with i l l n e s s under discussion are as expected. Diagnoses. Frequency data for the highest l e v e l of diagnosis by subjects of each age group for the s p e c i f i c i l l n e s s e s i s given in Table 7. To examine whether developmental trends might in part be due the degree of f a m i l i a r i t y , incidence and/or v i s i b i l i t y of the i l l n e s s under discussion, Kendall correlations (Y) between age group and l e v e l of diagnosis were calculated for each s p e c i f i c i l l e s s . As with the d e f i n i t i o n s , i t was expected that the correlations would be nonsignificant for common i l l n e s s e s such as colds or chicken pox. In contrast to what was expected, s i g n i f i c a n t p o s i t i v e r elationships were found for a l l i l l n e s s e s : colds,'!' = .31, p_<.04; chicken pox, *X = .45, p_<.001; a l l e r g i e s , *X = .65, p_<.00l; diabetes, T'= .47, p_<.001; and cancer, T = .49, p_<.001. To examine whether subjects within each age group demonstrated varying levels of diagnosis as a function of the s p e c i f i c i l l n e s s under discussion, Friedman's 2-way (Ill n e s s P a g e 4 4 Table 7 Level of Diagnoses for Specific Illnesses by Subjects  of Each Age Group Level of Diagnosis Illness 1 2 3 4 Kindergarten Colds 3 0 1 12 Chicken Pox 3 3 2 8 Allergy 11 2 2 1 Diabetes 8 2 6 0 Cancer 10 1 5 0 Grade 3 Colds 0 0 2 14 Chicken Pox 0 0 0 16 Allergy 2 0 2 14 Diabetes 3 4 9 0 Cancer 2 3 11 0 (table continues) Page 45 Table 7 (cont.) Level of Diagnosis Illness 1 2 3 4 Grade 7 Colds 0 0 0 16 Chicken Pox 0 0 0 16 Allergy- 0 1 0 15 Diabetes 2 7 5 2 Cancer 2 5 7 2 - Adults Colds 0 0 0 16 Chicken Pox 0 0 0 16 Allergy 0 0 0 16 Diabetes 0 2 3 11 Cancer 0 3 3 10 Note. Each table entry indicates the number of respondents within each group whose diagnosis of a specific illness (as indicated by the row label) was at the level indicated by the column label. Page 46 x Level of Diagnosis) ANOVA was performed for each age group. It was expected that, with age, there would be fewer differences in the l e v e l of diagnosis used for each s p e c i f i c i l l n e s s . It was also expected that higher leve l s of diagnosis would be used by a l l age groups for more common/visible i l l n e s s e s . The Friedman 2-way ANOVA supported such differences for the k indergarten, %**( 4) = 25.35, p_<.0001; grade 3, % z ( 4) = 37.59, p_<.0001; and grade 7 groups, X?"( 4) = 35.24, pjC.OOol. For the adult group, there was no difference in the a b i l i t y to diagnose each s p e c i f i c i 1 lness, yf^( 4) = 5.70, p_>.05. Dimens ions 111 ne ss in Ge ne ra 1 The subjects' ratings of the dimensions for i l l n e s s in general were examined for o v e r a l l group diff e r e n c e s . A 4 x 4 (Group x Dimension) Multivariate analysis of variance (MANOVA) revealed s i g n i f i c a n t e f f e c t s for Dimension, F_(3,180) = 5.20, p_<.003; and Group x Dimension, F(9,180) = 2.80, p_<.005; but not for Group. Mean ratings of the dimensions for each age group are given in Table 8. This analysis was followed with a series of i n d i v i d u a l analyses of variance (ANOVAs) for each dimension. S i g n i f i c a n t Group e f f e c t s were found for severity, F(3,60) = 5.36, p_<. 003; and s u s c e p t i b i l i t y , F_(3,60) = 3.16, p_<.04; but not for control-of-onset or control-of-healing. Post-hoc Tukey tests (at the .05 s i g n i f i c a n c e level) showed that, for severity, the grade 7 group's mean rating was s i g n i f i c a n t l y lower than that of the grade 3 and kindergarten groups. For s u s c e p t i b i l i t y , P a g e 47 Table 8 Mean Ratings of the Dimensions for Illness i n General  by Subjects of Each Age Group Subject Group Dimension Kindergarten Grade 3 Grade 7 Adult Severity 5-56 5 .88 3 .63 4 . 5 0 Susceptibility 4 .63 5-19 4 .81 3.19 Control-of-onset 5-75 5-56 5-38 5.50 Control-of-healing 5.50 4 .81 5.31 5.81 Page 48 the adult group's mean rating was s i g n i f i c a n t l y lower than that of the grade 3 group. To compare our results to those of Neuhauser et a l . (1978), a difference score between personal control-of-healing and parental control-of-healing was also computed. This score was averaged for each for each of the c h i l d groups: the kindergarten (M=-0.38), grade 3 (M=-0.31) groups rated parental control as being greater than their own whereas the grade 7 (M=+0.69) group rated parental control as being less than their own c o n t r o l . However an ANOVA revealed no s i g n i f i c a n t Group differences in these scores. A measure of medicine's control-of-healing was also obtained for each group: kindergarten (M=5.88), grade 3 (M=6.13), grade 7 (M=5.50), and adults (M=4.44). An ANOVA revealed that there were s i g n i f i c a n t Group differences on t h i s score, F(3,60) = 6.36, p_<.001. A Tukey test (at the .05 sig n i f i c a n c e level) indicated that this e f f e c t was due to the adult group's mean rat i n g being s i g n i f i c a n t l y lower than that of the grade 3 group. Age of 111 Person The subjects' ratings of the dimensions for i l l persons of d i f f e r e n t ages were examined for possible group differences in the d i s t i n c t i o n s made between d i f f e r e n t aged i l l persons on the bases of these dimensions. An o v e r a l l 4 x 4 x 4 (Group x Dimension x Age of 111 Person) MANOVA revealed s i g n i f i c a n t main e f f e c t s for Dimension, F(3,180) = 8.88, p_<.001; and Age of 111 Person, F(3,180), p_<.001; but not for Group. S i g n i f i c a n t interactions were also found for Group x Dimension Table 9 Mean Ratings of the Dimensions f o r Persons of D i f f e r e n t  Ages by Subjects of Each Age Group Subject Group Age of Person Kindergarten Grade 3 Grade 7 Adult Severity Infants 6.19 6*38 5.31 5-88 Children 4.81 4.88 4 . 0 0 4.31 Adults 3 .63 4 .50 3.31 3.50 E l d e r l y 4.81 6.56 5.19 5-31 S u s c e p t i b i l i t y Infants 4 .44 4.25 5.25 4.75 Children 4 .38 4 .63 4 .50 4 . 6 3 Adults 3 .50 4 .00 3.56 2 .94 E l d e r l y 4 .56 5-81 4 . 9 4 5.13 (table continued) Page 50 Table 9 (corrt.) Subject Group Age of Person Kindergarten Grade 3 Grade 7 Adult Control-of -onset Infants 1.94 2.06 1.75 2.06 Children 3.69 4.88 4.44 3-56 Adults 5-63 5-75 5.75 5.94 Elderly 4.69 3-56 4.75 5.88 Control-of- healing Infants 2 .31 1.81 1.38 1.44 Children 3-19 4.19 4 .06 3-75 Adults 5-38 5.13 5.81 6.00 Elderly 5 .25 4 .50 4.88 5.94 Page 51 x Age of 111 Person, F(27,540) = 1.86, p_<.006; and Dimension x Age of 111 Person, F(9,540) = 52.43, p_<.001; but not for Group x Dimension or Group x Age of 111 Person. This analysis was followed with a series of individual 4 x 4 (Group x Age of 111 Person) MANOVAs as well as post-hoc Tukey comparison tests for each dimension. The mean ratings of the dimensions for i l l persons of d i f f e r e n t ages by subjects of each age group are given in Table 9. Sever i t v . A 4 x 4 (Group x Age of 111 Person) MANOVA revealed s i g n i f i c a n t main e f f e c t s for Group, F(3,60) = 4.68, p_<.006; and Age of 111 Person, F(3,180) = 27.91, p_<.0001; but the Group x Age of 111 Person int e r a c t i o n was nonsignificant. For means, refer to Table 9. An o v e r a l l Tukey test (at the .05 si g n i f i c a n c e level) to compare the mean severity ratings for i l l persons of d i f f e r e n t ages within each group and between groups was performed. (The error term remained constant for each of these comparisons.) A l l groups rated severity for infants as greater than that for adults. The grade 3 and grade 7 groups also rated s e v e r i t y for the e l d e r l y as greater than that for adults. A separate Tukey test (at the .05 si g n i f i c a n c e level) compared the means averaged across a l l subject groups on the ratings for the d i f f e r e n t aged i l l persons: Severity for infants, children, and the elderle y was rated s i g n i f i c a n t l y greater than that for adults; a d d i t i o n a l l y , s e v e r i t y for infants and the e l d e r l y was rated s i g n i f i c a n t l y greater than that for chi l d r e n . There were no s i g n i f i c a n t differences between groups on the rating of s e v e r i t y for any one p a r t i c u l a r age of i l l persons (as Page 52 indicated by the ove r a l l Tukey t e s t ) . However, another Tukey test (at the .05 sig n i f i c a n c e level) comparing each group's ov e r a l l ratings of se v e r i t y indicated that the group main e f f e c t was due to the grade 3 group giving s i g n i f i c a n t l y higher ratings of se v e r i t y for a l l ages than did either the grade 7 or adult groups. S u s c e p t i b i l i t y . A 4 x 4 (Group x Age of 111 Person) MANOVA revealed a s i g n i f i c a n t main e f f e c t for Age of 111 Person, P(3,180) = 10.19, p_<.0001; but no Group e f f e c t or Group x Age of 111 Person i n t e r a c t i o n . For means, refer to Table 9. As indicated by an ov e r a l l Tukey test (at the .05 sign i f i c a n c e l e v e l ) , kindergarten, grade 3, and grade 7 groups did not s i g n i f i c a n t l y d i f f e r e n t i a t e between i l l persons of di f f e r e n t ages on the basis of s u s c e p t i b i l i t y . For the adult group, only a s i g n i f i c a n t difference between ratings for adults and the e l d e r l y was found: E l d e r l y were rated as most susceptible to i l l n e s s ; adults, the least susceptible to i l l n e s s . A separate Tukey test (at the .05 si g n i f i c a n c e l e v e l ) , comparing the means averaged across a l l subject groups, found the means for infants, children, and the e l d e r l y to be s i g n i f i c a n t l y higher than that of adults. There were no s i g n i f i c a n t differences between groups on the ratings of s u s c e p t i b i l i t y for any one pa r t i c u l a r age of i l l persons (as indicated by the ov e r a l l Tukey t e s t ) . Control-of-onset. A 4 x 4 (Group x Age of 111 Person) MANOVA revealed s i g n i f i c a n t e f f e c t s for Age of 111 Person, F(3,180) = 83.50, pK.0001; and Group x Age of 111 Person, Page 53 Table 10 Significant Differences i n the Mean Ratings of Control- of -onset for Persons of Different Ages by Subjects of  Each Age Group Subject Group Comparison Kinder-garten Grade 3 Grade 7 Adult . Com-bined Infants < Elderly * * * * • Infants < Adults • * * # * Infants<Children • * * * Children< Elderly * Children< Adults * • Elderly<Adults * * * p_< .05 Page 54 F(9,180) = 3.26, p_<.002; but not for Group. For means, refer to Table 9. Tukey post-hoc comparison tests (at the .05 si g n i f i c a n c e level) were again performed. The s i g n i f i c a n t differences between the means within each group and between the means averaged across a l l subject groups are summarized in Table 10. As can be seen from the table, two trends in the d i s t i n c t i o n between control-of-onset for a d u l t s / e l d e r l y and children occurred with development: f i r s t , a trend towards decreased d i s t i n c t i o n from the kindergarten group to the grade 3 and 7 groups; then a trend towards increased d i s t i n c t i o n from the grade 3 and 7 groups to the adult group. Another trend that occurred with development was that of decreased d i s t i n c t i o n between-control-of-onset for infants and chi l d r e n from the c h i l d groups (kindergarten, grade 3 and grade 7) to the adult group. In the control-of-onset rating for the el d e r l y , there was a s i g n i f i c a n t group diff e r e n c e : the grade 3 group rated t h i s as much lower than did the adult group. Control-of-healing. A 4 x 4 (Group x Age of 111 Person) MANOVA revealed s i g n i f i c a n t e f f e c t s for Age of 111 Person, F(3,180) = 112.59, p_<.0001; and Group x Age of 111 Person, F(9,180) = 2.58, p_<.009; but not for Group. For means, refer to Table 9. Tukey post-hoc comparison tests (at the .05 sig n i f i c a n c e level) were again performed. The s i g n i f i c a n t differences between the means within each group and between the means averaged across a l l subject groups are summarized in Table 11. As can be seen from the table, two trends in the d i s t i n c t i o n Page 55 Table 11 Significant Differences i n the Mean Ratings of Control- of-healing for Persons of Different Ages by Subjects of  Each Age Group Subject Group Comparison Kinder-garten Grade 3 Grade 7 Adult Com-bined Infants < Elderly * * * * • Infants< Adults • • • * * Infants< Children • * * » Children< Elderly * * • Children< Adults * * * Elderly <Adults * p_< .05 > Page 56 between control-of-healIng for a d u l t s / e l d e r l y and children occurred with development: f i r s t , a trend towards decreased d i s t i n c t i o n from the kindergarten group to the grade 3 and 7 groups; then, a trend towards increased d i s t i n c t i o n from the grade 3 and 7 groups to the adult group. Another trend that occurred with development was that of increased d i s t i n c t i o n between control-of-healing for infants and children from the youngest group (kindergarten) to the older groups (grade 3, grade 7, and a d u l t s ) . There were no s i g n i f i c a n t differences between groups in th e i r ratings of control-of-healing for any one p a r t i c u l a r age of i l l persons (as indicated by the o v e r a l l Tukey t e s t ) . Hea1th Status. A 4 x 4 (Group x Age of 111 Person) MANOVA revealed a s i g n i f i c a n t e f f e c t for Age of 111 Person, F(3,180) = 15.63, p_<.0001; but no Group e f f e c t or Group x Age of 111 Person i n t e r a c t i o n . Mean ratings of health status for persons of d i f f e r e n t ages are given in Table 12. As indicated by an o v e r a l l Tukey comparison test (at the .05 l e v e l of s i g n i f i c a n c e ) , the kindergarten, grade 7, and adult groups did not s i g n i f i c a n t l y d i f f e r e n t i a t e between persons of d i f f e r e n t ages on the basis of health status.. However, the grade 3 group perceived both children and adults to be s i g n i f i c a n t l y more healthy than the e l d e r l y . A separate Tukey test (at the .05 s i g n i f i c a n c e level) was performed for the means averaged across a l l subject groups: Infants, children, and adults were a l l rated as s i g n i f i c a n t l y healthier than the e l d e r l y . There were no s i g n i f i c a n t differences between groups on the rating of health for any one p a r t i c u l a r Page 57 Table 12 Mean Ratings of Health Status f o r Persons of D i f f e r e n t  Ages by Subjects of Each Age Group Subject Group Age of Person Kindergarten Grade 3 Grade 7 Adult Infant 5.75 4.63 5.00 5.44 Children 6 .06 5.88 5-31 5 .63 Adults 6 .19 5.75 5.00 5.44 E l d e r l y 4.75 4 . 0 6 4.19 4.06 Page 58 age of persons (as Indicated by the o v e r a l l Tukey t e s t ) . Spec i f ic IIlnesses The subjects' ratings of the dimensions for each s p e c i f i c i l l n e s s were examined for possible group differences in the d i s t i n c t i o n s made between s p e c i f i c i l l n e s s e s on the bases of these dimensions. An ov e r a l l 4 x 4 x 5 (Group x Dimension x Illn e s s ) MANOVA revealed s i g n i f i c a n t main ef f e c t s for Group, F(3,60) = 3.03, p_<.04; and I l l n e s s , F( 4,240) = 10.84, p_<.001; but not for Dimension. S i g n i f i c a n t interactions were found for Group x Dimension, F(9,180) = 2.14, p_<.03; Dimension x Il l n e s s , F(12,720) = 23.21, p_<.001; and Group x Dimension I l l n e s s , F(36,720) = 2.06, p_<.001; but not for Group x I l l n e s s . This analysis was followed with a series of ind i v i d u a l 4 x 5 (Group x Illn e s s ) MANOVAs as well as post-hoc Tukey comparison tests for each dimension. The mean ratings of the dimensions for the s p e c i f i c i l l n e s s e s by subjects of each age group are given in Table 13. Sever i t v . The 4 x 5 (Group x Il l n e s s ) MANOVA revealed s i g n i f i c a n t e f f e c t s for I l l n e s s , F( 4,240) = 57.07, p_<.0001; and Group x I l l n e s s , F(12,240) = 2.32, p_<.009; but no Group e f f e c t . For means, refer to Table 13. An o v e r a l l Tukey test (at the .05 si g n i f i c a n c e level) to compare the mean severity ratings for each i l l n e s s within each age group and between age groups was performed. (The error term remained constant for each of these comparisons.) A separate Tukey test (at the .05 sig n i f i c a n c e leve) compared the average means across a l l groups on each i l l n e s s . The Page 59 Table 13 Mean Ratings of the Dimensions f o r S p e c i f i c I l l n e s s e s  by Subjects of Each Age Group Subject Group I l l n e s s Kindergarten Grade 3 Grade 7 Adult Severity Colds 3-19 3.31 2 .31 2 .31 Chicken Pox 4.31 4.19 3.88 2.50 A l l e r g y 4 .00 4.19 2 .75 3-75 Diabetes 4 .50 5.44 4.44 4.69 Cancer 5 .50 6.94 6.69 6.63 S u s c e p t i b i l i t y Colds 5-38 5 .06 5-38 4.81 Chicken Pox 4 .69 3.75 4 .50 5-31 A l l e r g y 3.69 3.56 3.31 3-56 Diabetes 4.69 4.44 3.63 2.81 Cancer 4.38 4.13 3 .63 3.68 (table continues) P a g e 60 Table 13 (cont.) Subject Group I l l n e s s Kindergarten Grade 3 Grade 7 Adult Control-of-onset Colds 5.50 5-56 5.31 5 .50 Chicken Pox 5.13 4 .19 3 .88 2.75 Allergy- 4.31 3.31 3.31 3-38 Diabetes 4.06 4 .19 3-88 3.81 Cancer 3.94 4 . 0 0 3.75 3 .94 Contr*ol-of • -healing Colds 5.13 5.31 5-13 5.31 Chicken Pox 5 .00 3 .94 3 .69 3 .50 A l l e r g y 4 .38 3.63 3.63 5-63 Diabetes 4 . 8 8 3-38 3 .88 5-38 Cancer 5.06 2 .44 2.31 4 . 4 4 Page 61 s i g n i f i c a n t differences are summarized in Table 14. As predicted, there was increased d i f f e r e n t i a t i o n between s p e c i f i c i l l n e s s e s on the basis of s e v e r i t y with age. Although the younger age groups d i f f e r e n t i a t e d less between the s p e c i f i c i l l n e s s e s on the basis of severity, a l l age groups ordered the i l l n e s s e s in the same way. As shown in Table 13, cancer was rated as most severe, followed by diabetes, a l l e r g i e s , and colds. (The only exception was chicken pox, an i l l n e s s for which there was less agreement as to i t s r e l a t i v e severity.) There were no s i g n i f i c a n t differences between the age groups for t h e i r ratings of any one p a r t i c u l a r i l l n e s s , as is indicated by the o v e r a l l Tukey tes t . S u s c e p t i b i l i t y . A 4 x 5 (Group x I l l n e s s ) MANOVA revealed a s i g n i f i c a n t I l l n e s s e f f e c t , P(4,240) = 8.14, p_<.0001; but no Group e f f e c t and no Group x I l l n e s s i n t e r a c t i o n . For means, refer to Table 13. As indicated by an o v e r a l l Tukey comparison test (at the .05 s i g n i f i c a n c e l e v e l ) , the kindergarten, grade 3, and grade 7 groups did not s i g n i f i c a n t l y d i f f e r e n t i a t e between s p e c i f i c i l l n e s s e s on the basis of s u s c e p t i b i l i t y . For adults, only a s i g n i f i c a n t difference between diabetes and chicken pox was found: chicken pox was rated as most easy to get; diabetes, least easy to get. A separate Tukey test (at the .05 s i g n i f i c a n c e l e v e l ) , comparing the average means across a l l groups on each i l l n e s s , showed the mean for chicken pox to be s i g n i f i c a n t l y higher than those of a l l e r g i e s , diabetes, and cancer. This indicates some d i f f e r e n t i a t i o n between P a g e 6 2 Table 14 S i g n i f i c a n t Differences i n theMean Ratings of Severity f o r S p e c i f i c I l l n e s s e s by Subjects of Each Age Group Subject Group Comparison Kinder- Grade Grade Adult Com-garten 3 7 bined Cold< Chicken Pox * Chicken Pox < Aller g y A l l e r g y < Diabetes * Diabetes < Cancer * * * Cold < Aller g y * Chicken Pox<Diabetes « * All e r g y < Cancer * * * * Cold< Diabetes , * * * # Chicken Pox < Cancer * * * * Cold< Cancer * * * * * * E < .05 Page 63 contagious and noncontagious i l l n e s s e s on this s u s c e p t i b i l i t y dimension. There were no s i g n i f i c a n t differences between the age groups for their ratings of any one pa r t i c u l a r i l l n e s s as is indicated by the ov e r a l l Tukey t e s t . Control-of-onset. A 4 x 5 (Group x Illn e s s ) MANOVA revealed a s i g n i f i c a n t I l l n e s s e f f e c t , F_(4,240) = 12.88, p_<.0001; but no Group e f f e c t and no Group x Il l n e s s i n t e r a c t i o n . For means, refer to Table 13. The o v e r a l l Tukey test (at the .05 si g n i f i c a n c e level) indicated that the kindergarten group did not s i g n i f i c a n t l y d i f f e r e n t i a t e between s p e c i f i c i l l n e s s e s on the basis of control-of-onset. However, the grade 3, grade 7, and adult groups rated control-of-onset s i g n i f i c a n t l y higher for colds than for a l l e r g i e s . The adult group also rated colds as s i g n i f i c a n t l y higher than chicken pox on th i s dimension. For chicken pox, there was also a s i g n i f i c a n t group difference: the adult group rated the control-of-onset for chicken pox much lower than did the kindergarten group. A separate Tukey test (at the .05 sig n i f i c a n c e l e v e l ) , comparing the average means across a l l groups on each i l l n e s s , showed that the mean for colds was s i g n i f i c a n t l y higher than those of chicken pox, a l l e r g i e s , diabetes, and cancer. Control-of-healing. A 4 x 5 (Group x Illn e s s ) MANOVA revealed s i g n i f i c a n t main ef f e c t s for both Group, F(3,60) = 6.16, p_<.002; and I l l n e s s , F( 4, 240) = 9 . 87, rj<.0001; as well as a s i g n i f i c a n t Group x Il l n e s s interaction, F_(12, 240) = 3.32, pjC.0002. For means, refer to Table 13. As indicated by an ov e r a l l Tukey comparison test (at the P a g e 6 4 . 05 s i g n i f i c a n c e l e v e l ) , t h e k i n d e r g a r t e n c h i l d r e n d i d n o t s i g n i f i c a n t l y d i f f e r e n t i a t e b e t w e e n s p e c i f i c i l l n e s s e s on t h e b a s i s o f c o n t r o l - o f - h e a l i n g . H o w e v e r , f o r t h e g r a d e 3 a n d g r a d e 7 g r o u p s , c o n t r o l - o f - h e a l i n g was r a t e d s i g n i f i c a n t l y h i g h e r f o r c o l d s t h a n f o r c a n c e r ; a s w e l l , f o r t h e a d u l t g r o u p , c o n t r o l - o f - h e a l i n g was r a t e d s i g n i f i c a n t l y h i g h e r f o r a l l e r g i e s t h a n f o r c h i c k e n p o x . S i g n i f i c a n t g r o u p d i f f e r e n c e s were f o u n d i n t h e r a t i n g s f o r a l l e r g i e s , d i a b e t e s a n d c a n c e r : The a d u l t g r o u p h a d a h i g h e r mean f o r a l l e r g i e s t h a n d i d t h e g r a d e 3 o r g r a d e 7 g r o u p s ; t h e a d u l t g r o u p h a d a h i g h e r mean f o r d i a b e t e s t h a n d i d t h e g r a d e 3 g r o u p ; a n d b o t h t h e k i n d e r g a r t e n a n d a d u l t g r o u p s had a h i g h e r mean on c a n c e r t h a n d i d t h e g r a d e 3 o r g r a d e 7 g r o u p s . As w e l l , a T u k e y t e s t ( a t t h e . 0 5 l e v e l o f s i g n i f i c a n c e ) c o m p a r i n g e a c h g r o u p ' s o v e r a l l r a t i n g s o f c o n t r o l - o f - h e a l i n g i n d i c a t e d t h a t b o t h t h e g r a d e 3 a n d g r a d e 7 g r o u p s g a v e s i g n i f i c a n t l y l o w e r o v e r a l l r a t i n g s t h a n d i d e i t h e r t h e k i n d e r g a r t e n o r a d u l t g r o u p s . A n o t h e r s e p a r a t e T u k e y t e s t ( a t t h e . 0 5 s i g n i f i c a n c e l e v e l ) , c o m p a r i n g t h e a v e r a g e means a c r o s s a l l g r o u p s on e a c h i l l n e s s , s h o w e d t h a t t h e mean f o r c o l d s was s i g n i f i c a n t l y h i g h e r t h a n t h o s e f o r c h i c k e n p o x , a l l e r g i e s , d i a b e t e s , a n d c a n c e r ; a n d t h a t t h e mean f o r c a n c e r was s i g n i f i c a n t l y l o w e r t h a n t h o s e f o r a l l e r g i e s a n d d i a b e t e s . A d d i t i o n a l m e a s u r e s o f c o n t r o l - o f - h e a l i n g i n c l u d e d d i f f e r e n c e s c o r e s b e t w e e n p e r s o n a l c o n t r o l a n d p a r e n t a l c o n t r o l f o r t h e k i n d e r g a r t e n , g r a d e 3 , a n d g r a d e 7 g r o u p s s o t h a t a c o m p a r i s o n m i g h t be made b e t w e e n o u r r e s u l t s and t h o s e o f N e u h a u s e r e t a l . ( 1 9 7 8 ) . A 4 x 5 ( G r o u p x I l l n e s s ) MANOVA Page 6 5 showed no s i g n i f i c a n t main e f f e c t s for Group and Illn e s s and no Group x I l l n e s s i n t e r a c t i o n . A measure of medicine's control-of healing was also obtained for each s p e c i f i c i l l n e s s : The means for each group are given in Table 15. A 4 x 5 (Group x Il l n e s s ) MANOVA revealed s i g n i f i c a n t e f f e c t s for I l l n e s s , F(4,240) = 7.74, •pjC.0001; and Group x I l l n e s s , F(12,240) = 9.30, p_<.0001; but no Group e f f e c t . As indicated by an o v e r a l l Tukey comparison test (at the .05 s i g n i f i c a n c e l e v e l ) , the kindergarten children did not s i g n i f i c a n t l y d i f f e r e n t i a t e between s p e c i f i c i l l n e s s with respect to the role medicine could play in control-of-healing. However, for the grade 3 and grade 7 groups, medicine's control-of-healing was rated s i g n i f i c a n t l y higher for colds than for cancer; a d d i t i o n a l l y for the grade 3 group, t h i s control measure was s i g n i f i c a n t l y higher for colds than for diabetes. For the adult group, not only was there increased d i f f e r e n t i a t i o n between s p e c i f i c i l l n e s s e s on t h i s basis, but an in t e r e s t i n g r e v e r s a l : medicine's control-of-healing for colds and chicken pox was rated as s i g n i f i c a n t l y lower than that for a l l e r g i e s , diabetes and cancer. S i g n i f i c a n t group differences were found in the ratings for colds, chicken pox, diabetes, and cancer: Both the kindergarten and grade 3 groups had higher means for colds than did the adult group; the kindergarten, grade 3, and grade 7 groups had higher means for chicken pox than did the adult group; the adult group had a higher mean for diabetes than did the grade 3 group; and both the kindergarten and adult group had higher means for P a g e 66 Table 15 Mean Ratings of Medicine's Control-of-healing f o r S p e c i f i c  Illnesses by Subjects of Each Age Group Subject Group I l l n e s s Kindergarten Grade 3 Grade 7 Adult Colds 5-63 5-94 5 . 00 3.56 Chicken Pox 4.81 5.13 4 . 0 0 2.38 A l l e r g y 5.81. 4o44 4.63 5-38 Diabetes 5-50 4.19 4.81 6.13 Cancer 5-81 4.38 3.38 5.44 Page 67 cancer than did the grade 7 group. A separate Tukey test (at the .05 sig n i f i c a n c e l e v e l ) , comparing the average mean across a l l groups on each i l l n e s s , showed that the mean for chicken pox was s i g n i f i c a n t l y lower than those for colds, a l l e r g i e s , diabetes, and cancer. Rank inqs on the d imensi ons. The subjects were a d d i t i o n a l l y asked to rank order the s p e c i f i c i l l n e s s e s on each dimension. These rankings gave information with respect to whether there was a s i g n i f i c a n t ordering of the s p e c i f i c i l l n e s s e s on each dimension, even i f the scores given on the 7-point scale did not s i g n i f i c a n t l y vary from one another for a p a r t i c u l a r age group. For each group, the mean ranks for the s p e c i f i c i l l n e s s e s on these dimensions are given in Table 16 . To look at whether there was intragroup agreement for the ordering of i l l n e s s e s on each dimension, a Kendall's c o e f f i c i e n t of concordance (W) was calculated. It was expected that agreement amongst subjects would increase with age. Table 17 summarizes these values of W. For a l l groups, there was s i g n i f i c a n t agreement with respect to the ranking of the s p e c i f i c i l l n e s s on a l l dimensions. However, as detailed below, there was an ov e r a l l increase in the degree of concordance with increasing age for three of the four dimensions. For severity, agreement among subjects increased with age (see Table 17). A l l groups ranked cancer, diabetes, a l l e r g i e s and colds in the same way from most severe to least severe (see Table 16), but there was a difference in the ordering of Page 6 8 Table 16 Mean Rankings of the S p e c i f i c Illnesses on Each Dimension  by Subjects of Each Age Group Subject Group I l l n e s s Kindergarten Grade 3 Grade 7 Adult Severity Colds 4 . 0 6 4 . 75 4 . 88 4 . 81 Chicken Pox 3-38 3. 63 3. 25 4 . 06 Allergy 3-69 3- 50 3- 81 3. 06 Diabetes 2 .19 2. 13 2. 06 2. 06 Cancer 1.69 1. 00 1. 00 1. 0.0 S u s c e p t i b i l i t y Colds 1.75 1. 25 ' 1. 31 1. 00 Chicken Pox 2 .06 2. 69 2 . 31 2 . 50 A l l e r g y 3-50 2. 81 3. 88 3. 00 Diabetes 3.88 3. 69 3. 50 4 . 38 Cancer 3.81 4 . 56 4 . 00 4 . 13 (table continues) P a g e 69 Table 16 (cont.) Subject Group I l l n e s s Kindergarten Grade 3 Grade 7 Adult Control- of-onset Colds 1.75 1 .25 1.69 1. 44 Chicken Pox 2 .44 2 .56 3 .00 2. 38 Allergy- 2 .75 2 .81 3 .25 3- 19 Diabetes 3 .69 3-63 2 .94 3. 63 Cancer 4 .38 4 » 7 5 4.13 4. 38 Control--of-healing Colds 1.75 1 .25 1 .25 1. 81 Chicken Pox 2 .88 2 .69 2 .81 2 . 81 A l l e r g y 3-25 3-13 3 .06 3- 00 Diabetes 3-31 3.44 3.44 3. 38 Cancer 3.81 4 .50 4.44 4. 00 Page 70 Table 17 Degree of Intragroup Agreement f o r the Ordering of the  S p e c i f i c I l l n e s s e s on Each Dimension by Subjects of Each  Group Subject Group Dimensions Kindergarten (w) Grade 3 (W) Grade 7 CD Adult (I.) Severity .41* . 8 5 * • 91* • 93* S u s c e p t i b i l i t y .41* .61* .53* .74* Control-of-onset .43* .67* • 31* .51* Control-of-healing .24* .56* .54* .26* * p_xC01 Page 71 a l l e r g i e s and chicken pox. The grade 3 and adult groups ranked a l l e r g i e s as more severe than chicken pox, but the kindergarten and grade 7 groups ranked chicken pox as more severe than a l l e r g i e s . On the basis of comments obtained from the subjects, i t seems that a d i f f e r e n t c r i t e r i o n was employed here by the groups. The f i r s t groups may have focused on the duration (or chronicity) of the i l l n e s s while the l a t t e r groups focused on the r e l a t i v e i r r i t a b i l i t y of the i l l n e s s e s 1 symptoms. For s u s c e p t i b i l i t y , agreement among subjects also seemed to increase with age, although there was a decline in agreement for the grade 7 group (see Table 17). A l l groups ranked colds, chicken pox, a l l e r g i e s and cancer in the same way from the most susceptible to least susceptible (see Table 16) but there was not agreement between the groups with respect to the r e l a t i v e s u s c e p t i b i l i t y of diabetes. The kindergarten and adult groups ranked i t lower than cancer; the grade 3 group ranked i t as higher than cancer (but lower than a l l e r g i e s ) ; and the grade 7 group ranked i t as higher than a l l e r g i e s (but lower than chicken pox). Again, i t seems a d i f f e r e n t c r i t e r i o n is employed by the groups or a d i f f e r e n t understanding/knowledge of the inherent s u s c e p t i b i l i t y to an i l l n e s s versus the external factors influencing s u s c e p t i b i l i t y . For control-of-onset, agreement among subjects was greatest for the grade 3 group: there was an increase in agreement from the kindergarten to the grade 3 group, then a decline from the grade 3 group to the grade 7 group, and Page 7 2 another increase from the grade 7 to adult group (see Table 17). However, a l l age groups, except the grade 7 group, ranked colds, chicken pox, a l l e r g i e s , diabetes, and cancer in the same way from the most control to the least control (see Table 16). The grade 7 group's ordering was colds, diabetes, chicken pox, a l l e r g i e s and cancer, although the ranks for a l l but colds and cancer were very close. With respect to the c r i t e r i o n used to rank i l l n e s s e s on t h i s dimension, the younger groups seemed to make the i r judgements using a c r i t e r i o n of incidence, whereas the older group also used other c r i t e r i a such as knowledge of the prevention available for each i l l n e s s . For control-of-healing, agreement was quite low for the kindergarten and adult groups (however, s t i l l s i g n i f i c a n t ) but considerably higher for the grade 3 and grade 7 groups (see Table 17). A l l age groups ranked colds, chicken pox, a l l e r g i e s , diabetes and cancer in the same way from the most control to the least control (see Table 16). The c r i t e r i a used for making judgements were the l i k e l i h o o d of recovering from the i l l n e s s , manageability of the i l l n e s s , as well as the a v a i l a b i t y of e f f e c t i v e medical treatments. With age, more of these factors were considered simultaneously. The lower agreement among subjects in the adult group may be due to the r e l a t i v e weight the d i f f e r e n t subjects within the group placed on d i f f e r e n t c r i t e r i a . Page 73 Discussion The re s u l t s of t h i s study indicate that children's conceptualizations of i l l n e s s appear to be influenced by both cognitive development and the abstractness and/or f a m i l i a r i t y of the i l l n e s s under discussion. Developmental differences were found for descriptions of i l l n e s s in general as well as s p e c i f i c i l l n e s s e s . For s p e c i f i c i l l n e s s e s , these differences were more or less pronounced depending on f a m i l i a r i t y or experience with the i l l n e s s for the subjects and/or the v i s i b i l i t y of the i l l n e s s ' symptoms. Children's understanding of the underlying dimensions of Ill n e s s appear to also be influenced by t h e i r l e v e l of cognitive development. With development, there was increased d i f f e r e n t i a t i o n between i l l n e s s e s on the bases of the four dimensions under study, although childr e n of a l l ages ordered the i l l n e s s e s in much the same way. A d d i t i o n a l l y there were developmental differences in the way in which these dimensions were perceived with respect to the age of the i l l person. Each of these findings w i l l now be further discussed and considered within a s t r u c t u r a l i s t developmental framework. As there is a high c o r r e l a t i o n between any p a r t i c u l a r subject group and l e v e l of cognitive development, for t h e o r e t i c a l reasons, i t was considered appropriate to discuss these re s u l t s in terms of cognitive development. Verbal Descr i p t i ons of I llness I l l n e s s in genera1. As was expected, a discussion of i l l n e s s in general led the c h i l d to focus on the sick i n d i v i d u a l rather than on i l l n e s s i t s e l f . This was e s p e c i a l l y Page 74 true for the older subjects' d e f i n i t i o n s of i l l n e s s in general. I t seems that, with development, there was a trend toward considering the psychosocial aspects of i l l n e s s : the older subjects made increased reference to the psychological/emotional and behavioral changes which occur with i l l n e s s whereas they made decreased reference to general somatic feelings and very l i t t l e reference to the s p e c i f i c symptoms of i l l n e s s . This may be best explained by the ch i l d ' s increasing a b i l i t y to consider the less v i s i b l e perceptual referents of a s i t u a t i o n . Thus the c h i l d begins to consider the psychosocial as well as the physical aspects of i l l n e s s . As well, the subjects seemed to interpret i l l n e s s in general as r e f e r r i n g to very common complaints such as malaise or lethargy rather than r e f e r r i n g to the f u l l range of possible i l l n e s s e s . For these general problems, physical changes are of a less severe and less definable nature. As such, the psychosocial changes may be the most s a l i e n t features of the i l l n e s s s i t u a t i o n . In their diagnoses of i l l n e s s in general, not su r p r i s i n g l y , a l l subjects made more reference to both general somatic feelings and s p e c i f i c physical symptoms of i l l n e s s than to the psychosocial aspects of i l l n e s s . However, although there was a trend for older subjects to increasingly consider general somatic feelings as indicators of i l l n e s s , no such increase occurred with age in the use of s p e c i f i c physical symptoms. A d d i t i o n a l l y , the older subjects gave increasing consideration to psychological/emotional changes as indicators of i l l n e s s , although these were less often referred Page 75 to than were the previously mentioned Indicators of i l l n e s s . With development, an i n d i v i d u a l seems to increasingly judge whether s/he is i l l against a general model or f e e l i n g of well-being. For i l l n e s s in general t h i s may indeed be a better i n i t i a l indicator of i l l n e s s than are more s p e c i f i c symptoms. Behaviors do not seem to be as prominent in descriptions of self-diagnosis as they were in d e f i n i t i o n s of i l l n e s s perhaps because these changes only occur af t e r one has diagnosed his/her i l l n e s s . When asked about prevention of i l l n e s s in general, a l l subjects gave more consideration to the physical factors in maintaining one's health (proper n u t r i t i o n , exercise, and sleep) rather than psychological factors. Only a small proportion of the adults mentioned that p o s i t i v e mental attitudes (or a generally p o s i t i v e "outlook on l i f e " ) may be important to one's general health. N u t r i t i o n was regarded as the most important s e l f c a r e a c t i v i t y in fostering health by a l l age groups; a finding which i s consistent with that of Rashkis (1965). The youngest children were the least capable of understanding the concept of prevention; t h i s may r e f l e c t the fact that preoperational children know and understand the least about causation of i l l n e s s (Bibace & Walsh, 1980; Simeonsson, Buckley, & Monson, 1979). They were more l i k e l y to consider means of restoring one's health (medicine) than were the older, more c o g n i t i v e l y advanced age groups. It had been expected that, with development, subjects would increasingly make reference to preventative factors which suggest some understanding/knowledge of contagion (such Page 76 as avoiding sick persons or getting vaccinations). Although the question was worded such that subjects might be cued to consider contagion ("What can you do to keep from getting s i c k ? " rather than "What can you do to stay healthy?"), very few subjects mentioned such factors and there were no age trends. One s h i f t from childhood to adulthood which might suggest an increased understanding of i l l n e s s c a u s a l i t y was that children mentioned the importance of keeping warm when outdoors (a frequent parental admonition) as important in health maintenance whereas no adults mentioned t h i s factor. It may be that adults do not mention t h i s factor because i t is an event which i s merely contiguous/associated with i l l n e s s ; while i t may increase an individual's s u s c e p t i b i l i t y or v u l n e r a b i l i t y to an i l l n e s s such as a cold, on i t s own, i t can not a c t u a l l y cause the i l l n e s s . S p e c i f i c i l l n e s s e s . The subjects' descriptions of s p e c i f i c i l l n e s s e s indicate that the v i s i b i l i t y of an i l l n e s s ' symptoms as well as the subjects' l e v e l of experience with an i l l n e s s may influence the s o p h i s t i c a t i o n of both d e f i n i t i o n s and diagnoses of i l l n e s s . While there were s i g n i f i c a n t differences between age groups in d e f i n i t i o n s and diagnoses of every s p e c i f i c i l l n e s s (no matter how common the i l l n e s s or how v i s i b l e i t s symptoms, a finding which concurs with the claims made by Bibace & Walsh 1980,1981); within a p a r t i c u l a r age group, the f a m i l i a r i t y and the v i s i b i l i t y of an i l l n e s s gave r i s e to differences in d e f i n i t i o n s and diagnoses for more f a m i l i a r / v i s i b l e versus the less f a m i l i a r / v i s i b l e i l l n e s s e s . However, to f u l l y understand t h i s demonstrated influence of Page 77 f a m i l i a r i t y and/or v i s i b i l i t y on d e f i n i t i o n s and diagnoses, i t appears necessary to also take into account the subject's l e v e l of cognitive development. For d e f i n i t i o n s of a l l i l l n e s s e s , there was a developmental trend to increasingly consider the cause or underlying mechanism of a s p e c i f i c i l l n e s s . While the a b i l i t y or tendency to consider causation was limited by cognitive development, i t s consideration seemed to be a d d i t i o n a l l y affected by the f a m i l i a r i t y / v i s i b i l i t y of the i l l n e s s under discussion (as Simeonsson et al.} 1979, also found). Although this might seem cou n t e r - i n t u i t i v e , the only evidence of the concrete operational c h i l d ' s (grade 3 group) a b i l i t y to begin to consider i l l n e s s causation was found for cancer, a less f a m i l i a r / v i s i b l e i l l n e s s . However, the older children and adults considered causation for the other i l l n e s s e s as well. But even within these formal operational groups (grade 7 and adult groups), there was s t i l l increased reference to causation for the less f a m i l i a r / v i s i b l e i l l n e s s e s as compared to the more f a m i l i a r / v i s i b l e i l l n e s s e s . Thus the degree to which an i n d i v i d u a l i s f a m i l i a r with an i l l n e s s and the degree to which an i l l n e s s provides v i s i b l e perceptual referents influence the degree to which an individual w i l l tend to consider i l l n e s s causation or simply focus on the i l l n e s s ' symptoms. It may also be that, because the e f f e c t s of less f a m i l i a r / v i s i b l e i l l n e s s e s are more longterm and severe, the i n d i v i d u a l feels more of a need to search for an explanation of these i l l n e s s e s than s/he does for an i l l n e s s for which s/he i s l i k e l y to experience r e l a t i v e l y t r a n s i t o r y and less Page 78 severe e f f e c t s . There also appears to be an i n t e r a c t i o n between these influences of f a m i l i a r i t y and v i s i b i l i t y and l e v e l of cognitive development: Older subjects (grade 7 and adult groups) tended to give more sophisticated d e f i n i t i o n s for the less f a m i l i a r / v i s i b l e i l l n e s s e s than for the more f a m i l i a r / v i s i b l e i l l n e s s e s , whereas for the younger subjects (kindergarten and grade 3 groups), the opposite tendency was true. It seems that a l l age groups were more l i k e l y to focus on the symptoms of the more f a m i l i a r / v i s i b l e i l l n e s s e s . This is l i k e l y due to the greater sallency of the physical symptoms for these i l l n e s s e s . Thus age differences were less pronounced for the more f a m i l i a r / v i s i b l e i l l n e s s e s . A d d i t i o n a l l y i t was noted that symptoms were never referred to by any of the subjects in t h e i r d e f i n i t i o n s of diabetes and cancer. For these i l l n e s s e s , the most v i s i b l e perceptual referents appear to be the medical treatments and their outcomes or events which may merely p r e c i p i t a t e the i l l n e s s (some examples for cancer are chemotherapy, amputation of limbs, smoking). For the diagnoses of a l l i l l n e s s e s , there was increasing s o p h i s t i c a t i o n in the subjects' responses with development. With development, subjects appear to be increasingly able to self-diagnose an i l l n e s s using s p e c i f i c symptoms which di s t i n g u i s h i t from i l l n e s s in general. Again developmental differences were most pronounced for the less f a m i l i a r / v i s i b l e i l l n e s s e s (a finding which further supports Neuhauser and colleagues', 1978, claims). Whereas most subjects of a l l age Page 79 groups were able to use s p e c i f i c symptoms to diagnose colds and chicken pox, younger subjects were less able to diagnose a l l e r g i e s , diabetes, and cancer in the same way. For diabetes and cancer in p a r t i c u l a r , i t was not u n t i l adulthood that subjects appeared able to use s p e c i f i c symptoms in th e i r diagnoses. Diagnoses, thus, appear to be p a r t i c u l a r l y influenced by one's experience/familiarity with an i l l n e s s . For instance, adults reported the most experience/familiarity with diabetes and cancer and were the only group c l e a r l y able to use s p e c i f i c warning signs/symptoms in t h e i r diagnoses of these i l l n e s s e s . (However, i t may also be that one's perceived v u l n e r a b i l i t y to an i l l n e s s influences the degree to which an in d i v i d u a l w i l l either attend to or seek out medical information with respect to an i l l n e s s ' warning signs.) Thus in the adult's a b i l i t y to diagnose i l l n e s s there were fewer differences for the s p e c i f i c i l l n e s s e s . In contrast, there were greater d i s p a r i t i e s in children's a b i l i t i e s to diagnose d i f f e r e n t s p e c i f i c i l l n e s s e s : whereas childre n were capable of self-diagnosing f a m i l i a r i l l n e s s e s using s p e c i f i c symptoms, they could at best only use general i l l n e s s symptoms to diagnose less f a m i l i a r i l l n e s s e s . Again, t h i s may be due to the fact that these i l l n e s s e s do indeed have less v i s u a l l y obvious perceptual referents/symptoms. While the concrete operational (grade 3) and formal operational (grade 7) children could at least suggest ways in which they might be assisted in diagnosing those i l l n e s s e s they knew less about, the preoperational (kindergarten) children on the whole made Page 80 no attempt to go beyond an "I don't know" answer. Thus, with development, the c h i l d appears to be more l i k e l y to seek out s p e c i f i c medical information. As can be seen from our r e s u l t s , i t is indeed important to consider the abstractness of the concept under discussion. In subjects' d e f i n i t i o n s and diagnoses of i l l n e s s in general the focus was on the i l l person and the e f f e c t of i l l n e s s on his/her emotional and behavioral state. However, in subjects' d e f i n i t i o n s and diagnoses of s p e c i f i c i l l n e s s e s , the focus was on the i l l n e s s i t s e l f : i t s s p e c i f i c physical symptoms and underlying causes. A d d i t i o n a l l y , the a b s t r a c t n e s s / v i s i b i l i t y of the s p e c i f i c i l l n e s s under discussion also exerted some ef f e c t on the s o p h i s t i c a t i o n of the subjects' responses. Thus, while s i g n i f i c a n t age trends were found in d e f i n i t i o n s and diagnoses, regardless of the s p e c i f i c i t y / a b s t r a c t n e s s of the i l l n e s s concept under discussion, d i f f e r e n t information was yielded by a general versus s p e c i f i c approach to discussing i l l n e s s . Dimensions of I l l n e s s The findings with respect to the way in which subjects conceptualize the dimensions of i l l n e s s - severity, s u s c e p t i b i l i t y , control over onset, and control over healing -are considered to be of p a r t i c u l a r s i g n i f i c a n c e . Since previous research work has given r e l a t i v e l y l i t t l e attention to the c h i l d ' s understanding of these dimensions, the present research w i l l not only extend our knowledge of development in t h i s conceptual domain, but may also help to disambiguate previous research findings. It may be that the Page 81 sophistication/content of children's verbal descriptions of i l l n e s s may r e f l e c t and be influenced by t h e i r understanding of these underlying dimensions of i l l n e s s (this has also been suggested by Potter & Roberts, 1984). Il l n e s s in genera1. In general, younger, less c o g n i t i v e l y advanced subjects (kindergarten and grade 3) perceived the s e v e r i t y of i l l n e s s to be s i g n i f i c a n t l y greater than did the older, more c o g n i t i v e l y advanced subjects (grade 7 and a d u l t s ) . There also appears to be a decrease in one's perception of s u s c e p t i b i l i t y to i l l n e s s with development (although t h i s decrease was only s i g n i f i c a n t for our adult group). These general trends for s e v e r i t y and s u s c e p t a b i l i t y were also observed by Potter & Roberts (1984) in a comparison of preoperational versus concrete operational c h i l d r e n . Younger children's perceptions of s u s c e p t i b i l i t y may r e f l e c t the fact that they indeed do experience common i l l n e s s e s more frequently than do older c h i l d r e n and adults (Spock & Rothenberg, 1985) or may r e f l e c t an increased f e e l i n g of v u l n e r a b i l i t y . Unlike. Neuhauser and her colleagues (1978), we did not find s i g n i f i c a n t increases with development on our measures of subjects' perceptions of their control over either the onset or healing of i l l n e s s in general. Although there was a trend for older, more c o g n i t i v e l y advanced children to perceive their own control over the healing process as being greater than the assistance t h e i r parents might give them, t h i s trend was not s i g n i f i c a n t . However, in subjects' ratings of the role medicine could play in control-of-healing, a s i g n i f i c a n t Page 8 2 t r e n d f o r o l d e r s u b j e c t s ( p a r t i c u l a r l y t h e a d u l t s ) t o p e r c e i v e i t s c o n t r o l a s b e i n g s i g n i f i c a n t l y l e s s t h a n d i d t h e y o u n g e r s u b j e c t s ( p a r t i c u l a r l y t h e g r a d e 3 g r o u p ) was f o u n d . T h i s may s u g g e s t t h a t w i t h d e v e l o p m e n t s u b j e c t s do i n d e e d p e r c e i v e t h e m s e l v e s t o h a v e more p e r s o n a l c o n t r o l o v e r h e a l i n g a n d t h u s t h e y r a t e m e d i c i n e ' s r o l e a s b e i n g s m a l l e r . A d d i t i o n a l l y , i t may j u s t be t h a t o l d e r s u b j e c t s h a v e a more r e a l i s t i c p e r c e p t i o n o f what m e d i c i n e c a n a n d c a n n o t do f o r t h e m b a s e d on s p e c i f i c k n o w l e d g e t h e y h a v e g a i n e d w i t h d e v e l o p m e n t . T h e y o u n g e r s u b j e c t s ' p e r c e p t i o n o f t h e r o l e m e d i c i n e p l a y s i n h e a l i n g a p p e a r s t o r e f l e c t t h e " m a g i c a l " c a u s a l t h i n k i n g t h a t i s c h a r a c t e r i s t i c o f t h e p r e o p e r a t i o n a l p e r i o d o f c o g n i t i v e d e v e l o p m e n t . Age o f i 1 1 p e r s o n . The s u b j e c t s ' r a t i n g s o f t h e s e d i m e n s i o n s o f i l l n e s s f o r i n d i v i d u a l s o f d i f f e r e n t a g e g r o u p s a l s o r e v e a l e d some i n t e r e s t i n g t r e n d s . T h e r e was a n o v e r a l l t r e n d f o r s u b j e c t s ' r a t i n g s o f s e v e r i t y t o d e c r e a s e w i t h d e v e l o p m e n t . H o w e v e r , f o r t h e o t h e r d i m e n s i o n s , t h e r e were no s i g n i f i c a n t d e c r e a s e s o r i n c r e a s e s i n t h e s u b j e c t s ' r a t i n g s w i t h d e v e l o p m e n t . More i n t e r e s t i n g l y , h o w e v e r , a r e t h e t r e n d s w i t h d e v e l o p m e n t t h a t o c c u r e d i n s u b j e c t s ' d i f f e r e n t i a t i o n b e t w e e n d i f f e r e n t a g e d i n d i v i d u a l s on t h e b a s e s o f t h e s e d i m e n s i o n s o f i l l n e s s . Due t o t h e o b v i o u s h e l p l e s s n e s s o f a n i n f a n t , t h e f i n d i n g t h a t e v e n t h e y o u n g e s t s u b j e c t g r o u p s m i g h t be a b l e t o d i s t i n g u i s h i n f a n t s f r o m t h e o t h e r a g e g r o u p s , p a r t i c u l a r l y t h e a d u l t a n d e l d e r l y a g e g r o u p , h a d b e e n a n t i c i p a t e d . F o r s e v e r i t y , i t was i n d e e d f o u n d t h a t a l l s u b j e c t g r o u p s Page 83 s i g n i f i c a n t l y distinguished between the se v e r i t y of Illness for infants and adults, with i l l n e s s rated as most severe for infants. This finding was also true for both control dimensions, with a l l subject groups rating infants' control over the onset and healing of i l l n e s s as s i g n i f i c a n t l y lower than that of both adults and the e l d e r l y . Further d i s t i n c t i o n s that were made between d i f f e r e n t aged individuals on these dimensions appear to be more dependent on the age of the respondent. The d i f f e r e n t i a t i o n made between the infant and c h i l d groups as well as between the c h i l d , adult, and e l d e r l y groups appear to be p a r t i c u l a r l y affected by the age of the respondents. It had been expected that the older (grade 3 and grade 7) children might rate these dimensions for children, adults, and the e l d e r l y more equivalently, whereas the younger (kindergarten) children and adult subject groups would not do so. This expectation was substantiated by subjects' d i f f e r e n t i a t i o n between d i f f e r e n t aged individuals on both control dimensions. Whereas the grade 3 and grade 7 subject groups did not s i g n i f i c a n t l y d i s t i n g u i s h between children, adults, and the e l d e r l y in terms of their control over the onset and healing of i l l n e s s , both the kindergarten and adult groups rated children's control over the onset and healing of i l l n e s s as s i g n i f i c a n t l y less than that of adults and the e l d e r l y . This finding, as well as the finding that the grade 3 and grade 7 groups were more l i k e l y (as compared to the kindergarten group) to perceive children's control over both the onset and healing of i l l n e s s s to be greater than that of infants, lends support to Neuhauser Page 84 and colleagues' (1978) claim that from the preoperational to the concrete operational stage of development there is a trend for children to perceive themselves as having increasing control over i l l n e s s . However, to uncover t h i s trend, i t seems that ch i l d r e n must be s p e c i f i c a l l y cued to think about the d i f f e r e n t a b i l i t i e s they might have compared to other age groups. Indeed the approach taken by Neuhauser and her colleagues in t h e i r interview was to precede the control question with instructions that predisposed c h i l d r e n to think about things that they could and could not do for themselves. Additional d i s t i n c t i o n s between adults and the e l d e r l y were made on the dimensions of s e v e r i t y and s u s c e p t i b i l i t y . There was a trend with development for subjects to increasingly perceive that s e v e r i t y of i l l n e s s i s also greater for the e l d e r l y than for adults, however t h i s perceived difference was only s i g n i f i c a n t for the grade 3 subjects. This same trend was again observed for an individual's s u s c e p t i b i l i t y to i l l n e s s , although t h i s difference between the e l d e r l y and adults was only s i g n i f i c a n t for the adult subject groups. While a l l subjects appear to d i f f e r e n t i a t e between d i f f e r e n t aged persons on these dimensions of i l l n e s s , there does not seem to be any s i g n i f i c a n t trend toward d i f f e r e n t i a t i n g between individuals of these same age groups on a measure of health status. Subjects appear to perceive individuals of a l l age groups to be equally healthy. Thus i t appears that stereotypes of d i f f e r e n t aged persons may be influenced by perceptions of i l l n e s s for these individuals P a g e 85 r a t h e r t h a n b y p e r c e p t i o n s o f t h e i r g e n e r a l h e a l t h . I t a l s o seems l i k e l y t h a t t h e s e p e r c e p t i o n s o f i l l n e s s f o r d i f f e r e n t a g e d p e r s o n s w i l l a f f e c t t h e ways i n w h i c h a n i l l p e r s o n i s p e r c e i v e d a n d t h u s t r e a t e d b y i n d i v i d u a l s i n h i s / h e r e n v i r o n m e n t . I n t h i s s t u d y , t h e r e s e e m e d t o be i n d i v i d u a l a n d a g e d i f f e r e n c e s i n t h e f a c t o r s t h a t s u b j e c t s may h a v e c o n s i d e r e d when t h e y r a t e d t h e s e d i m e n s i o n s o f h e a l t h a n d i l l n e s s f o r d i f f e r e n t a g e d i n d i v i d u a l s . W h i l e t h e r e were o n l y s l i g h t d e v e l o p m e n t a l t r e n d s i n s u b j e c t s ' r a t i n g s o f t h e s e d i m e n s i o n s a n d d i s c r i m i n a t i o n b e t w e e n p e r s o n s o f d i f f e r e n t a g e g r o u p s on t h e s e d i m e n s i o n s , i t i s s u s p e c t e d t h a t t h e f a c t o r s w h i c h a r e c o n s i d e r e d b y s u b j e c t s when m a k i n g t h e s e r a t i n g s u n d e r g o g r e a t e r c h a n g e s w i t h d e v e l o p m e n t . I t seems v e r y l i k e l y , a s P e e v e r s & S e c o r d (1973) s u g g e s t , t h a t y o u n g e r c h i l d r e n f o r m t h e i r i m p r e s s i o n s o f t h e s e v e r i t y , s u s c e p t i b i l i t y , a n d b o t h c o n t r o l d i m e n s i o n s f o r d i f f e r e n t a g e p e r s o n s on t h e b a s e s o f more e g o c e n t r i c f e e l i n g s w h e r e a s o l d e r c h i l d r e n f o r m t h e s e i m p r e s s i o n s on t h e b a s e s o f a c t u a l i n f o r m a t i o n t h e y h a v e o b t a i n e d . A d d i t i o n a l l y , t h e r e may b e , a s L i v e s l e y & B r o m l e y (1973) s u g g e s t , a t e n d e n c y f o r c h i l d r e n t o c o n s i d e r p s y c h o l o g i c a l f a c t o r s more when m a k i n g a s s e s s m e n t s o f t h e s e d i m e n s i o n s f o r a d u l t p e r s o n s t h a n t h e y do when m a k i n g t h e s e same a s s e s s m e n t s f o r o t h e r c h i l d r e n . I t w o u l d be i n t e r e s t i n g i n a f u t u r e s t u d y t o make a g e c o m p a r i s o n s o f t h e s e f a c t o r s t h a t a r e c o n s i d e r e d i n a s s e s s i n g t h e s e d i m e n s i o n s f o r d i f f e r e n t a g e d p e r s o n s . Page 86 Speci f i c i l l n e s s e s . There were s i g n i f i c a n t trends in the c h i l d ' s a b i l i t y to d i f f e r e n t i a t e between s p e c i f i c i l l n e s s e s on the bases.of the underlying dimensions of i l l n e s s . Interestingly, subjects of a l l age groups appear to be capable of c o n s i s t e n t l y rank ordering the s p e c i f i c i l l n e s s e s in the hypothesized d i r e c t i o n s on the dimensions of severity, s u s c e p t i b i l i t y , control over onset, and control over healing. Only with age/cognitive development, however, was there increased d i f f e r e n t i a t i o n in subjects' ratings of the i l l n e s s e s on these dimensions. This trend was most clear for s e v e r i t y : The youngest subjects were only able to c l e a r l y d i s t i n g u i s h between the most and least severe i l l n e s s e s (cancer and c o l d s ) . However, with development, increased d i s t i n c t i o n was made between i l l n e s s e s of varying degrees of s e v e r i t y such that the oldest groups were capable not only of d i s t i n g u i s h i n g between other more and less severe i l l n e s s but also of d i s t i n g u i s h i n g between the two most severe i l l n e s s e s (diabetes, which is a chronic, and i f not treated, f a t a l i l l n e s s ; and cancer, which also tends to be a chronic i l l n e s s , and even i f treated may be f a t a l ) . That even the youngest children were aware of the difference in s e v e r i t y for the most severe r e l a t i v e to the least severe of these i l l n e s s e s complements previous research work by Waechter (1971) and Spinetta, Rigler, & Karon (1973). They report that f a t a l l y i l l c h i l dren, even as young as 6 to 10 years of age, appear to be aware of the seriousness of t h e i r i l l n e s s despite e f f o r t s to s h i e l d them from an awareness of t h e i r diagnoses or prognoses. While children diagnosed Page 87 with leukemia were not yet capable o£ t a l k i n g about th i s awareness in adult terms, they expressed a greater degree of both h o s p i t a l - r e l a t e d and nonhospital-related anxiety than did a group of control children with chronic but nonfatal i l l n e s s (Spinetta, Rigler, & Karon, 1973). Waechter (1971) comments that although great e f f o r t s are made to s h i e l d f a t a l l y i l l c hildren from their diagnoses or prognoses, t h i s information seems to be conveyed to the c h i l d through the anxiety of t h e i r parents, an altered emotional climate in t h e i r homes, and/or through the fa l s e cheerfulness or evasiveness of those around them. The present study indicates that not only is the f a t a l l y i l l c h i l d aware of his/her prognosis but so are his/her n o n a f f l i c t e d healthy peers. Thus the c h i l d may bring already formed expectations/perceptions of the i l l n e s s ' s e v e r i t y into such an i l l n e s s s i t u a t i o n even before s/he i s diagnosed as being f a t a l l y i l l . The general mood, a f f e c t and emotional stance of informed adults in the i l l n e s s s i t u a t i o n may merely reinforce the c h i l d ' s already formed impressions of the r e l a t i v e s e v e r i t y of his/her i l l n e s s . Our findings that even the kindergarten subjects were able to rank order s p e c i f i c i l l n e s s e s quite consistently in terms of t h e i r s u s c e p t i b i l i t y further supports Gochman and colleagues' (1972) claim that, at some time before the age of 7 years, children apparently acquire a consistent h i e r a r c h i c a l pattern of health problem expectancies which remain stable over time. While they found this pattern comparing common i l l n e s s e s , accidents, and dental problems, our r e s u l t s Page 88 indicate that children also form perceptions of t h e i r v u l n e r a b i l i t y to more s p e c i f i c i l l n e s s e s at an early age and that these perceptions appear to remain stable over time. Unlike severity, very few d i s t i n c t i o n s were made between i l l n e s s e s on the basis of s u s c e p t i b i l i t y . It had been expected that the older c h i l d r e n and adults would be able to d i s t i n g u i s h between contagious and noncontagious i l l n e s s e s on th i s dimension. However, only adults s i g n i f i c a n t l y distinguished between the most and least contagious of these i l l n e s s e s . That the younger childre n (kindergarten and grade 3) did not s i g n i f i c a n t l y d i s t i n g u i s h between s p e c i f i c i l l n e s s e s on the dimension of s u s c e p t i b i l i t y is consistent with Kister & Patterson's (1989) finding that these younger children are far more l i k e l y than are older c h i l d r e n to overextend the concept of contagion to i l l n e s s e s for which i t is inappropriate to do so. It seems our questioning was not s p e c i f i c enough for t h i s dimension of s u s c e p t i b i l i t y . The way in which th i s questions was worded ("How easy i s i t to get....?") i s too open-ended and seems to have caused the older subjects to not only consider the contagiousness of an i l l n e s s but also other factors such as the incidence of the i l l n e s s in the general population or a person's predisposition to the i l l n e s s . Our questioning with respect to one's s u s c e p t i b i l i t y to p a r t i c u l a r i l l n e s s e s was purposely less s p e c i f i c than might have been desirable as the researcher was concerned that i f the questioning was more s p e c i f i c ("How easy is i t to catch....?"), subjects would be cued to consider contagion in Page 89 their verbal descriptions of Illness whereas they might not otherwise tend to do so. For both control measures, a l l age groups again c o n s i s t e n t l y ordered the i l l n e s s e s in the same way from most to least c o n t r o l . However, agreement within groups with respect to t h e i r rank ordering appeared to decrease rather than increase with development. It is suspected that t h i s may be due to the fact that older subjects may be considering more of the possible factors that w i l l influence control when ranking s p e c i f i c i l l n e s s e s on these dimensions, and that there may be individual differences in the weight given one factor over another. In a more limited way, as compared to ratings of i l l n e s s s e verity, there was also increasing d i f f e r e n t i a t i o n made between s p e c i f i c i l l n e s s e s with respect to the control one has over either the onset or healing of the i l l n e s s e s . Whereas the kindergarten subjects did not make s i g n i f i c a n t d i s t i n c t i o n s between any of the s p e c i f i c i l l n e s s e s on the basis of control, the older, more c o g n i t i v e l y advanced subjects appeared capable of making at least limited d i s t i n c t i o n s between i l l n e s s e s on t h i s basis. For control over onset, the older subjects rated control over the onset of a common/contagious i l l n e s s (cold) as being s i g n i f i c a n t l y greater than one's control over the onset of an i l l n e s s to which one may be predisposed ( a l l e r g i e s ) . Adults also rated one's control over the onset of a less contagious i l l n e s s (cold) as greater compared to a more contagious i l l n e s s (chicken pox). Page 90 For control over healing, the grade 3 and grade 7 subjects rated one's control over the healing of a less severe i l l n e s s (cold) as much greater than that for a more severe i l l n e s s (cancer). However, adults seemed to focus on interventions available when making the i r ratings and thus rated control over healing greater for an i l l n e s s with e f f e c t i v e medical interventions ( a l l e r g i e s ) than that for an i l l n e s s with no e f f e c t i v e medical interventions (chicken pox). In subjects' ratings of the role medicine could play in the control-of-healing for s p e c i f i c i l l n e s s e s , with development, subjects appeared to increasingly d i f f e r e n t i a t e between i l l n e s s e s for which medical intervention would be more versus less e f f e c t i v e . Whereas the kindergarten groups did not s i g n i f i c a n t l y d i f f e r e n t i a t e between s p e c i f i c i l l n e s s e s on t h i s basis, the grade 3 and grade 7 groups did assign a greater role to medicine in the healing of a less severe/chronic i l l n e s s (cold) as compared to more severe/chronic i l l n e s s e s (diabetes, cancer). Ratings of t h i s s p e c i f i c dimension of control appear to be dependent on more s p e c i f i c knowledge of medical treatment and thus an inte r e s t i n g reversal occured with age: Adults assigned a greater role to medicine in the healing of more severe/chronic i l l n e s s e s ( a l l e r g i e s , diabetes, cancer) as compared to less severe/chronic i l l n e s s e s (cold, chicken pox). It thus appears that even the young c h i l d can d i s t i n g u i s h between s p e c i f i c i l l n e s s e s that are at opposite ends of a p a r t i c u l a r dimension's continuum (for instance, most severe vs. least severe) and that, with the attainment of more Page 91 advanced cognitive l e v e l s , the c h i l d can make Increasingly fi n e r d i s t i n c t i o n s between s p e c i f i c i l l n e s s e s on these dimensions. These results with respect to the the development of children's a b i l i t y to discriminate between i l l n e s s e s on the bases of the i r underlying dimensions, concur with the findings of Offenbach (1983) in the area of children's judgements of color and form. In both content areas, children and adults appear to judge the differences between s t i m u l i in sim i l a r ways (order the st i m u l i in the same way), although the stimulus differences are perceived more sharply by adults. As well, i t appears that perceptually simple dimensions are organized e a r l i e r than are more abstract conceptual dimensions. With perceptually simple dimensions (which in the case of i l l n e s s may correspond to our measure of severity as well as the age of an i l l person as discriminating v a r i a b l e s ) , younger children appear able to perform more l i k e older c h i l d r e n . Offenbach (1983) suggests that this may occur because, younger children are able to relate cues of a perceptually organized dimension s i m i l a r to the way older children relate cues of an organized conceptual dimension. This development p a r a l l e l s c l o s e l y more general cognitive a b i l i t i e s such as concrete s e r i a t i o n and verbal s e r i a t i o n . Although even the preoperational c h i l d can accurately order i l l n e s s e s along the four dimensions, s i g n i f i c a n t d i f f e r e n t i a t i o n s between i l l n e s s e s on the bases of their more vi s u a l dimensions do not appear to be made u n t i l the onset of concrete operations; and increased d i f f e r e n t i a t i o n s between i l l n e s s e s on their less v i s i b l e dimensions does not appear to Page 9 2 be made u n t i l the onset of formal operations. Impl icat ions and Fut ure Research These re s u l t s suggest that the young c h i l d i s aware of and understands ( a l b e i t in a limited way) the i l l n e s s dimensions of severity, s u s c e p t i b i l i t y , control over onset, and control over healing before s/he is able to convey t h i s information in his/her verbal descriptions of i l l n e s s . As suggested by previous researchers (Waechter, 1971; Spinetta, R i g l e r , & Karon, 1973), i t may be that the a f f e c t i v e elements which surround i l l n e s s s i t u a t i o n s give the c h i l d his/her i n i t i a l i n t u i t i v e understanding of these dimensions. With development, th i s i n i t i a l understanding becomes more f i n e l y a r t i c u l a t e d and d i f f e r e n t i a t e d . The way in which these dimensions are understood by the c h i l d w i l l undoubtedly influence his/her attitudes towards the prevention and treatment of i l l n e s s . For the youngest children, i t may be most important for adults to provide simple explanations of the r e l a t i v e severity, s u s c e p t i b i l i t y , and control dimensions of i l l n e s s . For the concrete operational children, adults could begin to provide explanations of i l l n e s s c a u s a l i t y , although these would necessarily have to be t i e d to concrete perceptual referents. F i n a l l y , for formal operational children, more sophisticated and abstract causal explanations can be provided. Although the degree to which children are concerned with and can understand i l l n e s s c a u s a l i t y changes over development, a l l childre n seem equally concerned abouth the more a f f e c t i v e aspects of i l l n e s s . Thus, i t seems important that adults Page 9 3 recognize that children are se n s i t i v e to the emotional cues surrounding an i l l n e s s . As such, adults should provide an atmosphere in which children can discuss and validate t h e i r emotional reactions to i l l n e s s . It would thus be p r o f i t a b l e for future research work to study in more d e t a i l the factors which childre n of d i f f e r e n t ages do and do not take into account when they consider in the dimensions of i l l n e s s . A more complete understanding of the developmental differences in children's consideration of these factors when they make evaluations of these i l l n e s s dimensions w i l l further allow adults to deal more e f f e c t i v e l y with misconceptions childr e n may have of these dimensions for s p e c i f i c i l l n e s s e s . Page References Bibace, R., & Walsh, M. E. (1980). Development of c h i l d -ren's concepts of i l l n e s s . Pediatr i c s . 6 6(6), 912-917. Bibace, R., & Walsh, M. E. (1981). Children's conceptions of i l l n e s s . In R. Bibace & M. E. Walsh (Eds.), New  Directions for Child Development: Children's Concep- t ions of Health , 111 ness and Bod i 1 y Funct ions ( pp. 31-4 8 ) . San Francisco: Jossey-Bass. Burns, W. J., & Zweig, A. R. (1980). Self-concepts of c h r o n i c a l l y i l l c h i l d r e n . The Journal of Genet ic Psychology. 137, 179-190. Campbell, J. D. (1975). I l l n e s s i s a point of view: The development of children's concepts of i l l n e s s . Child Development. 4j5_(l), 92-100. Carandang, M. L. A., Folkins, C. H., Hines, P., & Steward, M. S. (1979). The role of cognitive l e v e l and s i b l i n g i l l n e s s in children's conceptualizations of i l l n e s s . Amer ican Journal of Orthopsychiatry, 48_( 2 ), 335-341. Ei s e r , C , Patterson, D., & Eis e r , J. R. (1983). Children' knowledge of health and i l l n e s s : Implications for health education. Chi Id: Care, Health and Development, 9, 285-292. Ei s e r , C , Patterson, D., & E i s e r , J . R. (1984). I l l n e s s experience and children's concepts of health and i l l n e s s . C hild: Care, Health and Deve lopment, 10, 157-162. Page 9 5 F r i t z , B. R. (1974). The cognitive re q u i s i t e s for conventional moral judgement. Dissertation Abstracts  I nternational, 35., 1887B. (University Microfilms No. 74-23, 547) Ginsburg, H., & Opper, S. (1979). Piaget's theory of  i n t e l l e c t u a l development (2nd ed. ) . Englewood C l i f f s : Prentice-Hall Inc. Gochman, D. S. (1971). Children's perceptions of vulner-a b i l i t y of i l l n e s s and accident: A r e p l i c a t i o n , extension and refinement. HSMHA Health Reports. 86, 247-252. Gochman, D. S., Bagramian, R. A., & Sheiham, A. (1972). Consistency in children's perceptions of v u l n e r a b i l i t y to health problems. Health Service Reports, 87, 282-288. Inhelder, B., & Piaget-, J. (1958). The growth of l o g i c a l  think ing from childhood to adolescenee (A. Parsons & S. Milgram, Trans.). New York: Basic. (Original work published 1955) K i s t e r , M. C , & Patterson, C. J. (1980). Children's conceptions of the causes of i l l n e s s : Understanding of contagion and use of immanent j u s t i c e . Chi Id  Development, 51, 839-846. Kuhn, D., & Brannock, J. (1977). Development of the i s o l a t i o n of variables scheme in experimental and "natural experiment" contexts. Developmental Psychology, 13, 9-14. Leventhal, H., Meyer, D., & Nerenz, D. (1980). The common sense representation of i l l n e s s danger. In S. J. Rachman (Ed.), Contributions to med i c a l psycho logy. Vol.2 (pp. 7-30). Page 96 Livesley, W. J . & Bromley, D. B. (1973). Person percept ion in childhood and adolescence. London: Wiley. M i l l s t e i n , S. G., Adler, N. E., & Irwin, C. E. (1981). Conceptions of i l l n e s s in young adolescents. P e d i a t r i c s , 6_8(6), 834-839 . Natapoff, J . N. (1978). Children's views of health: A developmental study. American Journal of Public Health, 6_8(10), 995-1000. Neuhauser, C , Amsterdam, B., Hines, P., & Steward, M. (1978). Children's concepts of healing: Cognitive development and locus of control factors. Amer ican Journal of Ortho- psych ia t r y . 48.(2), 335-341. Offenbach, S. I. (1983). The concept of dimension in research on c h i l d r e n ' s l e a r n i n g . Monographs of the Society for  Research i n Chi Id Deve lopment, 48., (6, S e r i a l No. 204). Peevers, B. H., & Secord, P. F. (1973). Developmental changes in a t t r i b u t i o n of des c r i p t i v e concepts to persons. Journa1  of Personality and So c i a l Psychology, 27, 120-128. Perrin, E. C , & Gerrity, P. S. (1981). There's a demon in your b e l l y : Children's understanding of i l l n e s s . Ped i a t r i c s , 67, 841-849. Piaget, J. (1928). Judgement and reasoning in the c h i l d (M. Gabain, Trans.). New York: Harcourt, Brace and Co. (Original work published 1924) Piaget, J. (1952) . The c h i l d 1s concept ion of number (C. Gattegno & F. Hodgson, Trans.). London: Routledge & Kegan Paul. (Original work published 1941) Page 9 7 Piaget, J . , & Inhelder, B. (1974). The c h i l d ' s construction of quant i t ies (A. Pomerans, Trans.). London: Routledge & Kegan Paul. (Original work published 1941) Pomeranz, V. E., & Schultz, D. (1977). The mothers' and  fathers 1 medical encyclopedia. New York: L i t t l e , Brown & Co. Potter, P. C , & Roberts, M. C. (1984). Children's percep-tions of chronic i l l n e s s : The roles of disease symptoms, cognitive development, and information. Journal of  P e d i a t r i c Psychology, 9.(1), 13-27. Rashkis, S. R. (1965). Child's understanding of health. A. M. A. Archives of Genera 1 Psychiatry, 12, 10-17. Simeonsson, R. J., Buckley, L., & Monson, L. (1979). Con-ceptions of i l l n e s s c a u s a l i t y in h o s p i t a l i z e d c h i l d r e n . Journal of P e d i a t r i c Psychology. 4.(1), 77-84. Spinetta, J. J . , Rigler, D., & Karon, M. (1973). Anxiety in the dying c h i l d . P e d i a t r i c s . 52, 841-845. Spock, B., & Rothenberg, M. B. (1985). Dr. Spock's baby  and c h i l d care. New York: Simon & Schuster, Inc. Waechter, E. H. (1971). Children's awareness of f a t a l i l l n e s s . American Journa1 of Nursing, 71, 1168-1172. Walker, L. J . (1982). Verbal s e r i a t i o n : Children's solution strategies and stage of cognitive development. Canad ian Journal of Behavioural Science, 14., 175-189. Whitt, J . K., Dykstra, W., & Taylor, C. A. (1979). Children's conceptions of i l l n e s s and cognitive development. Implications for p e d i a t r i c p r a c t i t i o n e r s . C l i n i c a l P e d i a t r i c s . 18. 327-339. Page 99 The Development of C h i l d r e n s ' U n d e r s t a n d i n g of I l l n e s s Consent form f o r c h i l d ' s p a r t i c i p a t i o n . C h i l d ' s Name: C h i l d ' s B i r t h d a t e : I have read the a t t a c h e d l e t t e r d e s c r i b i n g the study and I u n d e r s t a n d the n a t u r e and e x t e n t o f ay c h i l d ' s p a r t i c i p a t i o n . I am aware of the v o l u n t a r y n a t u r e o f my c h i l d ' s p a r t i c i p a t i o n i n t h i s p r o j e c t and u n d e r s t a n d t h a t my c h i l d may wit h d r a w from the s t u d y a t any time. I a l s o u n d e r s t a n d t h a t r e f u s a l t o p a r t i c i p a t e o r w i t h d r a w a l from the study w i l l not j e o p a r d i z e my c h i l d ' s academic s t a t u s i n any way. I n v i e w o f t h e s e c o n s i d e r a t i o n s , I c o n s e n t to my c h i l d ' s p a r t i c i p a t i o n i n t h i s s t u d y . I do not c o n s e n t to my c h i l d ' s p a r t i c i p a t i o n i n t h i s s t u d y . P a r e n t ' s s i g n a t u r e Consent form f o r p a r e n t ' s p a r t i c i p a t i o n . Name Phone number where you can be reached I have read the a t t a c h e d l e t t e r d e s c r i b i n g the 3tudy and I u n d e r s t a n d the n a t u r e and e x t e n t o f my p a r t i c i p a t i o n . I am aware o f the v o l u n t a r y n a t u r e o f my p a r t i c i p a t i o n i n t h i s p r o j e c t and understand t h a t I may with d r a w from the s t u d y a t any t i m e . In view o f these c o n s i d e r a t i o n s , I agree to p a r t i c i p a t e i n t h i s s t u d y . I do not agree to p a r t i c i p a t e i n t h i s s t u d y . S i g n a t u r e P a g e 100 A p p e n d i x B P r o t o c o l " T o d a y , w e ' r e g o i n g t o t a l k a b o u t what y o u know a b o u t b e i n g s i c k . I ' d l i k e y o u t o t e l l me a s much a s y o u know, s o s o m e t i m e s I m i g h t a s k y o u t o t e l l me m o r e . I f y o u d o n ' t know a n y m o r e i t ' s a l r i g h t , j u s t t e l l me. I 'm j u s t m a k i n g s u r e I ' v e l e t y o u t e l l me a l l y o u c a n b e f o r e I a s k y o u t h e n e x t q u e s t i o n . " 1 . G e n e r a l C o n c e p t o f 111 n e s s : V e r b a l Des c r i p t i o n s Have y o u e v e r b e e n s i c k ? How d i d y o u know y o u were s i c k ? How i s b e i n g s i c k d i f f e r e n t f r o m b e i n g h e a l t h y ? On one d a y y o u know y o u ' r e w e l l , a n d on a n o t h e r d a y y o u know y o u ' r e s i c k . W h a t ' s t h e d i f f e r e n c e ? What c a n y o u do t o k e e p f r o m g e t t i n g s i c k ? R a t i n q s o f t h e d i m e n s i ons o f i 1 1 n e s s i n q e n e r a 1 "Now w e ' l l u s e t h e l a d d e r I s h o w e d y o u b e f o r e t o h e l p y o u a n s w e r some q u e s t i o n s a b o u t b e i n g s i c k . " S e v e r i t y : How b a d i s i t t o be s i c k ? ( l = n o t b a d ; 7 = v e r y b a d ) S u s c e p t i b i l i t y : How e a s y i s i t t o g e t s i c k ? ( l = n o t e a s y ; 7 = v e r y e a s y ) C o n t r o l o v e r o n s e t o f i 11 n e s s : How much c a n y o u do t o k e e p f r o m g e t t i n g s i c k ? ( l = c a n ' t do a n y t h i n g ; 7=can do a l o t ) C o n t r o l o v e r h e a l i n g o f i 11 n e s s : How much c a n y o u do t o h e l p y o u r s e l f g e t b e t t e r ? How much c a n y o u r p a r e n t s do t o h e l p y o u g e t b e t t e r ? ( F o r a d u l t g r o u p , s u b s t i t u t e t h e f o l l o w i n g q u e s t i o n : How much c a n y o u do t o h e l p y o u r c h i l d g e t b e t t e r ? ) How much c a n m e d i c i n e do t o h e l p y o u g e t b e t t e r ? ( l = c a n ' t do a n y t h i n g ; 7=can do a l o t ) P a g e 101 H e a l t h S t a t u s : How h e a l t h y do y o u t h i n k y o u a r e m o s t o f t h e t i m e ? ( l = n o t h e a l t h y ; 7 = v e r y h e a l t h y ) R a t i n q s o f t h e d i m e n s i ons o f i 11 n e s s f o r p e r s o n s o f  s p e c i f i c a g e s P r e s e n t t h e f o l l o w i n g a g e g r o u p s i n r a n d o m o r d e r s : B a b i e s C h i l d r e n ( y o u r a g e ) A d u l t s ( p a r e n t s ) T h e E l d e r l y ( o l d p e o p l e ) "Now I want y o u t o t h i n k a b o u t t h e same q u e s t i o n s f o r p e o p l e o f d i f f e r e n t a g e s . " S e v e r i t y : How b a d i s i t f o r t o be s i c k ? ( l = n o t b a d ; 7 = v e r y b a d ) S u s c e p t i b i l i t y : How e a s y i s i t f o r t o g e t s i c k ? ( l = n o t e a s y ; 7 = v e r y e a s y ) C o n t r o l o v e r o n s e t o f i 11 ne s s : How much c a n do t o k e e p f r o m g e t t i n g s i c k ? ( l = c a n ' t do a n y t h i n g ; 7=can do a l o t ) C o n t r o l o v e r h e a l i n g o f i 11 n e s s : How much c a n do t o h e l p t h e m s e l v e s g e t b e t t e r ? ( l = c a n ' t do a n y t h i n g ; 7= c a n do a l o t ) H e a l t h S t a t u s : How h e a l t h y a r e ? ( l = n o t h e a l t h y ; 7 = v e r y h e a l t h y ) P a g e 102 2 . S p e c i f i c I l l n e s s e s : c o l d c h i c k e n pox a l l e r g i e s d i a b e t e s c a n c e r The f i v e o r d e r s o f p r e s e n t a t i o n a r e : (1) c a n c e r , d i a b e t e s , a l l e r g i e s , c h i c k e n p o x , c o l d s (2) d i a b e t e s , a l l e r g i e s , c h i c k e n p o x , - c o l d s , c a n c e r ( 3 ) a l l e r g i e s , c h i c k e n p o x , c o l d s , c a n c e r , d i a b e t e s ( 4 ) c h i c k e n p o x , c o l d s , c a n c e r , d i a b e t e s , a l l e r g i e s (5) c o l d s , c a n c e r , d i a b e t e s , a l l e r g i e s , c h i c k e n p o x . " N e x t I 'm g o i n g t o t a l k w i t h y o u a b o u t d i f f e r e n t k i n d s o f s i c k n e s s e s / i l l n e s s e s . Y o u m i g h t know more a b o u t some s i c k n e s s e s t h a n o t h e r s , b u t I t h i n k y o u ' l l know s o m e t h i n g a b o u t e a c h o n e . I f y o u ' r e n o t s u r e a b o u t o n e , d o n ' t w o r r y ; j u s t t e l l me what y o u d o know. I d o n ' t want y o u t o be a f r a i d t o t e l l me what y o u ' r e t h i n k i n g b e c a u s e y o u t h i n k y o u m i g h t be w r o n g . M o s t c h i l d r e n ' s / p e o p l e ' s a n s w e r s a r e b e t t e r t h a n t h e y t h i n k t h e y w i l l b e . " V e r b a 1 D e s c r i p t i o n s Have y o u e v e r had ? / H a v e y o u e v e r known someone who h a d ? Do y o u know what i s ? / T e l l me what i s ? How do y o u know y o u h a v e ? / H o w d o e s someone know t h e y h a v e ? R a t i n q s o f t h e d i m e n s i ons o f i l l n e s s  S e v e r i t y : How b a d i s i t t o h a v e ? ( l = n o t b a d ; 7 = v e r y b a d ) S u s c e p t i b i l i t y : How e a s y i s i t t o g e t ? ( l = n o t e a s y ; 7 = v e r y e a s y ) C o n t r o l o v e r o n s e t o f i l l n e s s : How much c a n y o u do t o k e e p f r o m g e t t i n g ? ( l = c a n * t do a n y t h i n g ; 7=can do a l o t ) Paqe 103 Control over heal ing of i 11 ness : How much can you do to help yourself get better from ? How much can your parents do to help you get better? (For adult group, substitute the following question: How much can you do to help your c h i l d to get better?) How much can medicine do to help you get better? (l=can't do anything; 7=can do alot) 3. Ranking of each i l l n e s s "Now I want you think about a l l the sicknesses/illnesses we talked about, and put them in order."* Severity: I want you to put the sicknesses in order of how bad they are to have; from the one that is most bad to the one that is least bad to have. (Assign ranks from 1 to 5) S u s c e p t i b i l i t y : I want you to put the sicknesses in order of how easy they are to get; from the one that is most easy to the one that is least easy to get. (Assign ranks from 1 to 5) Contro 1 over onset of i l lness: I want you to put the sicknesses in order of how much you can do to keep from getting them; from the one that you can do most to the one that you can do least to keep from getting. (Assign ranks from 1 to 5) Contr ol over heal ing of i 11 ne ss : I want you to put the sicknesses in order of how much you can do to help yourself get better from them; from the one that you can do least to the one that you can do most to help yourself get better. (Assign ranks from 1 to 5) *If the c h i l d has problems following ranking instructions, further help can be given. e.g., For se v e r i t y - Which is the worst sickness to have? Once the c h i l d has made his/her choice, ask: Now, which is the worst sickness to have? Continue following t h i s procedure. 

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