Open Collections

UBC Theses and Dissertations

UBC Theses Logo

UBC Theses and Dissertations

Cognitive level, age, and verbal ability as predictors of children's concepts of health and illness Palulis, Patricia Adele 1986-12-31

You don't seem to have a PDF reader installed, try download the pdf

Item Metadata

Download

Media
[if-you-see-this-DO-NOT-CLICK]
UBC_1986_A8 P33_4.pdf [ 4.38MB ]
[if-you-see-this-DO-NOT-CLICK]
Metadata
JSON: 1.0098694.json
JSON-LD: 1.0098694+ld.json
RDF/XML (Pretty): 1.0098694.xml
RDF/JSON: 1.0098694+rdf.json
Turtle: 1.0098694+rdf-turtle.txt
N-Triples: 1.0098694+rdf-ntriples.txt
Original Record: 1.0098694 +original-record.json
Full Text
1.0098694.txt
Citation
1.0098694.ris

Full Text

COGNITIVE L E V E L , A G E , AND VERBAL ABILITY AS PREDICTORS OF CHILDREN'S CONCEPTS OF H E A L T H AND ILLNESS  by PATRICIA A D E L E PALULIS B.A., McMaster University, 1965  A THESIS SUBMITTED IN PARTIAL FULFILMENT OF T H E REQUIREMENTS FOR T H E DEGREE OF MASTER OF ARTS  in T H E F A C U L T Y OF GRADUATE STUDIES Educational Psychology and Special Education  We accept this thesis as conforming to the required standard  T H E UNIVERSITY OF BRITISH COLUMBIA August 1, 1986  ®  Patricia Adele Palulis, 1986 9 S  In presenting this thesis in partial fulfilment of the requirements for an advanced degree at T h e U n i v e r s i t y of British Columbia, I agree that the L i b r a r y shall make it freely available for reference and study. I further agree that permission for extensive copying of this thesis for scholarly purposes m a y be granted by the H e a d of m y D e p a r t m e n t or by his or her representatives. It is understood that copying or publication of this thesis for financial gain shall not be allowed without m y written permission.  E d u c a t i o n a l Psychology and Special Education  T h e U n i v e r s i t y of British C o l u m b i a 2075 Wesbrook Place Vancouver, Canada V 6 T 1W5  Date: A u g u s t 1, 1986  ABSTRACT T h i s study was designed to investigate the relative contributions of cognitive level, age, and verbal ability to the prediction of children's concepts of health and illness. T h e rationale for the study was based on the premise that children's cognitive  developmental  level would have relevance when p r e p a r i n g programs for child health education. T h e sample consisted of 40 subjects ranging i n age from 5 to 13 years who were already participants in the Preadmission Preparation P r o g r a m s S t u d y , a research project being conducted at B . C . ' s Children's H o s p i t a l in V a n c o u v e r . There were 10 children selected from each of four age groups: 5-6; 7-8; 9-10; and 11-13. T h e subjects were administered a H e a l t h Questionnaire and a battery of Piagetian tasks representing both the operational and f o r m a l operational stages of cognitive development.  concrete  V e r b a l ability  was  measured by the Peabody Picture V o c a b u l a r y T e s t - Revised ( P P V T - R ) . In a stepwise multiple regression equation, with level of health concept as  the  criterion variable a n d cognitive level, age, and verbal ability as the predictor variables, it was hypothesized that, (1) cognitive level would be a stronger predictor of level of health concept than the predictors of age a n d verbal ability, (2) cognitive level together with age would be a stronger predictor than either index on its own, and (3) verbal ability would account for a significant portion of the variance with regard to level of health concept over and above  that already accounted  for b y cognitive  level and age.  T h e expected  entry  sequence into the prediction equation was cognitive level on step 1, age on step 2, and verbal ability on step 3. T h e results  indicated that all three predictor variables, taken individually, were  significantly correlated with the criterion variable; however, the expected entry sequence of variables into the prediction equation and the expected net effect of combined variables were not supported b y the data analyses. A g e was selected for entry on step 1 and verbal ability was selected for entry on step 2; cognitive level was not selected to enter the prediction equation. W h e n forced into the equation on step 3, cognitive level contributed a negligible  ii  additional  amount  of variance  to  the  efficacy  of prediction. A l t h o u g h cognitive  correlates  highly with level of concept, w h e n the effects of age are partialed out,  level the  contribution of cognitive level is not significant. G i v e n some of the limitations of the study, s m a l l sample size a n d restricted range of scores for level of health concept and for the Piagetian assessment, it was suggested that in a further studj' with a greater representation of formal operational thinkers, there m a y be more support for the hypotheses. Directions for future research were discussed in terms of conducting a similar study with a sample that has a good representation of both concrete  a n d formal operational  thinkers so that the prediction strength of cognitive level can be tested within a restricted age limit. A n o t h e r suggestion was that research focus on the interaction of specific cognitive concepts with health concepts to provide a greater understanding of the  developmental  sequence of conceptualization of health and illness. Implications for child health education were discussed in terms of knowledge cognitive developmental level enabling medical personnel to communicate more with children a n d p l a n appropriate intervention strategies for them.  111  of  effectively  iv  TABLE OF CONTENTS ABSTRACT  ii  LIST O F T A B L E S  vii  ACKNOWLEDGEMENT  viii  1.  2.  INTRODUCTION  1  1.1  B a c k g r o u n d of the P r o b l e m  1  1.2  Statement of the Problem  5  1.3  Definition of T e r m s  6  1.4  Justification of the Study  6  REVIEW OF T H E LITERATURE 2.1  8  Concepts of H e a l t h and Illness within a F r a m e w o r k of Psychodynamic Theory  2.2  2.3 3.  4.  Concepts  8 of H e a l t h  and Illness within  a F r a m e w o r k of  Cognitive  Developmental T h e o r y  11  Statement of the T h r e e Hypotheses  25  METHODOLOGY  27  3.1  Pilot S t u d y  27  3.2  Subjects  29  3.3  Procedures  29  3.4  Scoring  36  3.5  Statistical A n a l y s i s  37  RESULTS  38  4.1  38  Quantitative A n a l y s i s 4.1.1 L e v e l of Concept of H e a l t h and Illness  38  Piagetian A s s e s s m e n t of Cognitive L e v e l  39  Index of A g e  40  4.1.2  4.1.3  V  4.1.4 Verbal Ability  41  Correlations Between V a r i a b l e s  43  Stepwise Multiple Regression A n a l y s i s  43  Contingency Tables and C h i Square Statistics  48  4.1.5  4.1.6  4.1.7  4.2  Qualitative A n a l y s i s  52  4.2.1 L e v e l of Concept of H e a l t h and Illness  52  Observations from the Qualitative A n a l y s i s  54  4.2.2  5.  DISCUSSION  56  5.1  Discussion of Hypothesis 1  57  5.2  Discussion of Hypothesis 2  58  5.3  Discussion of Hypothesis 3  59  5.4  Discussion of the Criterion V a r i a b l e ( H T O T )  60  5.5  Discussion of the Qualitative A n a l y s i s  61  5.6  Limitations of the Study  63  5.7  Directions for F u t u r e Research  64  5.8  Implications for Child H e a l t h Education  65  5.9  S u m m a r j ' o f Discussion  66  REFERENCES  67  APPENDIX A:  MATERIALS FORPIAGETIAN TASKS  72  A P P E N D I X B:  SAMPLE H E A L T H QUESTIONNAIRE  73  A P P E N D I X C:  SAMPLE PROTOCOL FORCONCRETE OPERATIONAL TASKS  75  A P P E N D I X D:  SAMPLE PROTOCOL FORF O R M A L OPERATIONAL TASKS  77  APPENDIX E:  MATRIX FORTWO-WAY CLASSIFICATION  79  APPENDIX F:  MATRIX FORTHREE-WAY CLASSIFICATION  80  APPENDIX G:  FORMAL OPERATIONAL TASK OF CORRELATIONS  APPENDIX H:  FORMAL OPERATIONAL TASK OF PROPORTIONS  LIST O F T A B L E S Table 1: Developmental Conceptions of Illness  22  Table 2: Children's Health Questionnaire  30  Table 3: Common Test Battery Sequence  32  Table 4: Scoring Categories for Developmental Conceptions of Illness  37  Table 5: Frequency table for Health Questionnaire (HTOT)  39  Table 6: Frequency table for Piagetian Assessment (PTOT)  40  Table 7: Frequency table for the index of age  41  Table 8: Frequency table for verbal ability (LQ)  42  Table 9: Means and standard deviations for Health Total (HTOT), - Piagetian Total (PTOT), Age, and Verbal Ability (LQ)  42  Table 10: Correlation coefficients for Health Total (HTOT), - Piagetian Total (PTOT), Age and Verbal Ability (LQ) Table 11: Multiple R for the criterion variable of Health Total (HTOT) -  43 with the  three predictors of Age, Verbal Ability (LQ), - and Piagetian Total (PTOT)  45  Table 12: B weights, Standard Error of B, and Beta weights for Multiple R for the criterion variable of Health Total (HTOT) with the three predictor variables of Age, Verbal Ability (LQ), and Piagetian Total (PTOT)  47  Table 13: Distribution of variables with regrouping in effect  48  Table 14: Chi square analysis  48  Table 15: Crosstabulation of A G E by P T O T  49  Table 16: Crosstabulation of A G E by H T O T  50  Table 17: Crosstabulation of H T O T by P T O T  51  ACKNOWLEDGEMENT T h e writer would like to express appreciation to D r . P a t r i c i a A r l i n for her guidance and  encouragement  in the preparation of this thesis and to D r . M a r s h a l l A r l i n for his  assistance in the statistical  analysis  and interpretation of results.  Appreciation is also  extended to L o r i L e v i t t for the preparation of the final manuscript. D r . Geoffrey Robinson is gratefully acknowledged for g r a n t i n g permission to use the subjects from the Preadmission Preparation P r o g r a m s Study (National H e a l t h Research and Development P r o g r a m , project no. 6610-1285-44).  viii  Chapter 1 INTRODUCTION This study was designed to investigate children's concepts of health and illness in relation to their cognitive developmental level as determined by performance on a set of Piagetian tasks measuring both concrete and formal reasoning. The study developed out of a major research project which involved preadmission preparation of children undergoing elective surgery at B.C.'s Children's Hospital (Robinson, Conry, & Harper, 1986). The rationale for the study was suggested by the literature supporting the premise that children's cognitive developmental level would have relevance when preparing programs for children in the area of health and illness. The question then is: how well can a child's cognitive developmental level predict the level of his conceptualizations of health and illness?  1.1 B A C K G R O U N D OF T H E P R O B L E M There is a growing literature concerned with children's concepts of health and illness and  the consequent  implications for appropriate materials and strategies for health  education and medical explanations by physicians and other professional personnel. In the past, major consideration has been given to the affective domain often interpreted from psychoanalytic theory (Beverly, 1936; Edelston, 1943; Langford, 1948, 1961; Freud, 1952). Many studies since the 1940's have commented on the emotional effect of hospitalization, surgery, and illness on children (Vernon, Foley, Sipowicz, & Shulman, 1965). More developmental  recently, level  studies  have  been  on children's concepts  directed of  toward  health  and  the  effect  illness  of  with  cognitive  therapeutic  intervention based on an interaction between the affective and cognitive domains. Bibace and Walsh (1980) in their study of the development of children's concepts of illness suggest that  teaching  materials  and  strategies  be  directed  toward  the  specific  cognitive  developmental level of the child. Brewster (1982) in her study of the concepts of illness of chronically ill hospitalized children recommends  1  that patient education programs be  2  designed to fit each child's cognitive and emotional needs. In their investigation of physician communication with children and parents, Pantell, Stewart, D i a s , Wells, and Ross (1981) acknowledge the importance of involvement at a cognitively appropriate level. Pantell et al. point out that effective studies  have  indicated  communication can be a therapeutic lever in that experimental a  reduction  in  the  number  of  surgical  complications  when  experimenters communicated with children prior to surgery. T h e i r suggestion that the child be an active participant in the medical process presupposes communication at a cognitively appropriate level. Contemporary literature strongly suggests that children's concepts of health and illness are highly correlated with developmental level. In a review of recent literature, Bibace and W a l s h (1981) identified three major groups of studies: (1) the predominantly early studies which basically examine concepts in relation to age without reference to specific developmental theories (Brodie, 1974; Campbell, 1975; Mechanic, 1964); (2) the intermediate  studies  which  relate  conceptual  level  to  age  and  then  offer  post-hoc  explanations in terms of cognitive developmental level (Palmer & L e w i s , 1975; Natapoff, 1978); and (3) those studies which use cognitive developmental theory to predict differences in concepts at differing ages ( C a r a n d a n g , F o l k i n s , H i n e s , & Steward, 1979; N e u h a u s e r , A m s t e r d a m , H i n e s , & Steward, 1978; Simeonsson, Buckley, & M o n s o n , 1979). Bibace and W a l s h (1980) attempted to show how the general stages of cognitive development are expressed in the particular content area of explanations of illness. T h e y were able to identify six qualitatively different categories of explanations of illness that are developmentally ordered using chronological age as the gross index of developmental status. Bibace and W a l s h acknowledge that all indices are embedded in content and that no index is realty independent. T h e y suggest, however, that age is probably the index least embedded in content a n d is, therefore, quite appropriate as a general index of developmental status. Several studies have relied on age as the sole indicator of developmental level (Neuhauser et al., 1978; Steward & Regalbuto, 1975; Steward & Steward, 1981). Other  3  researchers have opted for additional measures of performance such as Piagetian-type tasks of conservation and physical and social causality and other tasks such as role taking and social identity. In some studies these additional performance measures have served as the index of cognitive development with which to compare concepts of health and illness (Simeonsson et al., 1979; Carandang et al., 1979) while in other studies the focus appears to be on the intercorrelations among the tasks themselves (Perrin &  Gerrity,  1981;  Brewster, 1982). It is evident from the above studies that although the researchers recognize the importance of relating cognitive level to concepts of illness and health, there is no consistent means of establishing cognitive developmental level and little rationale is provided for the selection of particular tasks. In those studies which make reference to Piagetian tasks, researchers have focused on conservation tasks as the sole measure of cognitive level attainment (Bernstein & Cowan, 1975; Carandang et al., 1979; Perrin & Gerrity, 1981). By limiting their criterion to performance on just one measure, they have weakened the validity of their findings. While the structure of the development of cognitive skills is very complex, it is generally acknowledged that concrete operational thought is organized over a period of years. In their four-year study of the development of concrete operational thought, Tomlinson-Keasey, Eisert, Kahle, Hardy-Brown, and Keasey (1979) concluded that the process was one of "gradually emerging skills that are related" and that "the form of the relationship is such that certain skills precede others as prerequisites." This gradual process supports the directional nature of change documented by Kuhn (1972) and Arlin (1981). According to Arlin (1981), there are a minimum of three subsystems representing the concrete operational stage: seriation, classification, and  conservation. The  three  subsystems represent gradual acquisitions of concepts by the application of the "logic of classes" and the "logic of relations" to new situations as they are encountered.  4  T h e majority of studies involving Piagetian-type tasks have dealt with establishing the concrete level of thought; fewer studies have included measurement of formal thought. T h e measurement of f o r m a l thought in these studies has been based on performance in a task of conservation of volume and sometime an additional task related to abstract thinking. P e r r i n and G e r r i t y (1981) determined whether subjects had reached the stage of formal operations  by  their  understanding  of  conservation  of  volume  and  their  abstract  interpretation of a common proverb. A l t h o u g h m e a s u r i n g only a very limited aspect of formal operational thought, researchers, nevertheless, tend to attribute all the qualities of thought  processes  successfully  on  associated  one  or two  with  formal thought  representative  tasks,  to the which  subject may  who  lead  to  has type  performed I errors.  Conversely, they m a y be committing type II errors by eliminating large numbers of subjects who are essentially formal operational but lack the particular concept being measured. T h e studies under review have samples of subjects in various age groups, r a n g i n g from 3 to 16 years of age a n d yet the same tasks have been employed with little or no rationale provided for the selection of tasks. T h e traditional assessment of formal reasoning involves formal  concepts:  multiplicative  compensations,  performances on eight  probabilitj', correlations,  combinations,  proportional reasoning, the coordination of two or more systems of reference, mechanical equilibrium, and forms of conservation beyond direct verification (Inhelder & Piaget,  1958;  A r l i n , 1982). Inhelder and Piaget (1958) define these schemata as "the concepts which the subject p o t e n t i a l ^ can organize from the beginning of the formal level when faced with certain kinds of data, but which are not manifest outside these conditions." Hence, m a n y formal operational thinkers ma3 readily lack one or another of these schemata. r  5  1.2 STATEMENT OF THE PROBLEM A l t h o u g h there is considerable evidence  to support the premise that children's  conceptions of health and illness progress along a developmental sequence, there has been no consistent means of relating this developmental progression to the Piagetian stages of general cognitive development. Researchers have limited their assessment of cognitive level attainment to performance on one or a few tasks involving conservation of mass, weight, and volume rather than tapping into the framework of gradual acquisition of abilities and relating these acquisitions to the child's developing concepts of health and illness. T h e actual content area of concepts of health and illness has been investigated with increasing sophistication. Bibace a n d W a l s h (1980, 1981) have delineated well-documented sequences of development equivalent to the cognitive stages of Piagetian theory. U s i n g their system of coding for level of concept, this study purports to examine level of concept with regard to cognitive level, age, and verbal ability. T h e problem then that will be investigated in this study is to what extent the variables of cognitive level, age, and verbal ability contribute to the prediction of a child's level of conceptualization of health and illness. T h e expectations for the present research are: 1.  T h a t cognitive developmental level is a stronger predictor of the concomitant concepts of health and illness than developmental level based solely on the index of chronological age.  2.  T h a t cognitive level together with age will be a stronger predictor of level of concept than either index on its own.  3.  T h a t verbal ability (operating as an additional measure of cognitive competence) will also account for a significant portion of the variance with respect to these concepts. T h e variables to be investigated  definitions.  will now be described in terms of operational  6 1.3 D E F I N I T I O N O F T E R M S 1.  L e v e l of concept is defined as the category of explanation given b y the subject with respect to questions regarding concepts of health and illness.  2.  Cognitive developmental level is defined as the level of thought process associated with the attainment of a particular Piagetian stage as assessed b y the administration of a battery of tasks.  3.  V e r b a l ability is defined as the language quotient attained b y performance on a standardized test i.e. Peabody Picture V o c a b u l a r y Test-Revised ( P P V T - R ) which is considered to be a reliable and valid measure of receptive language.  1.4 J U S T I F I C A T I O N O F T H E S T U D Y In terms of clinical implications, m a n y researchers have given credence to the importance of cognitive developmental level whether determined by age or other indices. Cook (1975) contends that children's psychological reactions to illness and hospitalization cannot be understood without knowledge of their conceptions concerning these experiences. Bibace and W a l s h  (1981) suggest three practical uses for their research in the area:  establishing e m p a t h y , using the information to design meaningful educational strategies and materials, and understanding the degree of control over health a n d illness that a child might  feel.  Brewster  (1982)  recommends  that  hospital  personnel  put  "information  gathering" before "information giving". She suggests that staff m e m b e r s m u s t determine how children view the cause of their illness and the reason for treatment in order to design effective programs. T h e present study proposes to offer further support for the premise that children's conceptions of health and illness are closely related to their level of cognitive development. T h e study was designed to provide further knowledge in the field by presenting a more clearly defined rationale for the assessment of cognitive developmental level than has been put forth in previous studies. F u r t h e r m o r e , through the process of cross-validation, it m a y be possible for medical personnel to estimate cognitive level by posing questions related to causation of illness. In addition to using the general index of age, they will have access to a  7  further index in order to more accurately predict a child's conceptualization of health a n d illness a n d plan intervention strategies accordingly. T h i s additional index purports to be more sensitive to the concept of gradual acquisition of level of cognitive development. In s u m m a r y , then, the present research m a y have relevance both in terms of clinical implications and in terms of methodological strategies.  Chapter 2 REVIEW OF T H E L I T E R A T U R E According to the literature, children's concepts of health and illness have  been  viewed from the perspective of two major theoretical traditions. T h i s review will trace the shift in focus from the psychodynamic framework to the cognitive developmental framework and will critique the major studies of interest as they relate to the problem of the present study. E m p h a s i s will be placed on research that has been carried out within the cognitive developmental model with particular reference to those studies which have contributed to the formulation of the problem statement.  2.1 CONCEPTS  OF H E A L T H  AND ILLNESS WITHIN A FRAMEWORK OF  PSYCHODYNAMIC THEORY M u c h of the literature concerning children's conceptions related  to  the  psychodynamics  of illness  and  hospitalization.  of health and illness It  appears  to  documented that the experience of illness and hospitalization is a psychologically situation  be  is  well  stressful  with regard to both short term and long t e r m implications (Vernon, F o l e y ,  Sipowicz, & S c h u l m a n , 1965). W i t h i n the framework of psychodynamics, the  primary  emphasis has been on the impact of illness and hospitalization on children's emotional well being.  Psychoanalysis  has  been  the  major  theoretical  basis  for  understanding  and  intervening in the behavioral problems of ill children. It has been reported that the t r a u m a experienced  by the  child could result in mood swings, loss of self-confidence,  t a n t r u m s , and phobias (Freud,  temper  1952). M u c h of the negative affect was presumed to be  related to the child's belief that he was being punished for something that he has wrong and that he was to blame for the onset of illness (Beverly, Langford,  1936;  Nagy,  done 1951;  1948). F r o m the literature of these researchers, it seemed apparent that the  feelings of the sick child were related to his beliefs or concepts about illness. Children's concepts of health and illness were considered only in relationship to the  8  psychological  9  reactions  accompanying the illness  experience.  A number of studies evolved from  the  awareness of the importance of children's beliefs about illness in order to better understand their fears and to help alleviate them. M a n y of the earlier studies were more in the nature of observations, descriptions of case studies,  or general surveys rather t h a n in the form of methodologically controlled  research. There is, however, a similarity in their findings in terms of the association of punishment and wrongdoing with illness. One  of  the  earliest  researchers,  Beverly  (1936)  reported  the  association  of  punishment and blame with illness. In a survey of hospitalized cardiac and diabetic children, 90% of the respondents interpreted the cause of illness as wrongdoing. W h e n specifically questioned about their own illness, 90% of the cardiac patients reported that they became ill because "they h a d r u n too much", while 85% of the diabetic patients responded that "they ate too much sugar". B e v e r l y stated two reasons for the association of fear with medical procedures: the possibility of death, and the "mystery and magic" related to the background of medicine with the accompanying connotations of sin and punishment. B e v e r l y provided v e r y limited information regarding the format of his survey. M a n y of the conclusions that he has drawn appear to have been based on observation from individual case studies. Separation from parents during hospitalization was another frequently cited source of distress and thought to be connected with wrongdoing and punishment (Edelston,  1943;  L a n g f o r d , 1948). Edelston interpreted "separation anxiety" as being caused by a feeling of rejection due to a wrongdoing on the p a r t of the child. According to L a n g f o r d , parental admonitions directed to the child in terms of threats (i.e. that he would catch a cold if he didn't wear his boots) could lead to the conceptualization that illness was punishment. F r e u d (1952) discussed the effects of nursing, medical, and surgical procedures and the effects of pain and illness on children from a psychoanalytic perspective. She commented that some surgical procedures could be interpreted as mutilation or castration. W i t h regard to illness as an act of punishment, F r e u d observed that m a n y restrictive measures used as  10  punishment were also often in effect d u r i n g the process of treatment of illness: (i.e. food restrictions, bed and room confinement). A g a i n , it would appear that F r e u d ' s arguments were based on clinical experience from the viewpoint of psychoanalytic interpretation rather than through the use of controlled methodology. M a n y other studies have noted the association of wrongdoing, punishment,  and  blame with illness and hospitalization (Vernon et a l . , 1965). Children were found to have misconceptions  about the cause of illness  and the necessity of hospitalization.  Medical  procedures were seen as being punitive m a k i n g it difficult for medical personnel to c a r r y out their treatments and to intervene in the reduction of stress. A s misconceptions about illness and hospitalization came to be identified as factors contributing to psychological distress, researchers began to further explore the nature of children's beliefs about illness. T h e awareness of the  importance  of children's concepts of illness  and the  developmental  psychologist's increasing interest in cognition a n d causality have generated a considerable a m o u n t of research in this area (Bibace & W a l s h , 1981). The generally  studies  which  interpreted  have  children's  used  the  views  as  framework a  moral  of psychodynamic  issue.  Cook  (1975)  theory  have  contends  that  methodology is influential in the kinds of responses that children will m a k e . H e found that children's spontaneous explanations tended to be more i m m a t u r e t h a n they were actualty capable of giving and that spontaneous explanations were more frequently related to moral issues. F r o m the brief s u r v e y of studies in this section, it seems evident that the findings are subject to at least two major criticisms. F i r s t ,  there is a problem of confounding  theoretical implications. It would seem that the psychoanalytic approach is particularly susceptive to presupposing causality: i.e. linking "separation anxiety" with wrongdoing and punishment. findings  Secondly,  methodologies  difficult. M o s t early reports  differ  considerably  appear to be based  making  comparisons  on observations  made  among from  individual case studies. Questioning techniques v a r y considerably from eliciting notions of  11  causality from pictorial representations  to answering "yes-no" questionnaires.  L a c k of  adequate description of methodological procedures further weakens reliability and validity. T h u s it would seem that the theoretical orientation of the researcher and the type of methodology (i.e. questioning technique used during the investigation procedures) could have an effect on the type of responses elicited from children regarding their conceptualization of health and illness. These factors become further apparent in the discussion in the following section.  2.2 CONCEPTS  OF H E A L T H  AND ILLNESS WITHIN A FRAMEWORK OF  COGNITIVE D E V E L O P M E N T A L THEORY Several studies have focused on children's concepts of health and illness within the framework of cognitive levels of development. Different lines of reference have emerged from the cognitive developmental tradition. Some researchers have been concerned with understanding the physical mechanisms of health and illness ( C a r a n d a n g et a l . , P e r r i n & G e r r i t y , 1981; Bibace & W a l s h ,  1981)  1979;  while others have examined the m o r a l  implications (Kister & Patterson, 1980) and the psychosocial implications (Millstein, A d l e r , & Irwin, 1981). Those concerned with the physical mechanisms have related concept level with age (Bibace & W a l s h , 1981; Brodie, 1974) or other indices such as developmental level determined by Piagetian-type tasks, role taking tasks and others (Brewster, 1982; P e r r i n & G e r r i t y , 1981). Those concerned with m o r a l implications have focused on the examining of the concept of "immanent justice" in relation to concept achievement K i s t e r & Patterson,  (Medinnus,  1959;  1980). Still others have explored a dual model involving cognitive  development as well as psychosocial and/or m o r a l development  (Millstein et al.,  1981;  Simeonsson, B u c k l e y , & Monson, 1979). T h e survey of the literature in this section will focus on the studies concerned with understanding the physical m e c h a n i s m s of health and illness. Some studies are of particular interest because they have served as models for generating further research (Bernstein &  12  C o w a n , 1975; P e r r i n & G e r r i t y , 1981; Bibace & W a l s h , 1981). These and other studies will be critiqued in terms of their strengths a n d limitations and their relevance to the present study. A s with the early studies discussed in the previous section, the earliest operating  within  the  cognitive  developmental  framework  also  have  studies  methodological  weaknesses and limited information is provided regarding samples and procedures. It is, however, interesting to note the increasing sophistication in research design over the past four decades. One of the earliest researchers to report on developmental trends in the responses of her subjects was N a g y (1951, 1952,  1953). She investigated children's ideas about health  and illness and about "germs" and found that children between the ages of 3 and 5 could not understand the causes of illness; children of 6 or 7 y e a r s of age believed that illness was due to infection but could not specify a n y further; children of 8 to 10 y e a r s of age were able to associate infection with "germs"; children of 11 to 12 years of age were able to acknowledge that illnesses were caused by different "germs". N a g y provides v e r y limited information about her samples  and methodology which m a k e s her work difficult to interpret. H e r  interpretation of the data did not seem to take into account the moral aspect of causality. Bios (1956) appears to be the first researcher to organize results within a Piagetian framework. H i s stud}' (cited in Cook, 1975) involved 42 healthy children comprised of three age groups: 5 to 6 y e a r olds, 7 to 8 y e a r olds, and 9 to 10 year olds. Responses were elicited to questions related to a series of illustrations depicting situations related to illness. T h e data were interpreted in terms of three stages of development: (1) the descriptive stage, (2) the explanatory stage, and (3) the causative stage. Bios pointed out that these stages were similar to Piaget's categories of conceptual thinking. A t about the same time period, Gips (1956) investigated ill children's interpretations of the cause  of illness  and their concepts  of diagnosis,  therapy, and hospital setting.  A c c o r d i n g to Gips (cited in Cook, 1975), most children tended to view causation of illness in  13  terms of blame a n d the index of age determined whether the blame was attached to self or others. Gips questioned  100 hospitalized subjects about the blame for illness by using a  projective picture. B l a m e attributed to outside forces decreased with chronological age. Cook (1975) points out a pertinent limitation of the study in that the investigator's categorization system of causality of illness indicated that the basis for categorization was p r i m a r i l y on the nature of the causal agents that the child used with no consideration given to the additional qualifying statements. Gellert's (1961) investigation included both sick and healthy subjects. H e r sample was composed of 72 hospitalized children and 30 healthy children r a n g i n g from 4 to  16  years of age. T h e subjects were presented with a picture of a sick child l y i n g in bed and were asked questions related to the cause of illness. In support of G i p s ' results, Gellert also found that attribution of blame decreased with age which suggests a trend toward increasing objectivity. Cook levels the same criticism towards Gellert's study as he did at Gips in that her assumptions m a y have presupposed the n u m b e r of b l a m i n g statements to the detriment of objective ones. T h u s it would appear that different kinds of questioning techniques elicit different kinds of responses in the data m a k i n g comparisons among studies difficult to c a r r y out. Brodie (1974) found that the views of healthy children toward illness differed from those of ill children and from those of children with a high level of anxiety . In her study, 408 students comprised of 114 first graders, 135 third graders, and 159 fifth graders were tested with group "true-false"  questionnaires,  the  S a r a s o n G e n e r a l A n x i e t y Scale  for  Children ( G A S C ) and the Children's Illness A n x i e t y Scale (CIAS). In m a k i n g her final evaluations,  Brodie used  findings  from  other  studies  conducted on  ill children as  a  comparative framework. In view of the fact that different methodologies were used, the validity of her study was weakened (Cook, 1971). In reviewing the literature prior to the time of his study, Cook summarizes three important factors influencing children's concepts of health and illness: (1) the state of health  14  of the subjects, (2) the age of the subjects, and (3) the methods of investigation. Cook points out that state of health being a significant variable is congruent with Piaget's theory about the interaction of the affective and cognitive domains. A g e as a significant variable is clearly an  integral  divergence  aspect of Piagetian in results  is  at  theory.  least  As  for  partly due  the  to  third  the  fact  factor, that  Cook contends  "different  that  methods  of  investigation tap different kinds of thinking." It would appear that the early studies focused on concepts of health and illness in terms of general developmental progression with age and on discerning whether there were differences in concepts from healthy children as opposed to ill children. It is clear that efforts to  compare  results  methodologies theoretical ambiguous.  among  and differing  viewpoint. Direct  various  studies  assumptions  meet  made  E x p e r i m e n t a l constructs  comparisons  then  have  with  by  researchers  and  been  difficulty  operational  obscured  by  because depending definitions basic  of  differing  upon  their  are  often  theoretical  and  methodological differences. Cook (1975) investigated the comparative development of causality with regard to illness  and with regard to another non-medical phenomena  (i.e.  rain) within a  single  methodological framework involving both healthy a n d ill children. It was hypothesized that the level of m a t u r i t y of children's causal thinking would be influenced by age, state of health, a n d the nature of the phenomena explained. Cook found that children's explanations of  the  causes  of illness  and  rain  became  increasingly  mature  as  they  grew  older.  E x p l a n a t i o n s of r a i n were generally more m a t u r e t h a n explanations of illness. Sick children tended to give more i m m a t u r e explanations of both rain a n d illness t h a n healthy children. It was Cook's contention that the i m m a t u r i t y of children's explanations of illness was not of a purely cognitive nature; they represented an attempt to maintain cognitive and emotional control over an otherwise frightening situation. While acknowledging some methodological weaknesses in his study, Cook contends that his research demonstrated two important factors related to the m a t u r i t y of children's explanations: degree of structure within the  15  questioning technique, and the semantic form of questioning. H i s research is a n important advance because of his use of a strict methodology and his attempt to use a controlled methodology to investigate a problem which h a d previously resulted in conflicting data: that of the comparison of level of concept of healthy and ill children. Researchers continued to explore children's concepts of health and illness in relation to a v a r i e t y of variables. M e c h a n i c (1964) investigated the influence of mothers' attitudes on their  children's health  attitudes  and behaviour. G o c h m a n  (1971)  undertook a  study  regarding the relationship of perceived vulnerability to children's health beliefs. C a m p b e l l (1975) sought to provide information as to how views of illness evolved and changed. H e obtained d a t a from 264 children and their mothers regarding the m e a n i n g of illness and found age-linked differences and cross-generational differences. Natapoff  (1978) investigated  a n u m b e r of variables: age,  sex,  intelligence, and  socioeconomic status. She found that there were both qualitative and quanititative changes with  age  significant  consistent  with theories  variable; intelligence,  of concept develpment.  socioeconomic  status,  and  A g e proved to be the sex  differences  were  one not  significant. T h e group of studies just reviewed basically examined concepts in relation to age without reference to specific developmental theories or related conceptual level to age and then offered post-hoc explanations in terms of cognitive developmental level. T h e following studies to be reviewed are those which used cognitive developmental theory to predict differences in concepts at differing ages. While not specifically investigating concepts  of health and illness,  a study by  Bernstein and C o w a n (1975) has relevance in terms of methodology as it seems to have provided a model followed b}' m a n y researchers. Bernstein and C o w a n used a Piagetian framework in their investigation of children's concepts of how people get babies. T h e i r sample was composed of 60 children, 20 in each of three age groups: 3-4 year olds, 7-8 year olds, and 11-12 y e a r olds. T h e y found that children's concepts of how people get babies  16  followed a Piagetian developmental sequence. T h e i r methodology provided a framework of reference for further investigations including research on children's concepts of health a n d illness (Carandang et al., 1979; Brewster, 1982; Redpath & Rogers, 1984; F e l d m a n & V a r n i , 1985; and others). In the Bernstein and C o w a n study, the children were assessed by using a battery of tests including the Piagetian-type tasks of conservation of matter and volume. A n o t h e r important feature of their study is in the use of Piaget's clinical method of interviewing. E a c h answer was probed until the child's thinking became as explicit and as detailed as he was able to make it. T h e i r study represents a new attempt to gather systematic normative data directly from children. Bernstein and C o w a n predicted that their study would promote a common research strategy in the area of cognitive development, whereby a known task anchor would be used as a n index to locate previously unexplored areas of children's thought. T h e limitation of their strategy  was  in using only one indicator of concrete  reasoning as their index. A s previously discussed, the acquisition of cognitive stages is a gradual process and the discriminatory power of one or two tasks is limited in terms of providing a clear indication as to how far the child has advanced within this process. A l o n g with Bernstein and C o w a n (1975), other researchers were supporting the use of Piagetian-type tasks as the index of cognitive developmental level with which to compare concepts of health and illness. Simeonsson et al. (1979) used tasks of conservation as well as role taking skills and physical causality tasks to compare with conceptions of illness. T h e i r subjects consisted of 60 hospitalized children in three age groups (5, 7, 9 y e a r olds). T h e y found that scores for conservation tasks and role taking skills reflected developmental differences while scores relating to physical causality did not. Simeonson et al. do not provide any  discussion as to w h y this was so. T h e i r question for assessment of physical  causality was: W h a t makes clouds move? B u t they did not specify whether or not they used Piaget's  clinical methods  of eliciting answers.  affected their results. In general, their  findings  T h e i r method of questioning m a y  have  suggested developmental differences in  17  children's illness  causality  concepts;  they  also noted  that  some questions  were  more  developmentally sensitive t h a n others. Following in the same tradition, P e r r i n and G e r r i t y (1981) tested children at five different grade levels (Kindergarten, second, fourth, sixth, and eighth grades) in the areas of cause, prevention, and treatment of illness in addition to assessing their general cognitive development. Cognitive development was assessed through tasks involving conservation of mass,  weight,  and volume,  transformations,  interrelationships  among  parts,  physical  causality, and abstract thinking. T h e r e was no clearly defined rationale for the selection of these particular tasks. Although the results displayed a wide range of scores at each level, overall m e a n scores indicated a developmental sequence and parallel trend in each of these areas, increasing with each higher grade level. It is interesting to note that there was a wide range of scores at each level. P e r r i n and G e r r i t y observed that only one third of the eighth graders had reached the stage of f o r m a l operations as determined by their performance on tasks of conservation of volume and b y their abstract interpretation of common proverbs. Six other studies have been located using Piagetian tasks in assessing cognitive level in order to make a comparison with conceptualizations of health and illness. A l l of these studies cite Bernstein and C o w a n and/or P e r r i n and G e r r i t y as providing a model for particular aspects of their methodology. E a c h of these studies will be briefly reviewed in terms of what they have contributed to the problem. M y e r s - V a n d o , Steward, F o l k i n s , and H i n e s (1979) tested 12 chronically ill children diagnosed as h a v i n g congenital heart disease and 12 healthy children. A l t h o u g h the results indicated deficits in the chronically ill group with regard to general cognitive tasks,  illness  causality measures did not indicate differences between the two groups. Considering their age range (8 to 16 y e a r olds), and given no indication as to how m a n y children were in each age group regarding stages, their claim that cardiac disease affects the rate at which a child will attain conservation reasoning is questionable. M a n y studies refer to Piaget's factor" when  their hypotheses do not  work out.  The  "decalage  "decalage  factor" refers  to  the  18  developmental discrepancies between tasks based on differential experience.  Myers-Vando  et al. use the "decalage factor" to support low cognitive functioning and to explain high conceptual level for their cardiac patients. C a r a n d a n g et al. (1979) studied levels of illness concepts a m o n g children with diabetic  siblings.  Their  results  revealed  Piagetian level of cognitive development  a  significant  association  between  pretested  and illness conceptualization. C h i l d r e n with ill  siblings demonstrated lower conceptualization levels t h a n did children with healthy siblings. T h e sample for this study involved 36 children who had siblings ill with diabetes and 36 matched control children who had healthy siblings. T h e r e were three age levels within each group corresponding to the three cognitive levels. T h e y discuss the possible influence of the "dlcalage  factor" with stress as intrusion but also attribute the lower level of  illness  conceptualization b y children with ill siblings to the coping style of their mothers. T h e i r study appears to have been well conducted. T h e i r study supports that of Bernstein a n d C o w a n in the contention that Piagetian theory can be applied to understanding children's beliefs about new events. Brewster (1982) investigated the relationship between cognitive development and the understanding of illness causation in 50 chronically ill hospitalized children aged 5 to 12. Piagetian theory was used to explain and predict understanding. H e r results indicated a three-stage sequence in the development of the understanding of illness causation following Piagetian stages: Stage 1, disease is caused b y h u m a n action; Stage 2, a belief in univariate physical  causality;  Stage  3,  acknowledgement  of multiple  causation.  Neither  specific  illnesses, sex of child, nor length of hospitalization were found to affect level of response. A l t h o u g h Brewster found no relationship between length of hospitalization or type of illness and levels of cognitive understanding of illness, her sample included children with v a r y i n g degrees of experience with hospitalization and varied types of illness. F u r t h e r , these factors were distributed across four age groups and the sample size m a y have been insufficient to obtain significant correlations. T h e sample of children was divided into four age groups with  19  approximately equal numbers in each age group: ages 5-6 ( N = 13), ages 7-8 ( N = 11), ages 9-10 ( N = 12), ages 11-12 ( N = 11). Three other v e r y recent studies have followed the Piagetian task model: Redpath and Rogers (1984) using healthy children; Potter and Roberts (1984) exploring children's perceptions of chronic illness (i.e. epilepsy and diabetes) and F e l d m a n and V a r n i (1985) investigating conceptualizations of children with spina bifida. T h e study by Potter and Roberts is of particular interest because it represents the first attempt to devise and then evaluate a method of communicating with children about illness. U s i n g Piagetian tasks to determine the cognitive level of the child, the authors then attempted  to  find  out  whether  explanations  of  illness  increased  understanding and  acceptance of illness in peers. Potter and Roberts used the Piagetian water  and clay  conservation tasks adapted from P e r r i n and G e r r i t y (1981) to divide their subjects into two distinct groups: subjects performing at the preoperational level (unable to conserve on either task) or the concrete operational level (conserving on both tasks). T h o s e that did pass one task but not the other did not. participate further to ensure clearer distinctions in cognitive development. F u r t h e r m o r e , all preoperational subjects were d r a w n from the first grade while all concrete operational subjects were in the third or fourth grades. T h e authors have devised controlled groupings although based on limited assessment. A g e , alone, m a y have been the most powerful predictor of level of concept. T h e i r methodology, however, does not allow for the gradual acquisition of skills which is a n integral characteristic of the theory of Piagetian stages. T h e study by Redpath and Rogers (1984) serves to exemplify the difficulty with using only one or two tasks to determine cognitive level particularly if those tasks are not suitable for the particular age range involved in the study. Redpath and Rogers, working with a sample of 30 children at each of two grade levels (preschool and second grade), attempted to relate children's concepts of illness as well as concepts of hospitals, medical personnel, and operations to their cognitive development as measured by performance on a  20  conservation task and a causality task. T h e y found that children's understanding of medical concepts including illness was significantly related to their levels of cognitive development as measured by a causality task but not when m e a s u r e d by a conservation task. Redpath and Rogers attribute the failure to find more significance in their correlations to the low n u m b e r of subjects per cell and/or to vertical "decalage". H o w e v e r , another possible cause is that the particular tasks chosen were inappropriate for the ages represented i n the study. T h e tasks would likely have been too difficult for the preschoolers (mean age =  3.75 years) and too  eas3' for the second graders (mean age = 7.5). According to research by A r l i n (1981), 69% of children in grade one had achieved conservation of mass; it is predicted that by second grade the percentage would be substantially higher. T o m l i n s o n - K e a s e y et al. (1978) found that by the age of 7.9, 92% were considered to be concrete operational as determined b y understanding of conservation of mass and a further 5 % were considered to be transitional. It would seem apparent that the tasks chosen for this study would have little discriminatory power for the age levels being investigated. The r e m a i n i n g study to be discussed within that group choosing Piagetian tasks as the index for cognitive development is that of F e l d m a n and V a r n i (1985). Their study was designed to assess children with spina bifida in terms of their general cognitive development, conceptualizations of health and illness, and their understanding of their own specific illness. Feldman  and V a r n i  conceptualizations  found that children received higher scores in health and  than  general  cognitive  development  with  ratings  highest  in  illness their  explanations of spina bifida. T h e i r statistical analysis appears to be based solely on m e a n scores and standard deviations with no correlational studies being conducted. A particularly noteworthy feature of their discussion was their acknowledgement that they had not used a battery of tests and that a battery of tests would be necessarj' to w a r r a n t any general conclusions  regarding cognitive  developmental  levels.  They  also  chronological age alone was not a sufficient predictor of cognitive level.  acknowledged  that  21  F r o m the analysis of the above group of studies, it seems apparent that findings are often contradictory and that researchers often resort to the notion of "decalage" to explain contradictions rather t h a n e x a m i n i n g their methodology for potential weaknesses. Bibace and W a l s h (1981) have described five variables that m a y have an effect on responses: (1) the perceptual characteristics of the illness i.e. whether the illness is visable or not, (2) the degree of familiarity of the stimulus i.e. a common illness such as a cold compared with one that is not so familiar such as epilepsy, (3) the mode of presenting the task (i.e. verbal or pictorial), (4) the mode of questioning i.e. clinical method of inquiry versus  "true-false"  questions, and (5) the affective or emotional states of the subject. M a n y researchers have discussed whether  affective  states accelerate  or delay cognitive development but their  conclusions r e m a i n ambiguous because of contradictory findings. Other factors also m a y influence findings leading to conflicting results. In some studies sample size has been insufficient for the problems being investigated i.e. n u m b e r of variables  (Brewster,  1982).  T h e choice  of  tasks  is  sometimes  inappropriate and/or  incomplete for determining cognitive levels. In addition, statistical analyses involve different measures  of evaluation  m a k i n g comparisons  among  studies  difficult. J a c k s o n  (1980)  indicates that v a r i a t i o n in findings is "substantially due to statistical artifacts rather t h a n to situation-specific validity". Other studies have not employed Piagetian tasks for assessing several cognitive levels but rather have relied on the index of age. Bibace and W a l s h (1980, 1981)  were  instrumental in e x a m i n i n g the concepts of health and illness to further delineate how stages progress within this area. A l t h o u g h they used the index of age as their criterion for establishing developmental level, they have a well conducted study in terms of methodology. T h e i r study contributed to the formulation of the problem of the present study. Bibace and W a l s h developed a framework with which to describe children's concepts of illness by studying three groups of healthy children who were assumed to represent preoperational,  concrete  operational,  and  formal  operational  periods  of  cognitive  22  development based on chronological age. U s i n g a protocol to elicit responses to questions of illness concepts, the authors classified the answers into six types of explanations that were developmentally linked according to age. F r o m this developmental perspective, Bibace and W a l s h found that the type of illness explanation varied with the chrononlogical age of the child, with children giving more sophisticated explanations as they became older, indicating increasing cognitive development. U s i n g the Piagetian stages of cognitive development as a theoretical framework, they derived three major types of explanations that were basically consonant with processes.  the  Within  prelogical, concrete each  of  the  three  explanations were delineated. Table  logical, and formal major  categories,  logical stages  two  of  thought  additional subtypes  1 illustrates the three major categories  of  and their  corresponding subtypes of concepts of illness.  T a b l e 1: Developmental C o n c e p t i o n s o f I l l n e s s  I.  P r e l o g i c a l Explanations C a t e g o r y 1: Phenomenism C a t e g o r y 2: C o n t a g i o n  II.  Concrete-Logical C a t e g o r y 3: C o n t a m i n a t i o n C a t e g o r y 4: I n t e r n a l i z a t i o n  III. .  Formal-Logical Explanations Category 5 :  Physiological  Category 6 : P s y c h o p h y s i o l o g i c a l  ( B i b a c e & Walsh, 1981)  23  Bibace and W a l s h derived these categories from a study involving an initial sample of 180 children aged 4 to 14 y e a r s and then validated them in two subsequent studies. T h e strategy for evolving these categories was similar to that used by Kohlberg, Loevinger, and L a u r e n d e a u a n d P i n a r d (Bibace & W a l s h , 1981). T h e theories of Piaget and W e r n e r served initially as a general guideline for collecting observations. These observations were then used to set up provisional categories which specified the m a n n e r in which the abstract theoretical concepts became concrete. T h e categories delineated by Bibace and W a l s h will be briefly described. Within phenomenism  the and  category  of prelogical explanations,  contagion.  Phenomenism  there were  represented  the  two  most  subcategories:  developmentally  i m m a t u r e explanation in that the cause of illness was "an external concrete phenomenon that m a y co-occur with the illness but that is spatially and/or temporally remote". Children were essentially  unable to explain how these phenomena caused illness. Contagion was  found to be the most common explanation given b y the more mature children within the prelogical stage. T h e cause of illness was found in "objects or people that were proximate to, but not touching the child". The relation between cause and illness was explained only in terms of magic or proximity. W i t h i n the category of concrete-logical explanations, the two subcategories  were  contamination and internalization. C o n t a m i n a t i o n characterized the explanations of the younger children in the concrete-logical stage. In this category, the cause of illness  was  viewed as a person, object, or action that was external to the child and that h a d an aspect that was harmful to the bod}'. Contamination occurred through the child's body coming into physical contact with the person or object or by the child participating i n the h a r m f u l action. Internalization was the type of explanation offered b}' older children in the concrete logical stage. In this category, illness was located within the body but its cause might be external, usually a person or object connected to the internal effect of illness through the process of internalization, a process such as swallowing or inhaling.  24  Finally, within the stage of formal-logical explanations, the two subcategories were physiological and psychophysiological explanations. In physiological explanations, offered by younger children in the formal-logical stage, the cause may be initiated by external events, but the source and nature of the illness were with specific internal physiological structures and  functions. The physiological  explanation usually  involved a nonfunctioning or  malfunctioning internal organ or process. Psychophysiological explanations represented the most mature responses. The illness was also described in terms of internal physiological processes but with an additional and/or alternative psychological cause. Bibace and Walsh concluded that their findings were clearly congruent theoretical expectations regarding qualitative  differences in cognitive  with  developmental  processes. They claimed that the frequency distributions of normal children were congruent with Piagetian theory and therefore constituted empirical grounds for the validity of their categories. Bibace and Walsh have been cited in several studies which were modelled on the categorj' system which they formulated (Feldman & Varni, 1985; Steward & Steward, 1981; Meltzer, Bibace, & Walsh, 1984). Steward and Steward investigated children's conceptions of medical procedures. Meltzer et al. investigated children's conceptions of smoking. Both studies used independent means to gain access to stages and found categories that were congruent with those delineated by Bibace and Walsh. Bernstein and Cowan (1975), Perrin and Gerrity (1981), Brewster (1982), and Bibace and Walsh (1981) have been frequently cited as providing models for establishing scoring and coding categories. Of these studies, Bibace and Walsh represent the most sophisticated methodology. Their index of developmental level was based on age but they cautioned that age should be assumed to be correlated with stage not equivalent to stage. They emphasize that "it is crucial to note that age could not in any way be rigidly adhered to as the sole developmental marker", but could be used as a general index of development. Bibace and Walsh failed, however, to gain access independently of the effects of operational  25 level on the development of concepts.  Hence, it is the intent of the present study to  investigate the relationship of operational level and age to the development of concepts of health and illness. F u r t h e r m o r e , it is hypothesized that cognitive level will be a stronger predictor of level of concept than the index of age and, secondly, that cognitive level together with age will be a stronger predictor of level of concept than either index on its own. One  additional variable will be investigated, that of verbal ability. A l t h o u g h some  studies have concluded that intellectual functioning is not a significant factor (Natapoff, 1978), Peters (1978) suggests that linguistic facility is a factor when communicating to children about health a n d illness. Linguistic ability m a y mediate or be mediated b y cognitive competence.  T h e third hypothesis  then is that verbal  ability will  also  account for a  significant portion of the variance with respect to level of concept. A s a standardized test of receptive language ( P P V T - R ) had been included in the battery of tests administered in the Preadmission P r e p a r a t i o n P r o g r a m , it was decided to use the results in the present study. Three  variables then will  be investigated  within the  present  study:  cognitive  developmental level, chronological age, and verbal ability. T h e relative strength of each variable as a predictor of level of concept will be tested in a multiple regression analysis.  2.3 S T A T E M E N T O F T H E T H R E E  HYPOTHESES  In a stepwise multiple regression equation with level of concept as the criterion variable and cognitive level, age, and verbal ability as the predictor variables, the following hypotheses will be tested: 1.  Cognitive level will be a stronger predictor of level of concept than the predictors of age and  verbal ability. "Stronger" means that cognitive levels will enter the prediction  equation on step 1 and will account for a greater portion of the variance than that accounted for b y age or verbal ability. 2.  Cognitive level together with age will be a stronger predictor than either index on its own.  The amount of variance accounted for on the second step by the composite of  26 cognitive level and age will be greater t h a n that accounted for b y either index on the first step. 3.  V e r b a l ability will account for a significant portion of the variance with regard to level of concept over and above that already accounted for by cognitive level and age and will enter the prediction equation on step 3. T h e problem restated then is to determine the contribution made by each of the  independent variables of cognitive level, age, and verbal ability to the prediction of the criterion variable, level of concept. T h e methodology for testing the hypotheses will be described in the following chapter.  Chapter 3 METHODOLOGY Subjects were selected from the population of a study in progress pre-admission  preparation of children entering  B.C.'s  investigating  Children's Hospital for elective  surgery. Six categories of surgery were included in this major study: Orthopedic, E . N . T . (Ears, Nose, a n d T h r o a t ) , G e n i t a l - U r i n a r y , Plastic, D e n t a l , and G e n e r a l S u r g e r y . None of the surgical procedures was considered to be life-threatening. T h e r e were three types of admission procedures involved: D a y C a r e , Inpatient, and Admit-day-of-surgery. D u r i n g the Preadmission P r e p a r a t i o n P r o g r a m s Study, a series of six interviews was conducted with each of 200 children and their parents. These children were living in the L o w e r M a i n l a n d of British Columbia, in and around V a n c o u v e r . T h e children ranged in age from 5 to 12 years; age was determined as of date of surgery. T h i s researcher, as one of the research assistants for the Preadmission P r e p a r a t i o n P r o g r a m , received permission from the Project H e a d and the Project Coordinator to conduct the present study as a n additional investigation that might contribute to the purpose of the major study, that of investigating the preparation of children for surgery. T h e data for the present study was gathered during the sixth a n d final interview following surgery. It was decided that 20 of the first cases would be assessed as p a r t of a pilot study and the following 40 cases would be assessed as participants in the m a i n study.  3.1 P I L O T S T U D Y In a p r e l i m i n a r y investigation, during  which  time  this  researcher  20 cases were assessed as part of a pilot stud}'  had the  opportunity to become  familiar with  the  assessment instruments and procedures and the clinical technique for interviewing. T h e children, r a n g i n g in age from 5 to 12 years ( M e a n age  =  Children's H e a l t h Questionnaire and a set of Piagetian tasks.  27  9.4), were administered the  28  In order to test the first two hypotheses, a stepwise multiple regression analysis was conducted on the data from the 20 cases. L e v e l of concept was the dependent variable (criterion variable) with cognitive level and age entering the prediction equation at the first and  second  steps respectively.  B o t h of the  independent  variables  were  found  to  be  significantly correlated with the criterion variable beyond the .05 level of significance. T h e results of the multiple regression analysis indicated that a multiple R of .65 was obtained which accounted for 42% of the variance. A g e accounted for 15% of the variance while cognitive level accounted for a n additional 27% of the variance. T h e results of the analysis on the data from the pilot study support the proposed hypotheses that cognitive level is a stronger predictor of level of concept than age a n d that cognitive level together with age is a stronger predictor than either index on its own. Because of the limited n u m b e r of subjects in the pilot study, the results m u s t be interpreted with caution; the findings, however,  are  congruent with theoretical expectations and are encouraging for the present study. Following  the  pilot  study,  a  few  alterations  were  made  in  the  assessment  procedures. It was decided that two questions from the Children's H e a l t h Questionnaire would not be scored as they were not well suited to eliciting causality explanations from the children. (Table 2 contains the revised questionnaire.) T h e questions would be retained, nevertheless, so that children's ideas about the m e a n i n g of the terms "health" and "sick" could be explored as "warm-up" questions. It should be noted here that Simeonsson et al. (1979) found that some questions were more developmentally sensitive t h a n others. F u r t h e r modifications were introduced within the Piagetian assessment battery in order to improve the suitability of the tasks and procedures. T h e pilot study  served to permit the researcher  to gain some experience  with  Piagetian assessment techniques, to modify the task structures where necessary, and to test the hypotheses in a trial r u n . Training  sessions  in  Piagetian  assessment  techniques  were  provided by  researcher's supervisor and included practice sessions with children of various ages.  the  29  3.2 SUBJECTS F o r the present study, the 40 cases following those used in the pilot study were assessed as participants in the m a i n study. T h e r e were 10 children assigned to each of four age groups: 5-6 ( M e a n age = 5.98 years), 7-8 ( M e a n age = 7.78 years), 9-10 (Mean age = 9.53 years), and 11-13 ( M e a n age = 12.21 years). T h e 2 children who were 13 years of age had been 12 on the date of their surgery. T h e age s p a n of 5 to 13 years of age covers the period of the acquisition of concrete operational thought and the beginning of the formal operational stage. C h i l d r e n were assigned to each of the four cells in the order that they were assigned to this researcher until each cell h a d the required number of subjects. A s some surgical procedures tend to be age specific, some cells were filled earlier t h a n others. In order to complete the cells of the groups of older children, this researcher conducted the interview for 6 children who had originally been assigned to another research  final  assistant  working with the Preadmission P r e p a r a t i o n P r o g r a m . A l l of the d a t a for the present study was gathered b y this researcher.  3.3 P R O C E D U R E S The  children were  Rapport  was  interviewed  established  and assessed individually in their home  and a suitable  place,  free  from  environment.  distraction, was  found for  conducting the interview. T h e children were first interviewed with the Children's H e a l t h Questionnaire. T a b l e 2 represents the format of the Children's H e a l t h Questionnaire.  30  T a b l e 2: C h i l d r e n  1  s Health Questionnaire  1.  What does i t mean t o be h e a l t h y ?  2.  What s h o u l d c h i l d r e n do t o s t a y h e a l t h y ?  3.  What does i t mean t o be s i c k ?  4.  Why do c h i l d r e n g e t s i c k ?  5.  Why i s i t t h a t some c h i l d r e n g e t s i c k and o t h e r c h i l d r e n don't?  6.  What makes you g e t s i c k ?  7.  What makes you g e t b e t t e r ?  (Robinson, Conry, & Harper, 1986)  Questions were probed according to the clinical method initiated b y Piaget and Inhelder (1958) and modified by m a n y others ( L a u r e n d e a u & P i n a r d , 1962; Bernstein & C o w a n , 1975; Bibace & W a l s h , 1981). Following the completion of the Children's H e a l t h Questionnaire, the children were assessed by administering a representative sampling of Piagetian tasks chosen to give a reasonable estimate  of their cognitive developmental level. These tasks were chosen to  measure the gradual acquisition of concrete operational thought and formal operational thought. T h e tasks were selected from those protocols described by A r l i n (1978,  1981,  1982). T h e protocols were modifications of those used by Piaget and Inhelder (1958, 1964). A l t h o u g h there are 3 subsystems  representing the concrete operational stage -  seriation, classification, and conservation - seriation tasks were omitted from the format as it has been found that most children of the age range included in the study would have mastered these tasks as they represent the earliest stage of concrete operations (Arlin,  31  1981;  T o m l i n s o n - K e a s e y et  al.,  1979).  Nine  tasks  representing  the  subsystems  of  classification and conservation were included in this study. F o u r formal tasks were selected representing the early and middle developmental phases of formal reasoning: probability, correlations, combinations, and proportions (Arlin, 1982). Success in these tasks would give  some indication that the process  of formal  reasoning h a d begun. T h e instruments thus were chosen to be concordant with a structural perspective adhering to the gradual acquisition of cognitive stages. T w o other considerations that h a d to be dealt with were ease of administration and time  required for administration. A l t h o u g h commonly used  as  a  measure  of  formal  reasoning, the task of conservation of volume was not included in the battery as assessments  took  place  in  the  home  environment  and  this  task  would  have  the been  inconvenient to set up there. T i m e was also a further limitation as the administration of tasks h a d to fit within the guidelines set up by the Preadmission P r e p a r a t i o n P r o g r a m . Considering the age range under study and adhering to the process of g r a d u a l acquisition, it was felt that the tasks selected were appropriately representative of the total battery. Tasks  were  commenced  at  age  appropriate  levels  ascending/descending order until two consecutive failures/successes  and  continued  in  were achieved. Table 3  s u m m a r i z e s the common test battery sequence with suggested starting points according to the age of the subject being tested. See A p p e n d i x A for a list of required materials and Appendices B , C , and D for samples of test protocols.  32  T a b l e 3: Common T e s t B a t t e r y Sequence  Suggested S t a r t i n g Point A c c o r d i n g t o Age  Task  5-6 years  Simple C l a s s i f i c a t i o n  7 - 9 years  Two-way C l a s s i f i c a t i o n Class Inclusion Three-way C l a s s i f i c a t i o n  5-6 years  Number C o n s e r v a t i o n Quantity Conservation  7 - 9 years 10 - 13 y e a r s  Length C o n s e r v a t i o n Area Conservation Weight C o n s e r v a t i o n  Correlations Probability Combinations Proportions  (ERIBC: A r l i n , 1978)  33  T h e tasks used in the Piagetian assessment battery were as follows: 1.  Simple Classification: T h e subject was presented with 12 plastic attribute blocks and asked to place them in 2 or 3 groups. H e was then asked to make new groups.  2.  T w o - w a y Classification: T h e subject was presented with a m a t r i x (See A p p e n d i x E) and asked to select the picture that would best complete the pattern. H e was then asked to give the reason for his choice. F i n a l l y , he was asked if a n y other picture would be suitable for completing the pattern.  3.  Class Inclusion: T h e subject was presented with 7 green wooden blocks and 3 black wooden blocks and asked whether there were more green blocks or more wooden blocks and then was asked to give a reason for his choice.  4.  T h r e e - w a y Classification: T h e subject was presented with the three-way m a t r i x (See Appendix F ) a n d asked to select the picture that would best complete the pattern. H e was asked to give a reason for his choice and then asked i f a n y other picture would be equally suitable for completing the pattern.  5.  Conservation of number: T h e subject was presented with two rows of blocks, one row of green blocks and one row of black blocks, with equal spaces between blocks and asked if there were more black blocks or more green blocks or the same number of blocks. T h e green blocks were then pushed together and the subject was again asked if there were more, less, or the same number of blocks. T h e subject was then asked to give a reason for his answer.  6.  Conservation of Quantity: a.  Continuous: T h e subject was presented with two plasticine balls, approximately 5 cm. in diameter, and was asked if they were the same. (If subject said they were not the same, he was asked to make them the same.) W h e n the subject was satisfied that the two balls were the same, the examiner flattened one of the balls and asked the subject whether the balls had the same amount of plasticine or if one h a d more or less than the other. T h e subject was then asked to give a reason  34  for his choice. b.  Discontinuous: T h e two balls were again presented to establish equality. T h i s time the examiner broke up one of the balls into several pieces and the subject was aked whether the intact ball and the group containing the pieces had the same amount of plasticine or if one or the other had more or less plasticine. T h e subject was asked to give a reason for his choice.  7.  Conservation of L e n g t h : a.  T h e subject was presented with two shoelaces of equal length and was asked if the shoelaces were the same length. (If subject said they were unequal, he was asked to make them equal.) T h e examiner then said, "Let's pretend that these two laces are two garden snakes. It is a s u n n y day and they are crawling along." M o v i n g one of the laces ahead of the other, the examiner asked, "Are they still the same length or is one longer or shorter than the other?" T h e subject was asked to give the reason for his answer.  b.  T h e two shoe laces were again presented to establish equality. C u r l i n g up one of the shoe laces, the examiner said, "Now this snake decides it is time for a nap and so he curls up. Is he still just as long as the other snake or is he longer or shorter? W h a t do you think?" T h e subject was asked to give the reason for his response.  8.  Conservation of A r e a : T h e subject was presented with 2 sheets of "8 1/2 x 11" paper and was asked to confirm that they were the same. T h e subject w a s then presented with 2 sets of small, green self-adhesive circles (each set contained 10 circles) and was asked if they were the same. T h e examiner gave one of the papers to the subject along with one set of circles and kept the same for herself and then said, "This is your garden and this is m y garden. These are your cabbages and these are m y cabbages. Y o u plant your cabbages in your garden and I'll plant m y cabbages in m y garden. Go ahead now." T h e examiner observed whether the subject planted his cabbages close together or spread apart and then planted hers in the opposite w a y . T h e subject was then  35  asked, "Do the cabbages in your garden cover more ground, less ground, or just as m u c h ground as the cabbages in m y garden?" T h e subject was asked the reason for his response. 9.  Conservation of Weight: T h e subject was presented with the two balls of plasticine and was asked if they weighed the same. (If subject said they didn't, he was asked to m a k e them the same.) T h e examiner flattened one of the balls and asked if it was just as heavy as the other, or heavier, or lighter. T h e subject was asked to give a reason for his response.  10.  Probability: T h e subject was presented with a n envelope containing 3 yellow, 3 green, and 3 purple beads and was asked what his chances would be of getting a yellow bead if he were to pick one bead from the envelope. T h e subject w a s asked to give a reason for his answer. H e was then asked to pick one bead from the envelope and was asked what his chances would be of getting another bead of the same colour. A g a i n , he was asked to give a reason for his response.  11.  Correlations: T h e subject was presented with the card with the 12 faces (See A p p e n d i x G) and was asked if he could find a relationship between hair colour and eye colour based on the 12 faces. T h e subject was asked to give a reason for his response. H e was then asked what the chances would be of a person being blond haired and brown eyed based on the  12 faces on the card and was  again asked to give a reason for his  response. 12.  Combinations: T h e subject was presented with an electronic box with a light and 5 buttons. T h e examiner demonstrated that pressing some of the buttons would cause the light to go on. T h e subject was not permitted to view which buttons were being pressed. T h e subject was then asked to try and find out which buttons to press in order to make the light go on. T h e examiner observed which tactics were being employed.  13.  Proportions: T h e subject was presented with the pictures of M r . B i g and M r . S m a l l (See A p p e n d i x H ) . T h e examiner measured M r . B i g with big paper clips (6 big paper  36  clips) and M r . S m a l l with big paper clips (4 big paper clips). T h e examiner  then  measured M r . S m a l l with small paper clips (6 small paper clips) a n d asked the subject to estimate how tall M r . B i g would be if measured with small paper clips. T h e subject was asked to give a reason for his answer. T h e Peabody Picture V o c a b u l a r y Test-Revised ( P P V T - R ) h a d been  administered  during the first interview for the Preadmission Preparation P r o g r a m , approximately one week prior to surgery, and the results obtained were used to establish verbal ability.  3.4 SCORING Performance criteria for the Children's H e a l t h Questionnaire were inferred from the descriptions of Bibace and W a l s h (1980, 1981) with respect to the characteristics of each category of explanations. Questions 1 and 3 were used for clarification of the concepts of sickness and health and responses were not scored. A n s w e r s to the remaining questions were rated from 0-6 for a m a x i m u m total of 30 points. Table 4 represents  the scoring  categories. Inter-rater reliability, using a r a n d o m sample of 10 protocols, resulted in  76%  agreement. It was noted that 67% of the disagreements involved only a .5 point difference in scoring; 33% involved a 1.0 point difference in scoring.  37  Table 4 S c o r i n g C a t e g o r i e s f o r Developmental C o n c e p t i o n s of I l l n e s s  C a t e g o r y 0 : Incomprehension C a t e g o r y 1: Phenomenism C a t e g o r y 2: C o n t a g i o n C a t e g o r y 3: C o n t a m i n a t i o n C a t e g o r y 4: I n t e r n a l i z a t i o n C a t e g o r y 5: P h y s i o l o g i c a l E x p l a n a t i o n s C a t e g o r y 6: P s y c h o p h y s i o l o g i c a l E x p l a n a t i o n s  ( B i b a c e & Walsh, 1980) F o r the Piagetian tasks, criteria followed that of A r l i n (1981, 1982) based on work by Inhelder a n d Piaget. E a c h task was rated out of 2 points for a total score of 26 points. Inter-rater reliability, using a r a n d o m sample of 10 protocols, resulted in 96% agreement.  3.5 STATISTICAL ANALYSIS A stepwise multiple regression analysis will be performed on the data with level of concept as the dependent variable (criterion variable). Cognitive level will be the  first  variable to enter into the prediction equation and will account for the greatest proportion of the variance. A g e and verbal ability will also be significant predictors of level of concept but will enter into the prediction equation at the second and third steps respectively. T h e d a t a will be analyzed both quantitatively and qualitatively in order to examine the development of concepts in relation to each of the independent variables. T h e results will be reported in C h a p t e r I V .  Chapter 4 RESULTS T h i s chapter will present the results of the study and will include both a quantitative and a qualitative analysis of the data. T h e quantitative analysis will consist of the s u m m a r y statistics for each of the variables, the results of the stepwise multiple regression analysis, and  the subsequent  statistics.  construction of contingency tables  T h e qualitative analysis  will examine  and computation of C h i Square  the r a w d a t a in a n attempt  to  offer  additional insight into the results of the study.  4.1 QUANTITATIVE ANALYSIS  4.1.1 LEVEL OF CONCEPT OF HEALTH AND ILLNESS Level  of concept  of health  and illness  was  assessed by  means  of  a  Health  Questionnaire ( H T O T ) . E a c h question h a d a m a x i m u m score of 6 points rated according to which category of explanation had been  elicited. T h e range of scores for the H e a l t h  Questionnaire ( H T O T ) was from 10 to 26 out of a possible total of 30 points. T h e m e a n score was 17.95 with a standard deviation of 3.10 (N = 40). T h e r e was only one response which was scored at the lowest category, that of phenomenism (1), and only one response which was scored at the highest category, that of psychophysiological explanations (6). T h e remaining  responses  explanations  received  of contagion  (2),  scores  from  2  contamination (3),  to  5  representing  internalization (4),  the  corresponding  and physiological  causes (5). Table 5 indicates the distribution of H e a l t h Questionnaire scores ( H T O T ) . It is apparent from Table 5 that the scores tend to cluster about the m e a n which indicates a restricted range, a condition which m a y attenuate correlation (Glass & Stanley, 1970; F e r g u s o n , 1981).  38  39  Table 5:  F r e q u e n c y t a b l e f o r H e a l t h Q u e s t i o n n a i r e (HTOT)  HTOT  FREQUENCY  PERCENT  10-10.5 11-11.5 12-12.5 13-13.5 14-14.5 15-15.5 16-16.5  1 1 1 0 1 5 4  2.5 2.5 2.5 2.5 12.5 10.0  17-17.5 18-18.5 19-19.5  1 10 5  2.5 25.0 12.5  20-20.5 21-21.5 22-22.5 23-23.5 24-24.5 25-25.5 26-26.5  3 6 1 0 0 0 1  7.5 15.0 2.5  2.5  4.1.2 PIAGETIAN ASSESSMENT OF COGNITIVE L E V E L Cognitive developmental level was assessed through a battery of Piagetian tasks representing concrete operational thinking skills and formal operational thinking skills. Each task had a maximum score of 2 points for a total of 26 points. The range of scores for the Piagetian assessment battery (PTOT) was from 2 to 23 with a mean score of 12.60 and a standard deviation of 5.35 (N = 40). P T O T scores up to 10 points represent low concrete; P T O T scores from 11 to 16 represent mid concrete; P T O T scores from 17 to 26 represent the  transitional stage and include  high concrete  operational  and beginning formal  operational thinking. A minimum score of 2 suggests that even the subjects with the lowest scores had at least some attainment of concrete operational skills. There were 6 subjects who showed some sign of attaining formal operational thought; 4 of those subjects were in the 10-13 age group while the remaining 2 were in the 9-10 age group. Only one of the  40  subjects scoring points for formal operational tasks h a d obtained complete scores for all the concrete tasks. F r o m the following table then, it appears evident that the large majority of subjects fell within the concrete operational group. T a b l e 6 indicates the distribution of scores for the Piagetian assessment ( P T O T ) .  T a b l e 6:  Frequency t a b l e f o r P i a g e t i a n Assessment (PTOT)  PTOT  FREQUENCY  PERCENT  1-2 3-4 5-6 7-8 9-10  2 4 2 3 1  5.0 10.0 5.0 7.5 2.5  11-12 13-14  2 7  5.0 17.5  15-16 17-18 19-20 21-22 23-24  11 5 2 • 0 1  27.5 12.5 5.0 2.5  F r o m T a b l e 6 it is again evident that there is a somewhat restricted range of scores which  statistically  tends  to  reduce  the  size  of  the  correlation coefficients  when  the  relationship of P T O T to other variables is established.  4.1.3 INDEX OF AGE Chronological age was another prediction variable and ranged from 5.58 to  13.17  years. T h e age range of the subjects from the Preadmission Preparation P r o g r a m had been from 5 to 12 y e a r s with age determined as of day of surgery; however, as most of the data for  this study was collected 6 months after surgery, the m a x i m u m age h a d advanced to  include 2 subjects who were 13 years of age. T h e m e a n age for this study was 8.87 with a  41  standard deviation of 2.37 ( N = 4 0 ) . T h e subjects h a d been selected from 4 age groups: 5-6, 7-8, 9-10, 11-13. Table 7 shows the age breakdown at the time of the present assessment.  Table 7 :  4.1.4  Frequency t a b l e f o r t h e index of age  AGE  FREQUENCY  PERCENT  5 years 6 years  5 5  12.5 12.5  7 years 8 years 9 years  7 3 9  17.5 7.5 22.5  10 11 12 13  1 5 3 2  2.5 12.5 7.5 5.0  years years years years  V E R B A L  ABILITY  V e r b a l ability was  assessed by the Peabody Picture Vocabular3' T e s t - Revised  ( P P V T - R ) which is a measure of receptive vocabulary. T h e scores are standardized as a language quotient (LQ) with a m e a n of 100 and a s t a n d a r d deviation of 15. T h e range of L Q scores for this study was from 78 to 133 with a m e a n of 104.08 and a s t a n d a r d deviation of 13.95 (N = 40). T a b l e 8 indicates the distribution of L Q scores. Table 9 provides a s u m m a r y of the means and standard deviations for the criterion variable of H e a l t h T o t a l ( H T O T ) and for the three predictor variables of Piagetian T o t a l ( P T O T ) , A g e , and V e r b a l Ability ( L Q ) .  42  T a b l e 8:  Frequency t a b l e f o r v e r b a l a b i l i t y (LQ)  LQ  FREQUENCY  PERCENT  75-79 80-84 85-89 90-94 95-99  1 4 1 4 4  2.5 10.0 2.5 10.0 10.0  100-104 105-109  11 3  27.5 7.5  110-114 115-119 120-124 125-129 130-134  3 2 3 2 2  7.5 5.0 7.5 5.0 5.0  T a b l e 9: Means and s t a n d a r d d e v i a t i o n s f o r H e a l t h T o t a l (HTOT), P i a g e t i a n T o t a l (PTOT), Age, and V e r b a l A b i l i t y (LQ)  Variable  Mean  Standard Deviation  Cases  HTOT  17.95  3.10  40  PTOT  12.60  5.35  40  Age  8.87  2.37  40  104.08  13.95  40  LQ  43  4.1.5 C O R R E L A T I O N S B E T W E E N V A R I A B L E S The  data reported in Table 10 indicate the relationship between the  independent  (predictor) variables of P T O T , A g e , and L Q a n d the dependent (criterion) variable of H T O T . The  correlation coefficients  obtained  indicate  that  all of the  predictor variables  are  significantly correlated with the criterion variable. A g e , however, is more highly correlated with H T O T t h a n is P T O T , which is contrary to the direction of the first hypothesis. T h e correlation between A g e and H T O T is .75 (p < H T O T is .66 (p <  .01); the correlation between P T O T and  .01). T h e r e is also a v e r y high correlation between the two predictor  variables of A g e and P T O T which would be expected according to developmental theory; the correlation between A g e and P T O T is .77 (p < .01). L Q has a significant correlation with H T O T (.32, p < .05) but correlations with A g e (.02) a n d P T O T (.09) are not significant. A significant  correlation between L Q and A g e  would not be expected  as  age  has  been  controlled for within the standardized language quotient. T h e correlations between variables will influence their entry into the regression equation and will be further discussed in the results of the multiple regression analysis.  T a b l e 10: C o r r e l a t i o n c o e f f i c i e n t s f o r H e a l t h T o t a l (HTOT), P i a g e t i a n T o t a l (PTOT), Age and V e r b a l A b i l i t y (LQ)  HTOT PTOT AGE  PTOT  AGE  LQ  .66**  .75** .77**  .32** .09 .02  N=40; * p < .05; ** p < .01  4.1.6 S T E P W I S E M U L T I P L E R E G R E S S I O N A N A L Y S I S The results of the stepwise multiple regression analysis only p a r t i a l ^ support the hypotheses.  The  first  hypothesis  states that  cognitive  level  (PTOT)  would enter  the  regression equation on the first step and that age would enter on the second step when, in  44  fact, age entered first and P T O T was not selected to enter the equation. The  second hypothesis  states that chronological age together with cognitive level  ( P T O T ) would be a stronger predictor than either index on its own. T h e results partially support the second hypothesis.  T h e composite  only  of cognitive level and age does  account for more of the variance than that accounted for by cognitive level but does not account for a significant increase in the amount of variance over and above that accounted for b y age. T h e r e is no significant effect of P T O T with H T O T when age is partialed out. T h e combination of age and P T O T is only m i n i m a l l y stronger than age on its own with P T O T contributing a negligible additional amount of variance to the efficacy of prediction. The  third hypothesis  states that verbal ability would account for a  significant  portion of the variance with respect to level of concept over and above that accounted for b y age and cognitive level. T h e results of the study support this final hypothesis. V e r b a l ability does account for a small but significant portion of the variance. A stepwise regression model was chosen as it is one of the most commonly used methods  and is  essentially  a combination  of both  forward and b a c k w a r d  procedures  (Noru5is, 1985). A s in the forward procedure, the first variable to be considered for entrj' into the equation is the one with the strongest correlation with the dependent variable. If this variable meets the criterion for inclusion (the probability of F-to-enter is P I N = 0.05), the second variable then to be selected among the r e m a i n i n g variables is that which has the highest partial correlation with the dependent variable. If this second variable meets the criterion for inclusion, the first variable is then examined to see whether  is should be  removed according to the r e m o v a l criterion as in b a c k w a r d elimination (the probability of F-to-remove is P O U T  =  0.10). T h e process continues  alternating between forward and  b a c k w a r d procedures and terminates when there are no longer any variables that meet the entrj' and r e m o v a l criteria. A further criterion that m u s t be met before a variable is entered into  the  prediction equation  is  the  tolerance  of that variable with other  independent  variables already in the equation. T h e default tolerance value is 0.01. T h u s in the stepwise  45  regression model three criteria must be met by each of the independent variables (Kerlinger & Pedhazur, 1973; Pedhazur, 1982; NoruSis, 1985; Lai, 1986). The major statistical findings from the stepwise multiple regression analyses are reported in two tables. Table 11 represents the results of the stepwise multiple regression (see steps 1 and 2) and the results of a second regression analysis with P T O T forced into the regression equation (see step 3). From the first analysis, with only Age and L Q being selected to enter the equation, a multiple R of .81 was obtained which accounts for 6 5 % of the variance. Age accounts for 5 6 % of this variance. When L Q is entered into the prediction equation, it accounts for an additional 9% of the variance. In the first stepwise analysis, P T O T was not selected to enter into the prediction equation. The data in Table 11 then do not support the hypothesis that cognitive level is a stronger predictor of level of concept than age; rather, the data support age as the stronger predictor.  T a b l e 11: M u l t i p l e R f o r t h e c r i t e r i o n v a r i a b l e of H e a l t h T o t a l (HTOT) w i t h t h e t h r e e p r e d i c t o r s o f Age, V e r b a l A b i l i t y (LQ), and P i a g e t i a n T o t a l (PTOT)  Step  Variable  Multiple R  RSQ  RSQ Change  F  1  Age  .75  .56  .56  48.55**  2  LQ  .81  .65  .09  35.07**  3  PTOT  .82  .66  .01  23.83**  * p<.05  A  ** p<.01  second multiple regression  analysis was conducted on the data in which  operational level (PTOT) was forced into the prediction equation. A multiple R of .82 was obtained (see Table 11, step 3) which accounts for 6 7 % of the variance; operational level (PTOT) accounts for only 1% of this variance. The results then only partially support the  46  second hypothesis. T h e combination of P T O T a n d A g e is only m i n i m a l l y stronger t h a n A g e on its own. H o w e v e r , the composite of P T O T and A g e accounts for a significantly greater portion of the variance than that accounted for b y P T O T when P T O T is forced to enter the equation on step 1 in a further analysis. T h e third hypothesis states that V e r b a l A b i l i t y (LQ) would account for a significant portion of the variance with respect to level of concept ( H T O T ) . T h e results of the study support this final hypothesis. L Q accounts for a s m a l l but significant portion of the variance (9%) and together with A g e provides the best weighted composite of predictor variables for this study. T h e F ratio statistics reported in Table 11 test the overall regression model for each step ( L a i , 1986). A decrease in F values is evident i n Table 11; nevertheless,  all the F  values for the overall model computed for each step are significant (p<.01). A n explanation of the decrease in F values is provided below: E a c h time a variable is added to the equation, a degree of freedom is lost from the residual s u m of squares and one is gained for the regression s u m of squares. T h e standard error m a y increase when the decrease i n the residual s u m of squares is v e r y slight and not sufficient to make up for the loss of a degree of freedom for the residual s u m of squares. T h e F value for the test of the overall regression decreases when the regression s u m of squares does not increase as fast as the degrees of freedom for the regression. (NoruSis, 1985, p. 44) Table coefficients  12 indicates the B e t a coefficients  of the independent variables. T h e B e t a  permit a further interpretation of the relative importance of variables b y  providing a correlation of each independent variable with the dependent variable while partialing out the effects of the other independent variables. F r o m Table 12 it is evident that when age is entered into the prediction equation, it accounts for the greatest percentage of the variance. L Q maintains a significant portion of the variance because in fact age is controlled for within the formulation of the language quotient ( L Q ) . A l t h o u g h P T O T has a high correlation with H T O T when the effects of A g e and L Q are partialed out,  PTOT  accounts for a v e r y small proportion of the variance. In Table 12, the F ratio statistics test the significance of each independent variable with the effects of the other independent  47  variables in the equation partialed out. T h e F values indicate that the B e t a coefficients for Age  and L Q are  significant  (p<.01); however  the  B e t a coefficient  for P T O T  is  not  significant. These F values determine whether or not a variable will enter the regression equation.  T a b l e 12: B w e i g h t s , S t a n d a r d E r r o r o f B, and Beta weights f o r M u l t i p l e R f o r t h e c r i t e r i o n v a r i a b l e o f H e a l t h T o t a l (HTOT) w i t h t h e t h r e e p r e d i c t o r v a r i a b l e s o f Age, V e r b a l A b i l i t y (LQ), and P i a g e t i a n T o t a l (PTOT)  Variable  B  SE B  Beta  Age  .81  .20  .62  16.76**  LQ  .06  .02  .29  9.16**  PTOT  .09  .09  .16  1.12  *p<.05  All  F  **p<.01  possible  combinations  of predictor variables  were  entered  into  regression  equations with all possible positions of entry for each variable in order to find the most meaningful  combination.  Pedhazur  (1982)  refers  to  "meaningfulness"  being  in  part  "situation-specific" a n d not necessarily equivalent to statistical significance. Because it is clear that P T O T  has  a high correlation with H T O T ,  the  regression equation will be  examined in which P T O T enters on the first step and A g e enters on the second step. W h e n P T O T is forced into the regression equation on step 1, the multiple R is .66 ( R S Q = .44, R S Q C h a n g e = . 4 4 , F = 29.91, p < .01). W h e n A g e is entered on step 2, the multiple R increases to  .76  (RSQ = .58,  R S Q C h a n g e = .16,  F = 25.54, p  <  .01).  However, when  the  Beta  coefficients are examined for this analysis, the B e t a coefficient for P T O T is only .22 while the B e t a coefficient for A g e is .58. T h u s when age is partialed out the influence of P T O T is greatly diminished. W h e n P T O T is partialed out from A g e , the strength of A g e is retained.  48  F r e q u e n c y tables were computed in order to regroup the data into high, m e d i u m , and low ranges of scores. Table 13 indicates the percentage of scores/ages for high, m e d i u m and  low groupings for the criterion variable ( H T O T ) and the three predictor variables of  P T O T , A g e , and L Q .  T a b l e 13:  D i s t r i b u t i o n of v a r i a b l e s with regrouping i n e f f e c t  VARIABLE  LOW  MEDIUM  HIGH  HTOT  32.5%  40.0%  27.5%  PTOT  30.0%  50.0%  20.0%  Age  25.0%  47.5%  27.5%  LQ  35.0%  35.0%  30.0%  4.1.7 C O N T I N G E N C Y T A B L E S A N D C H I S Q U A R E  STATISTICS  Contingency tables were then constructed with the regrouping i n effect so that the data could be more closely examined. H T O T was (17-19.5), and high (20-26.5) ranges  regrouped into low (10-16.5), m e d i u m  of scores. P T O T  was  regrouped into low (1-10),  m e d i u m (11-16), and high (17-24) ranges of scores corresponding approximately to low concrete,  m i d concrete,  and transitional Piagetian stages of operational level. T h e high  range of P T O T scores represents the transition f r o m high concrete operational thinking to beginning formal operational thinking. A g e s were regrouped into low (5-6), m e d i u m (7-9), and high (10-13). T h e breakpoints for the age groupings occurred where there were n a t u r a l gaps in the  frequency  of age  representation.  (See  Tables 5, 6, a n d  7 for  frequency  distributions with regrouping represented.) C h i square analyses indicated that the following combinations of variables were not independent  of each other: A g e by P T O T  (X =21.24, df=4, p < 2  (x =34.94, d f = 4 , 2  p <  .01), A g e by  .01), and P T O T by H T O T ( x = 15.91, df=4, p <  indicates the results of the C h i Square analyses.  2  HTOT  .01). Table 14  49 T a b l e 14:  Variable  C h i Square a n a l y s i s  C h i Square  df  Age by PTOT  34.94**  4  Age by HTOT  21.24**  4  PTOT by HTOT  15.91**  4  LQ by HTOT  8.27  4  Age by LQ  6.15  4  PTOT by LQ  2.19  4  *p<.05  **p<.01  T a b l e 15:  C r o s s t a b u l a t i o n o f AGE by PTOT  PTOT COUNT ROW PCT  AGE Low 5-6  1.00  Med 7-9  2.00  High  3.00  [ I  Low 1-10  ! •+  I.OO —  ! J t_ 1 1  r  10-13 L  COLUMN TOTAL  J U  io  j  100.0  i  _ 2  -1 1  10.5  i  -  t  12 30.0%  2.00 -  -I  14 73.7  ! ! i  6 54.5  3.00  ! 10 25.0%  3 15.8 5 45.5  X  20 50.0%  ROW TOTAL  High 17-24  Med 11-16  8 20.0%  19 47.5% n  _i  11 27.5% 40 100.0%  T h e crosstabulation of A g e by H T O T (Table 15) indicates that while the majority of subjects (73%) in the 3 age groupings were concordant with the corresponding grouping for P T O T , there were, nevertheless, a number of subjects (27%) who were either higher or lower than would be expected. F r o m this table, it is apparent that all of the children in the  50  low A g e group also h a d low scores for P T O T .  F o r the middle A g e group, 73.7% had  corresponding m e d i u m P T O T scores; however,  10.5% had low P T O T scores while 15.8%  had high P T O T scores. F o r the high A g e group, 45.5% h a d corresponding high P T O T scores while the r e m a i n i n g 54.5% fell within the m e d i u m P T O T range. It appears then that less than h a l f of the high age  range  subjects had entered  the  transitional Piagetian  stage  between high concrete operational skills and beginning formal operational skills.  T a b l e 16:  C r o s s t a b u l a t i o n of AGE by HTOT  HTOT COUNT ROW PCT  j I  Low 10-16  j  1.00  !  2.00  J  |  • 7 70.0 i  3 30.0  ~» 1 J  AGE LOW 5-6  1.00  Med 7-9  2.00  High 10-13  3.00  1  crosstabulation  1  [  '  »  i 6 31.6 _j  10 52.6  1 —  i  COLUMN TOTAL  The  I  13 32.5%  of A g e by H T O T  3 27.3  ROW TOTAL  High 20-26  Med 17-19  T- • 1 !  ~t—  16 40.0%  (Table 16) indicates  3.00  | 1  10 25.0%  •  ! 1  3 15.8  J 1  19 47.5%  8 72.7  J I  11 27.5%  11 27.5%  1  40 100.0%  that the majority of  subjects in the low and high A g e groups were concordant with the corresponding groupings for H T O T . However, for the m e d i u m A g e group, only 52.6% fell within the corresponding mid H T O T grouping, while 31.6% fell in the low H T O T group and 15.8% fell in the high H T O T group. It is apparent then that the greatest discrepancies occurred within the middle A g e group with almost half of the subjects falling out of the expected H T O T grouping.  51  T a b l e 17:  C r o s s t a b u l a t i o n o f HTOT by PTOT  HTOT COUNT ROW PCT  Low 10-16  Med 17-19  High 20-26  1.00  2.00  3.00  ROW TOTAL  PTOT Low I- 10  1.00  9 75.0  3 25.0  Med I I - 16  2.00  3 15.0  10 50.0  7 35.0  20 50.0%  High 17-24  3.00  3 12.5  4 50.0  8  16 40.0%  11 27.5%  COLUMN TOTAL  13 32.5%  12 30.0%  20.0% 40 100.0%  The crosstabulation of P T O T by H T O T (Table 17) indicates that while the majority of subjects with low scores for P T O T also obtained low scores for HTOT, there were many discrepancies for both the medium P T O T range and high P T O T range. Only 5 0 % of the subjects in the medium P T O T group obtained scores that fell within the medium H T O T group; 1 5 % fell within the low H T O T group, while 3 5 % fell within the high H T O T group. Again, only 5 0 % of the subjects with high P T O T scores obtained scores that were in the high H T O T range; 37.5% fell within the medium H T O T range while 12.5% fell within the low H T O T range. As there were so few subjects in the high P T O T group, 12.5% refers to just one subject whose P T O T score is just a half point away from obtaining a medium H T O T score.  52  4.2 QUALITATIVE ANALYSIS  4.2.1 LEVEL OF CONCEPT OF HEALTH AND ILLNESS T h e responses to the H e a l t h Questionnaire ( H T O T ) will be examined in terms of their concordance with the categories delineated b y Bibace and W a l s h (1980). There  was  only one  response  which fell within the  lowest category,  that of  phenomenism. T h i s response was elicited from a 6 year old boy with a Piagetian score ( P T O T ) of 3, and a low average P P V T - R score ( L Q ) . T h i s subject had a developmental delay in expressive language and a long history of health complications. T h e following is an example of his responses. (What makes y o u get better?) T h e sunshine (How does it help you get better?) W h e n it's s u n n y (Tell me more about it.) Go a w a y (What goes away?) Sick (What makes it go away?) T h e sunshine goes in the house. (How does that m a k e the sickness go away?) I don't know. T h e responses i n the category of phenomenism are characterized by the cause of illness being a n external concrete phenomenon that m a y co-occur with the illness but is otherwise remote. It is not surprising that only one response fell within this category as the population used by Bibace and W a l s h for the preoperational level consisted of 4 y e a r olds. T h e second category specified by Bibace and W a l s h was that of contagion where the cause of illness was located i n objects or people that are in close proximity to the child. T h e r e were only 4 subjects from whom some category 2 responses were elicited. A l l of these subjects fell within the 5-6 age group and had P T O T scores ranging from 4 to 7. T h r e e of the subjects had average P P V T - R scores ( L Q ) ; one subject had a below average score. A n example of a categorj' 2 response is as follows: (Why do children get sick?) G e r m s (What are germs?) A cold (How do germs make you sick?) G e r m s come when somebody else has a cold. (Tell me more.) I don't know. The  large majority of responses were at the 3rd and 4th category levels, which  corresponds with the fact that most of the subjects were within some phase of concrete operational thought. T h e third category was that of contamination characterized by a  53 person, object, or action that is harmful to the body causing illness through contact with the object or person or through participation in the action. O f the total population of subjects, 28 or 70% had some responses that fell within category 3; category 3 responses were found within all age groups. T h e following represents an example of a category 3 response. (Why is it that some children get sick and other children don't?) C a u s e some people eat good food and some people don't. (Suppose the children eat good food and they still get sick.) T h e y go out in the cold without a jacket on a n d get cold. (How does that make them get sick?) Cold air m a k e s y o u get cold--you catch a cold. Category  4 involves  the  concept  of internalization which is  characterized b y  responses where the illness is located inside the body although the cause m a y be external; there m a y be some confusion about internal functions. In all, there were 27 subjects (67.5%) who gave some category 4 responses; again, all age groups were represented. T h e following example is taken from a category 4 response. (What makes y o u get sick?) I have an allergy - from pollen - you breathe in the pollen and get a sore throat and start to sneeze. (How does it m a k e y o u sneeze?) I don't know. A s it was at the high range of H e a l t h Questionnaire scores ( H T O T ) that Piagetian scores ( P T O T ) h a d the weakest prediction strength, this section of the qualitative analysis will examine the responses of the subjects with high H T O T scores. According to Bibace and W a l s h , the formal-logical explanations included two categories, that of the physiological type (category 5) and that of the psychophysiological type (category 6). T h e r e were v e r y few subjects who had attained category 5 and 6 responses. O n l y 5 subjects had any category 5 responses and only 1 subject h a d a category 6 response. Category 5, that of physiological explanations, is characterized by the cause of illness being understood in terms of internal physiological structures and functions. T h i s example was taken from a category 5 response. (What should children do to stay healthy?) E a t good foods - eat something from each of the 4 food groups - get lots of exercise (How does exercise and good food help you stay healthy?) M a k e s you strong in your a r m s and legs so y o u can s w i m better (How does it make you strong?) K e e p s your blood r u n n i n g healthy - it gives energy to your heart so it can p u m p the blood.  54  There was only one reponse that gave a psychophysiological exaplanation.  This  response was elicited from a 13 y e a r old subject who had achieved success on some of the f o r m a l operational tasks and had an above average P P V T - R (LQ) score. T h i s subject had a long history of hospitalizations involving surgical procedures. T h e following example  is  reproduced from the subject's H e a l t h Questionnaire. (What should children do to stay healthy?) G e t exercise. (How does that help you stay healthy?) Gets y o u r muscles exercised and stretched so they don't shrink and it won't be h a r d for y o u to r u n a mile. ( A n y t h i n g else?) Keeps y o u mentally alert makes you feel good that you've done something.  4.2.2 OBSERVATIONS FROM THE QUALITATIVE ANALYSIS In general, the responses reflect the fact that the majority of children were concrete operational in terms of cognitive developmental level. T h e large majority of responses were scored within categories 3 and 4 representing explanations involving contamination and internalization. T h e process of scoring these responses was often difficult because within the framework of each category the quality of explanation would v a r y considerably. O n l y 15% of the subjects had some responses within categories 5 and 6. Bibace and W a l s h (1980) found that 42% of 11 years olds fell within categories 5 and 6. However, another 54% of their 11 year olds gave explanations involving internalization and 4% gave explanations involving contamination. T h e r e is then considerable overlap which is to be expected as not all 11 year olds are at the formal operational stage of thought processes. T h e i r findings and the findings of the present study suggest that level of concept for children of this age level m a y be the most difficult to predict. It would appear that the responses in the present study basically adhere to the developmental  sequence  of  responses  proposed  by  Bibace  and  Walsh;  however,  for  categories 5 and 6, it would seem that an older group of children must be included in order to support these categories as being typical for the upper age group, p a r t i c u l a r ^ for support of category  6. A study by Meltzer, Bibace and W a l s h (1984) on children's conceptions  of  smoking confined both physiological and psychophysiological responses to one level (level 5)  55  and found that 58% of 11 y e a r olds gave level 5 responses to questions about smoking. A t the lower end of the scale, there were only 5 subjects from the present study (12.5%) whose responses fell within the first two categories of phenomenism and contagion, this  reflects  the  fact that the  lowest  age  range  was,  in fact,  approaching concrete  operational thinking. Bibace and W a l s h used a group of 4 year olds to represent their preoperational group and found that 54% of their 4 y e a r olds fell within the area of categories designated for preoperational thinkers. T h e y fell, however, in category 2, that of contagion; there were no subjects falling in category 1, that of phenomenism. T h u s , again, the category system appears to have the greatest strength within the concrete operational stage.  In the concluding chapter, the results of the qualitative and quantitative analyses will be further discussed in terms of the relative strengths and weaknesses of the the study and in terms of directions for future research.  Chapter 5 DISCUSSION T h i s final chapter will provide a discussion of the results of the study and will offer possible explanations for the lack of support for the first two hypotheses. Attention will then focus on the relative merits and limitations of the study with a view to suggesting directions for further research a n d implications for child health education. T h e general problem to be investigated variables  of cognitive  developmental  level,  in this study was  age,  to what extent  and verbal ability contribute  to  the the  prediction of a child's level of conceptualization of health and illness. T h e results of the P e a r s o n correlations indicate that all three predictor variables, taken individually, correlate significantly with the criterion variable. H o w e v e r , the expected entry sequence of variables into the stepwise multiple regression equation and the expected  net effect of combined  variables were not supported by the d a t a analyses. In the present research, it was hypothesized that in a stepwise multiple regression equation with level of concept as the criterion variable and cognitive level, age, and verbal ability as the predictor variables, (1) cognitive level would be a stronger predictor of level of concept t h a n the predictors of age and verbal ability, (2) cognitive level together with age would account for more of the variance in the prediction of level of concept than either index on its own, and (3) verbal ability would account for a significant portion of the variance with regard to level of concept over and above that already accounted for b y cognitive level a n d age. In statistical terms, it was expected that in the regression equation, cognitive level would enter on step 1, age would enter on step 2, and verbal ability would enter on step 3. E a c h of the three hypotheses will now be discussed.  56  57 5.1 DISCUSSION OF HYPOTHESIS 1 T h e first hypothesis states that cognitive developmental level would be a stronger predictor of level of concept t h a n the index of age or verbal ability and would enter the stepwise multiple regression equation on the first step. While both of the predictor variables of cognitive level and age are highly correlated with level of concept and each variable individually is a significant predictor of level of concept, it was age that emerged as the strongest predictor, entering the prediction equation on step 1. A l t h o u g h cognitive level h a d the second highest correlation with level of concept, it was not selected for entry into the prediction equation. W h e n forced into the prediction equation in a further analysis, cognitive level was found to contribute a negligible additional a m o u n t of variance to the efficacy of prediction. T h e B e t a coefficient for cognitive level indicates that when the effects of age and verbal ability are partialed out, the contribution of cognitive level is not significant. W h e n just cognitive level and age are presented as predictor variables a n d cognitive level is forced into the prediction equation on step 1 with age entering on step 2, t h e . B e t a coefficient for cognitive level indicates that when the effects of age are partialed out, again the contribution of cognitive level is not significant. O n l y when age is not presented as a predictor variable, and cognitive level together with verbal ability are entered into a prediction equation does cognitive level account for a significant portion of the variance. H o w e v e r , w h e n evaluating meaningfulness as situation-specific from statistical significance (Pedhazur, 1982), in terms of ease of accessibility, it is evident that the index of age is more easily accessible than a Piagetian measure of cognitive level a n d is also, in this study, statistically more significant. F r o m the above discussion it appears that age is both an easily accessible predictor of level of concept and a significant predictor of level of concept. Nevertheless, it m a y still be argued that the first hypothesis would be tenable under a different set of experimental conditions. It is theoretically congruent that both age a n d cognitive level follow along the same continuum of general developmental sequence. T h e formulation of the first hypothesis was based on the premise that a Piagetian assessment of cognitive skills would tap into the  58  process of the g r a d u a l acquisition of skills and perhaps be a more precise index t h a n that of age. It has already been noted in the reporting of results that frequency distributions for the variables of cognitive level and level of concept had somewhat restricted ranges. F r o m the results of this study, it was apparent that the majority of the subjects were in some phase of concrete operational thinking and that the majoritj' of responses to the H e a l t h Questionnaire were scored within the categories that corresponded to the concrete stage. H a d the study consisted of a larger representation of pre-operational and formal operational thinkers i n addition to concrete operational thinkers, there m a y have been a stronger correlation between cognitive level and level of concept. T h i s argument, particularly in terms of the acquisition of formal operational skills will be further discussed w h e n the criterion variable is examined.  5.2 DISCUSSION OF HYPOTHESIS 2 T h e second hypothesis states that cognitive developmental level together with age would be a stronger predictor t h a n either index on its own and the amount of variance accounted for by the composite of cognitive level and age would be greater t h a n that accounted for b y either index on its own. In fact the composite of cognitive level and age does account for more of the variance t h a n that accounted for b y cognitive level but does not account for a significant increase in the amount of variance over and above that accounted for  solely  by  the  index  of age.  Therefore, the  second hypothesis  was  only p a r t i a l l y  supported. T h e fact that age and cognitive level correlate about equally with level of concept (with  age  correlating slightly  higher)  and  that  age  and  cognitive  level  are  highly  inter-correlated implies that there will be a m i n i m a l net effect of combining the  two  predictors. T h e net effect of combining two predictors increases w h e n the factors are both substantially correlated with the criterion variable but have a low correlation with each other (Glass & Stanlej', 1970). Although cognitive level as well as age is a strong predictor of level of concept, when the effects of age are partialed out from cognitive level, the effect of  59  cognitive  level on the efficacy  of prediction is m i n i m a l .  G i v e n the  strong relationship  between cognitive level a n d age it m a y be that the value of a Piagetian assessment of cognitive skills becomes that of understanding the specific cognitive skills underlying the development  of conceptualization of health and illness  rather than that of prediction  strength.  5.3 D I S C U S S I O N O F H Y P O T H E S I S 3 T h e results  do support the  third hypothesis  that verbal ability would have  a  significant effect in the prediction of level of concept; however, verbal ability entered the prediction equation on step 2 rather t h a n on step 3 as was expected. A l t h o u g h cognitive level h a d a m u c h stronger correlation with level of concept than did verbal ability, when the effects of age are partialed out from cognitive levels, the effect of cognitive level in the prediction equation is not significant. V e r b a l ability, therefore, was selected to enter the prediction equation on step 2. V e r b a l ability was measured in terms of a standardized language quotient (LQ) in which age is controlled for. T h e P P V T - R was standardized on age reference groups (Dunn & Dunn,  1981). In obtaining the language quotient (LQ) the r a w scores are converted to  standardized scores so that a subject's scores can then be compared with those of a group of subjects  of the same chronological age.  In comparison, the Piagetian assessment score  ( P T O T ) was composed of r a w scores which, according to developmental theory, are expected to increase with age. V e r b a l ability then did not have a significant correlation with age but did have a significant correlation with level of concept and was selected along with age as the best weighted composite  of variables in the prediction equation to the exclusion of  cognitive level. T h e data analysis then lends support to v e r b a l ability, independent of age, as a significant variable in predicting level of concept. T h e third hypothesis supports the view held by Peters (1978) that linguistic ability is a relevant factor when communicating to children about health and illness. It should be  60  recalled at this point that verbal ability as defined in this study measured only receptive vocabulary and was not a comprehensive measure of linguistic ability. Nevertheless, it does serve to give a n indication of the relevance of language in predicting level of concept. A more comprehensive measure of language development including both receptive and expressive language skills is recommended for use in future research. W i t h regard to linguistic competence, Peters (1978) cautions that a good facility with language  can be misleading and can m a s k inability to conceptualize  at m a t u r e levels.  Brewster (1982) notes from clinical experience that the most articulate children are not necessarily the ones who cope well with their illnesses. A s in the discussion of the second hypothesis,  perhaps the nature of the relationship between verbal ability and level of  concept is of more importance than the evaluation of verbal ability as a predictor of level of concept.  5.4 DISCUSSION OF THE CRITERION VARIABLE (HTOT) It has already been observed that there is a restriction of range in the H e a l t h Questionnaire scores ( H T O T ) , a condition which m a y attenuate correlation coefficients when the relationship of level of concept with other variables is computed. In re-examining the Bibace and W a l s h (1980, 1982) research, it is apparent that there is considerable overlap of categories of explanation of level of concept of health and illness across different age groups. While the categories of contamination  (3)  and internalization (4),  designated  as  being  congruent with the concrete operational stage, are manifested by the large majority (89%) of 7 y e a r olds, the age group selected to represent the concrete stage, this consistency is not found for the categories representing pre-operational and formal operational stages. Bibace and W a l s h selected 4 year olds for their pre-operational group and found that 4% gave category 2 responses of contagion representing a pre-operational stage; however, a further 38% gave category 3 responses. F o r the group designated to be formal operational, 11 year olds were selected. O n l y 34% of the subjects in this age group scored within category 5 and  61  8% scored within category 6 while a further 54% gave category 4 responses and 4% gave category  3 responses.  It is  evident then that  the categories  corresponding to  formal  operational thinking are not necessarily representative of the majority of 11 y e a r olds. T h i s would be congruent with theoretical expectations,  as not all 11 year olds are formal  thinkers; in fact, a child of 11 is likely to be just beginning the transitional stage between high concrete a n d beginning formal operational thinking (Arlin, 1982). It m a y well be that a child m u s t have acquired the "frames of reference" formal operational concept before being able to give a multicausality explanation or a n interactive treatment prescription.  5.5 DISCUSSION OF THE QUALITATIVE ANALYSIS W h e n the protocols from the H e a l t h Questionnaire were examined qualitatively, the general sequence of development generally followed that of Bibace and W a l s h (1980, 1981). The  overlap of categories  across  ages has  already been discussed; however,  another  question comes to m i n d in that if 4 y e a r old, 7 y e a r old, and 11 y e a r old subjects all give a category 3 response or a category 4 response, does the quality of the response within a particular category differ from one age group to another and, if so, should this qualitative difference  be  accounted  for within the  scoring system?  This  researcher  found  some  difficulties with scoring particularly between categories 3 and 4 and between categories 4 and 5. Some of the children were somewhat reticent and it was sometimes felt that they perhaps understood more t h a n what they were willing or able to communicate. A measure of expressive language ability would appear to be an appropriate factor to be investigated i n future research. T h e ability to comprehend questions and explanations as well as the ability to communicate effectively would be likely to influence an adult's perception of a child's level of concept (Peters, 1978; Brewster, 1982; H a i g h t , Black, &. Di Matted, 1985). Other interesting observations were made d u r i n g the qualitative analysis. It was noted that in this studj', v e r y few of the children regarded their present condition as a n illness; the concept of illness to most of them m e a n t h a v i n g "a cold" or "the flu". In very few  62  of the cases did surgery get recognition as a treatment for illness although surgery of one form or another was part of their current treatment p l a n . It should be acknowledged here that the surgery involved was elective surgery and the conditions requiring surgery were not life-threatening. It is difficult to speculate then how m u c h the current state of health of the subjects or their hospitalization experiences would have influenced their responses and in w h a t direction - more mature  or less mature. T h e s e factors  may  very well  have  influenced the results in that the population of subjects included in the study did already have  some experience  with medical personnel, hospitalization, and surgical procedures.  E a c h subject h a d at least one hospitalization experience which involved surgery as each was a  participant in the  Preadmission P r e p a r a t i o n P r o g r a m s  Study  at  B . C . ' s Children's  H o s p i t a l . Some of these children would have received a preparation treatment as part of the experimental group while others in the control group would not have received this additional treatment.  Some of the subjects h a d long term conditions which h a d required frequent  hospitalizations. C u r r e n t state of health m a y also have been a factor. Researchers v a r y in terms  of their findings  with regard to the effect of illness  on cognitive  level and on  explanations of causality. Some find lower scores than would be expected and suggest that the lower scores m a y reflect a regressive reaction to stress (Cook, 1975); others find higher scores t h a n would be expected w h i c h they attribute to increased sophistication with regard to medical procedures and explanations  of causality of illness and effects of  treatment  (Feldman & V a r n i , 1985). Semantics can play a n important role in terms of questioning (Cook, 1975). It m a y be  that  leaving  sickness  as  an  open-ended  condition  elicits  different  responses  than  specifying a particular condition. T h e fact that the questions in this study were open-ended probably led to the frequent response to sickness as "a cold" as that was a condition very familiar to most children. T h e findings of the present study also support Cook's contention that  spontaneous  responses tend to be less m a t u r e a n d to have m o r a l overtones while probing elicited more  63  mature responses that went beyond the concepts of wrong-doing a n d punishment. Different questioning techniques then appear to elicit different types of responses.  5.6 LIMITATIONS OF THE STUDY T h e present study was limited in terms of sample size and restriction of range for H e a l t h Questionnaire scores and the Piagetian assessment scores. T h e sample included in this study was largely concrete operational a n d the H e a l t h Questionnaire scores reflected this limitation in that the large majority of responses were those delineated as being concordant with the concrete operational stage. T h e sample should have included a greater representation of formal operational thinkers in order to test the prediction strength for the higher categories of health concept. A l t h o u g h the study involved a more comprehensive Piagetian assessment than other studies discussed in the review of the literature, time restrictions and ease of administration did somewhat limit the choice of tests in the battery. It is recommended that in future research, the battery be extended to include conservation of volume as it is considered to be a traditional task in assessing the transition from concrete to formal reasoning and it was the subjects in this transitional stage that the present study did not adequately  represent.  T h e assessment battery then should also include a more comprehensive selection of formal operational tasks so that a measure of high and low stages of formal reasoning can be obtained to correspond with the two categories for the highest level of health concepts. It is suggested that for future research a group of 1 2 y e a r olds be selected to further test the hypotheses on the assumption that this age group would be representative of a combination of both concrete operational and formal operational thinkers and, with age restricted, the contribution of cognitive level to the prediction of level of concept could then be measured. T h e study sample consisted of a group of subjects from a particular population, that of children who h a d experienced hospitalization a n d surgery. A similar study conducted on a sample  of  school  children randomly  selected  would  eliminate  some  of  the  possible  64 confounding effects of medical experiences beyond those of a normal population. V e r b a l ability in this study was restricted to a measure of receptive vocabulary. A more comprehensive measure of linguistic ability assessing both expressive and receptive language skills as suggested in the discussion of the qualitative analysis m a y account for a greater  portion of the  variance than that  accounted for by  a measure  of  receptive  v o c a b u l a ^ and m a y be more meaningful in helping to understand the relationship between linguistic ability and level of health concepts.  5.7 D I R E C T I O N S F O R F U T U R E  RESEARCH  Suggestions for future research extend i n two directions. P e r h a p s the first centre of focus would be to conduct a further study with a greater representation of subjects who are formal operational as suggested in the discussion of the limitations of the study. W i t h age restricted (12 y e a r old subjects), it would then be possible to test the efficacy of cognitive level as a predictor of level of health concept. It is of particular interest to test the relationship of formal operational concepts to level of health concept as in the research by Bibace and W a l s h (1980, 1981). T h e group of 11 y e a r olds selected b y them to represent the formal operational stage did not consistently give responses in the categories designated to be formal operational. T h i s is to be expected as few 11 y e a r olds are formal operational, but what then would the relation be for subjects who are formal operational? A further suggestion for future research is to focus on the interaction of specific cognitive concepts with health concepts. In the Bibace and W a l s h study, there were v e r y few 11 years olds who had psychophysiological explanations. Is it necessary for a subject to have acquired the formal operational concept of "frames of reference" before being able to offer  multicausality explanations  of illness  or interactive  treatment  prescriptions? A  measure of the prediction strength of specific cognitive concepts in relation to level of health concept  may  provide  a  greater  understanding  conceptualization of health and illness.  of  the  developmental  sequence  of  65  The  relevance of cognitive developmental  level to child health education will be  discussed in the following section.  5.8 IMPLICATIONS FOR CHILD HEALTH EDUCATION F r o m this vantage  point, one m u s t then consider again the value of increased  knowledge about concept development and the contributions made to improve strategies used b y medical personnel to i m p a r t information to their y o u n g patients. It has already been noted that some researchers question the value of explanations with very y o u n g children. Others question the validity of t r y i n g to change concepts which though sometimes erroneous m a y serve as a defence m e c h a n i s m in allowing the child to cope w i t h his medical problems (Vernon et a l . , 1965). W h a t e v e r the personal philosphy or preferred strategy of the medical practitioner, it would seem that an awareness of cognitive level would assist in m a k i n g a judgement about which approach to take. Other problems persist, however, as Pantell et al. (1982) acknowledge, in that the physician's theoretical knowledge of children's cognitive understanding is poor. Also, m a n y paediatricians sill adhere to the more traditional approach of dealing primarily with the parents,  excluding  the  young  patients  from  understanding  and  participating in  the  m a n a g e m e n t of their illness. While there has been much discussion about developmental level being related to concepts of health and illness and the importance of strategies in health education based on developmental level, there has been little research conducted to test the success of particular strategies. A recent study b y Potter and Roberts (1984) represents an attempt to test the efficacy of strategies for explaining illnesses to children at differing ages. T h e results of their study indicate that children's comprehension of illnesses can be improved significantly with the provision of explanatory information, although preoperational children are less able to retain specific information.  66  Few researchers have proposed strategies and/or guidelines for explaining illness to children at different ages. In addition to Potter and Roberts who have made a contribution in this direction, Whitt et al. (1979) have proposed the use of metaphorical explanations, especially when dealing with young children. Thej' feel that because of limited cognitive and language abilities, children are at a disadvantage in interpreting medical information. Using the Piagetian stages as guidelines, they have devised methods for using cues from the child's perceptions and  experiences to form  metaphorical analogies as part of the  explanation process. However, some researchers have noted that children's comprehension of metaphors is limited (Billow, 1975; Boswell, 1979).  5.9 SUMMARY OF DISCUSSION In conclusion, it seems appropriate to suggest that although not all of the hypotheses were supported by the results of the current study, there is some evidence within the data to suggest that with a different population of subjects and a somewhat revised methodology another study might provide this support. In any case, it is apparent that cognitive level does correlate significantly with level of concept and can help to predict level of health concept.  Overall, this  investigation  has  provided  some additional insight  into  the  interrelationships of cognitive level, age, and verbal ability and the relationship of each with level of concept of health and  illness. In addition, some new  strategies have been  demonstrated in terms of comprehensiveness of assessment which indicate possible new directions in methodology for future research. In terms of implications for patient education, only further research can measure the value of cognitive theory in planning intervention but it is encouraging that research efforts have begun to systematically evaluate the efficacj' of various strategies.  REFERENCES  A r l i n , P . K . (1978). T h e application of Piagetian theory to instructional decisions: Report 78:1. V a n c o u v e r : T h e Educational Research Institute of British Columbia. A r l i n , P . K . (1981). Piagetian tasks as predictors of reading and m a t h readiness in grades K - l . J o u r n a l of Educational Psychology, 73, 712-721. A r l i n , P . K . (1982). A multitrait-multimethod validity study of a test of formal reasoning. Educational a n d Psychological M e a s u r e m e n t , 42, 1077-1088. Ault,  R. L . (1983). Children's U n i v e r s i t y Press.  Cognitive Development  (2nd  ed.).  New  York:  Oxford  Bernstein, A . C . & C o w a n , P . A . (1975). Children's concepts of how people get babies. Child Development, 46, 77-91. Bernstein, A . C . & C o w a n , P . A . (1981). Children's conceptions of birth and sexuality. In R. Bibace & M . E . W a l s h (Eds.), N e w directions for child development: Children's conceptions of health, illness and bodily functions (No. 14). S a n Francisco: Jossey-Bass. Billow, R. M . (1975). A cognitive developmental Developmental Psychology, 11, 415-423. B e v e r l y , B . I. (1936). T h e effect Pediatrics, 8, 533-543.  of illness  study  of metaphor  comprehension.  upon emotional development.  Journal  of  Bibace, R. & W a l s h , M . E . (1980). Development of children's concepts of illness. Pediatrics, 66, 912-917. Bibace, R. & W a l s h , M . E . (1981). Children's conceptions of illness. In R. Bibace & M . E . W a l s h (Eds.), N e w directions for child development: Children's conceptions of health, illness and bodily functions (No. 14). S a n Francisco: Jossey-Bass. B l o m , G . E . (1952). T h e reactions of hospitalized children to illness. Pediatrics, 22, 590-600. Bios, P . , J r . (1978). Children think about illness: their concepts and beliefs. In E . Gellert (Ed.), Psychosocial Aspects of Pediatric C a r e (pp. 1-17). N e w Y o r k : G r u n e & Stratton. Boswell, D . A . (1979). Metaphoric processing in the mature years. H u m a n Development, 22, 373-384. Brewster, A . B . (1982). Chronicallj' ill hospitalized children's concepts of their illness. Pediatrics, 6 9 , 3 5 5 - 3 6 2 . Brodie, B . (1974). V i e w s of healthy children toward illness. A m e r i c a n J o u r n a l of Public H e a l t h , 64, 1156-1159. C a m p b e l l , J . D . (1975). Illness is a point of view: the development of children's concepts of illness. Child Development, 46, 92-100. C a r a n d a n g , M . , F o l k i n s , C , H i n e s , P . , & Steward, M . (1979). T h e role of cognitive level and sibling illness. A m e r i c a n J o u r n a l of Orthopsychiatry, 49, 474-481. 67  68  Cook, S. (1975). T h e development of causal thinking with regard to physical illness among F r e n c h children. U n p u b l i s h e d doctoral dissertation. U n i v e r s i t y of K a n s a s , K a n s a s C i t y . (University Microfilms N o . 76-16, 710). Coppens, N . M . (1986). Cognitive characteristics as predictors of children's understanding of safety and prevention. J o u r n a l of Pediatric Psychology, 11, 189-202. C r i d e r , C . (1981). Children's conceptions of the body interior. In R . Bibace & M . E . W a l s h (Eds.), N e w directions for child development: Children's conceptions of health, illness and bodily functions (No. 14). S a n Francisco: J o s s e y - B a s s . Edelston, H . (1943). Separation anxiety in y o u n g children: A study of hospital cases. Genetic Psychology M o n o g r a p h s , 28, 3-95. E i s e r , C . (1984). C o m m u n i c a t i n g with sick and hospitalized children. J o u r n a l of Child Psychology and N u r s i n g , 25, 181-189. F e l d m a n , W . S. & V a r n i , J . W . (1985). Conceptualizations of health and illness b}' children with spina bifida. J o u r n a l of the Association for the Care of Children's H e a l t h , 13, 102-108. F e r g u s o n , G . A . (1981). Statistical analysis in psychology and education (5th ed.). York: McGraw-Hill.  New  F l a v e l l , J . H . (1963). T h e Developmental Psychology of J e a n Piaget. Princeton, N . J . : D . V a n Nostrand. F r e u d , A . (1952). T h e role of bodily illness in the m e n t a l life of the child. Psychoanalytic Study of Children, 7, 69-81. Gellert, E . (1965). Children's conceptions of the content and functions of the h u m a n body. Genetic Psychology M o n o g r a p h s , 65, 293-405. Gellert, E . (Ed.). (1978). Psychosocial Aspects of Pediatric C a r e . N e w Stratton.  York: Grune &  G o c h m a n , D . S. (1971). Some correlates of children's health beliefs and potential health behavior. J o u r n a l of H e a l t h and Social B e h a v i o r, 12, 148-154. Goslin, E . R. (1978). Hospitalization as a life crisis for the preschool child: A critical review. J o u r n a l of C o m m u n i t y H e a l t h , 3, 321-346. G r a t z , R . , & Z e m k e , R . (1980). Piaget, preschoolers, a n d pediatric practice. P h y s i c a l and Occupational T h e r a p y in Pediatrics, 1, 3-9. G r a t z , R. R., & P i l i a v i n , J . A . (1984). W h a t makes kids sick: Children's beliefs about the causative factors of illness. J o u r n a l of the Association for the C a r e of Children's H e a l t h , 12, 156-162. H a i g h t , W . L . , B l a c k , J . E . , & D i Matteo, M . R. (1985). Y o u n g children's understanding of the social roles of physician and patient. J o u r n a l of Pediatric Psychology, 10, 31-43. Inhelder, B . (1964). Some aspects of Piaget's genetic approach to cognition. In W . K e s s e n & C . K u d l m a n (Eds.) T h o u g h t in the y o u n g child. Chicago: T h e Society for Research in C h i l d Development.  69  Inhelder,  B . , & Piaget,  J . (1958).  T h e growth  of logical thinking from childhood to  adolescence. N e w Y o r k : Basic Books. Inhelder, B . , & Piaget, J . (1964). T h e early growth of logic in the child. N e w  York:  H u m a n i t i e s Press. Inhelder, B . , & Sinclair, H . (1969). L e a r n i n g cognitive structures. In P . M u s s e n , J . L a n g e r & M . Covington (Eds.) T r e n d s and issues in developmental psychology (pp. 2-21). N e w Y o r k : Holt, R i n e h a r t and Winston. Inhelder, B . , Sinclair, H . , & Bovet, M . (1974). L e a r n i n g and the development of cognition. Cambridge, M a s s . : H a r v a r d U n i v e r s i t y Press. J a c k s o n , G . B . (1980). Methods for integrative reviews. Review of Educational Research, 50,438-460. Kerlinger, F . N . & Pedhazur, E . J . (1973). Multiple Regression in B e h a v i o r a l Research. N e w Y o r k : Holt, R i n e h a r t and Winston, Inc. K i s t e r , M . C , & Patterson, C . J . (1980). Children's conceptions of the causes of illness: U n d e r s t a n d i n g of contagion and use of i m m a n e n t justice. C h i l d Development, 51, 839-846. K o f s k y , E . (1966). A scalogram study of classificatory development. Child Development, 37, 191-204. K u h n , D . (1972). M e c h a n i s m s of change in the developent of cognitive structures. Child Development, 43, 833-844. L a i , C . (1986). U B C S P S S X : . Statistical Package for social sciences -- Extended version release 2.0 (Under M T S ) . V a n c o u v e r : C o m p u t i n g Centre, U . B . C . Langford, W . S. (1948). P h y s i c a l illness and convalescence: J o u r n a l of Pediatrics, 33, 242-250.  T h e i r m e a n i n g to the child.  Langford, W . S. (1961). T h e child in the pediatric hospital: A d a p t a t i o n to illness hospitalization. A m e r i c a n J o u r n a l of O r t h o p s y c h i a t r y , 31, 667-684.  and  L a u r e n d e a u , M . , & P i n a r d , A . (1962). C a u s a l thinking in the child: experimental approach. N e w Y o r k : International Universities Press.  and  A  genetic  L e w i s , C . E . , L e w i s , M . A . , L o r i m e r , A . , & P a l m e r , B . B . (1977). Child-initiated care: the use of school n u r s i n g services by children in a n "adult-free" system. Pediatrics, 60, 499-507. Mechanic, D . (1964). T h e influence of mothers on their children's health attitudes  and  behavior. Pediatrics, 33, 444-453. Medinnus, G . R. (1959). Immanent, justice  in children: A review of the literature and  additional data. T h e J o u r n a l of Genetic Psychology, 94, 253-262. Meltzer, J . , Bibace, R . , & W a l s h , M . E . (1984). Children's conceptions of smoking. J o u r n a l of Pediatric Psychology, 9, 41-56. Millstein, S. G . , A d l e r , N . E . , & Irwin, C . E . (1981). Conceptions of illness  in young  70  adolescents. Pediatrics, 68, 834-839. M y e r s - V a n d o , R . , Steward, M . S., Folkins, C . H . , & Hines, P . (1979). T h e effects of congenital heart disease on cognitive development, illness causality concepts, and vulnerability. A m e r i c a n J o u r n a l of Orthopsychiatry 49, 617-625. N a g e r a , H . (1978). Children's reactions to hospitalization and illness. Child P s y c h i a t r y and H u m a n Development, 9, 3-19. N a g y , M . H . (1951). Children's ideas of the origin of illness. H e a l t h Education J o u r n a l , 9, 6-12. N a g y , M . H . (1952). Children's ideas on the activity of germs. H e a l t h Education J o u r n a l , 10, 15-20. Nag3% M . H . (1953). T h e representation of "germs" by  children. J o u r n a l of  Genetic  Psychology, 83, 227-240. Natapoff,  J . N . (1978). Children's views of health:  A developmental study.  American  J o u r n a l of Public H e a l t h , 68, 995-1000. Neuhauser, C , A m s t e r d a m , B . , H i n e s , P . , Steward, M . (1978). Children's concepts of healing: cognitive development and locus of control factors. A m e r i c a n J o u r n a l of O r t h o p s y c h i a t r y , 48, 335-341. Norusis, M . J . (1985). S P S S X A d v a n c e d Statistics Guide. New Y o r k : M c G r a w - H i l l Book Company. Pantell, R. H . , Stewart, T . J . , D i a s , J . K . , Wells, P . , & Ross, A . W . (1981). P h y s i c i a n communication with children and parents. Pediatrics, 70, 396-402. Pedhazur, E . J . (1982). Multiple Regression in B e h a v i o r a l Research (2nd ed.). N e w Y o r k : Holt, R i n e h a r t and Winston. P e r r i n , E . C , & G e r r i t y , P . S. (1981). There's a understanding of illness. Pediatrics, 67, 841-849.  demon  i n your  belly:  Children's  Peters, B . M . (1978). School-aged children's beliefs about causality of illness: A review of the literature. M a t e r n a l - C h i l d N u r s i n g J o u r n a l , 7, 143-154 Piaget, J . (1930). T h e child's conception of physical causality. London: K e g a n P a u l . Piaget, J . (1952). T h e language and thought of the child. London: Routledge and K e g a n Paul. Piaget (1952). T h e origins of intelligence in children. N e w York: International  Universities  Press. Piaget, J . (1976). J u d g m e n t and reasoning in the child. Totowa, N . J . : Littlefield, A d a m s & Co. Piaget, J . (1981). T h e child and reality. Kingsport, Tennessee: K i n g s p o r t Press, Inc. Piaget, J . , & Inhelder, B . (1969). T h e psychology of the child. N e w Y o r k : Basic Books, Inc.  71  Potter, P. C , & Roberts, M . C . (1984). Children's perceptions of chronic illness: T h e roles of disease symptoms, cognitive development, and information. J o u r n a l of Pediatric Psychology, 9, 13-25. Redpath, C . C , & Rogers, C . S. (1984). H e a l t h y young children's concepts of hospitals, medical personnel, operations, and illness. J o u r n a l of Pediatric Psychology, 9, 29-39. Simeonsson,  R . , Buckley, L . , & M o n s o n , L . (1979). Conceptions of illness causality in  hospitalized children. J o u r n a l of Pediatric Psychology, 4, 77-84. Steward, M . , & Regalbuto, G . (1975). Do doctors know what children know? A m e r i c a n J o u r n a l of Orthopsychiatry, 45, 146-149. Steward, M . S., & Steward, D . S. (1981). Children's conceptions of medical procedures. In R. Bibace and M . W a l s h (Eds.) N e w directions for child development: Children's conceptions of health, illness and bodily functions (No. 14). S a n Franscisco: Jossey-Bass. T o m l i n s o n - K e a s e y , C , Eisert, D . C , K a h l e , L . R., H a r d y - B r o w n , K . , & K e a s e y , B . (1979). T h e structure of concrete operational thought. Child Development, 50, 1153-1163. T u r i e l , E . (1969). Developmental processes in the child's moral thinking. In P . M u s s e n , J . L a n g e r , & M . Covington (Eds.) T r e n d s and issues in developmental psychology, (pp. 92-133). N e w Y o r k : Holt, R i n e h a r t and Winston. V e r n o n , D . T . , F o l e y , J . M . , Sipowicz, R. R., & S c h u l m a n , J . L . (1965). T h e psychological responses of children to hospitalization and illness: A review of the literature. Springfield, 111.: Charles C . T h o m a s . V i s i n t a i n e r , M . A . , & Wolfer, J . A . (1975). Psychological preparation for surgical pediatric patients: T h e effect on children's and parents' stress responses and adjustment. Pediatrics, 56, 187-202. W e r n e r , H . (1948). C o m p a r a t i v e psychology of mental development. N e w Y o r k : Science Editions. Whitt, J . K . , D y k s t r a , W . , & T a y l o r , C . A . (1979). Children's conceptions of illness and cognitive development: Implications for pediatric practitioners. Clinical Pediatrics, 18, 327-339.  APPENDIX A:  MATERIALS FOR PIAGETIAN TASKS  Concrete Stage Tasks Classification Simple Classification  12 a t t r i b u t e b l o c k s ( r e d , y e l l o w , b l u e , c i r c l e s , squares, t r i a n g l e s , t h i c k , t h i n , l a r g e , small)  T w o - w a y Classification  Matrix requiring classification a c c o r d i n g t o shape and c o l o u r  C l a s s Inclusion  10 wooden b l o c k s , 7 o f which were green and 3 of which were b l a c k  T h r e e - w a y Classification  Matrix requiring classification a c c o r d i n g t o shape, c o l o u r , and direction  Conservation Number  10 s m a l l green b l o c k s and 10 s m a l l black blocks  Quantity  2 p l a s t i c i n e b a l l s of approximately 5 cm. diameter each  Length  2 shoelaces - 61 cm. each  Area  2 sheets o f "8-1/2 x 11" paper and 20 s m a l l , green s e l f - a d h e s i v e c i r c l e s  Weight  2 p l a s t i c i n e b a l l s of a p p r o x i m a t e l y 5 cm. diameter each  Formal Stage Tasks Probability  3 y e l l o w , 3 green, and 3 p u r p l e beads and an envelope  Correlations  "8 x 5" c a r d w i t h 12 f a c e s w i t h blue/brown eyes and w i t h blond/brown hair  Combinations  E l e c t r o n i c box w i t h a l i g h t b u l b and 5 buttons  Proportions  P i c t u r e s of "Mr. B i g " and "Mr. S m a l l " , 10 b i g paper c l i p s , 10 s m a l l paper c l i p s  72  APPENDIX B:  S A M P L E H E A L T H QUESTIONNAIRE  73  74 Code Number  Age  Date _  CHILDREN'S HEALTH QUESTIONNAIRE 1.  What does i t mean to be healthy?  2.  What should children do to stay health^?  3.  What does i t mean to be sick?  4.  Why do c h i l d r e n get sick?  5.  Why i s i t that some children get sick and other children don't?  6.  What makes you get sick?  7.  What makes you get better?  (Robinson, Conry, & Harper, 1986)  APPENDIX C:  S A M P L E PROTOCOL FOR C O N C R E T E OPERATIONAL TASKS  .75  76 Code Number  Age  Date  CONCRETE TASKS Classification: 1-Way Classification^  Choice Shift  2-Way Classification  Choice Reason  Class Inclusion  Choice Reason  3-Way Classification^  Choice Reason  Conservation: Number  Same/More/Less Reason  Quantity (a)  Same/More/X^ess Reason Same/More/Less Reason  Length  (a)  Same/Longer/Shorter Reason  (b)  Same/Longer/Shorter Reason  Area  Same/More/Less Reason  Weight  Same/More/Less Reason  APPENDIX D:  S A M P L E PROTOCOL FOR F O R M A L OPERATIONAL TASKS  77  Code Number  Age  Date  FORMAL TASKS Probability: (Place i n an envelope 3 green, and 3 purple beads.) "What chances of getting a yellow bead i f to pick one bead from the envelope? you think so?"  3 yellow, are your you were Why do  (Let c h i l d pick one bead.) "What are your chances of getting another (name the colour drawn) bead on your 2nd t r y ? Why do you think so?  Correlations: (Present the card with the 12 faces.) "This card has 12 faces with blue or brown eyes and with blond or brown h a i r C a n you find a r e l a t i o n s h i p between h a i r colour and eye colour based on these 12 faces?" (Probe i f necessary) "What could you say about the eye colour of the blond haired people?" e t c . "What are the chances of a person being blond haired and brown eyed based on the 12 faces on the card? Why do you think so?  Combinations: (Demonstrate for the c h i l d that pressing some of the buttons on the electronic box w i l l cause the l i g h t to shine. Insert a f i l e card between the l i g h t source and the buttons so that the c h i l d cannot view which buttons are being pressed.) "Now you try and find out which buttons to press i n order to make the l i g h t come on." Probe, i f necessary, to determine what t a c t i c s are being employed. Record c h i l d ' s attempts. Proportions: (Set out the pictures of Mr. Big and Mr. Small.) "I am going to measure Mr. Big with these b i g paper c l i p s . He i s 6 big paper c l i p s t a l l . Now I am going to measure Mr. Small. He i s A b i g paper c l i p s t a l l . Let's measure the men using these small paper c l i p s . Mr. Small i s 6 small paper c l i p s t a l l . How t a l l do you think Mr. Big i s going to be i f I use these small paper c l i p s to measure him? What i s your guess? T e l l me why you think your answer i s right ?"  APPENDIX E:  MATRIX FOR TWO-WAY CLASSIFICATION  The 3 objects pictured above make a pattern. Which of me followi.-.g objects wiil go b. with the other 3 objects to complete the pattern}  79  A P P E N D I X F; MATRIX FOR THREE-WAY CLASSIFICATION  it£v"  Tht 3 objects pictured above make a pattern. Which of the following objects will jo best with the other 3 objects to complete the pattern/  80  A P P E N D I X G:  F O R M A L O P E R A T I O N A L T A S K OF C O R R E L A T I O N S  81  A P P E N D I X H : F O R M A L O P E R A T I O N A L T A S K OF PROPORTIONS  82  

Cite

Citation Scheme:

        

Citations by CSL (citeproc-js)

Usage Statistics

Country Views Downloads
United States 17 0
China 6 5
France 2 0
Latvia 2 0
South Africa 2 0
Russia 1 0
India 1 0
Canada 1 0
Hong Kong 1 0
City Views Downloads
Ashburn 10 0
Unknown 7 5
Shenzhen 5 5
Kansas City 2 0
Roodepoort 2 0
Burbank 2 0
Saint Petersburg 1 0
Mississauga 1 0
Beijing 1 0
Central District 1 0
Sunnyvale 1 0

{[{ mDataHeader[type] }]} {[{ month[type] }]} {[{ tData[type] }]}
Download Stats

Share

Embed

Customize your widget with the following options, then copy and paste the code below into the HTML of your page to embed this item in your website.
                        
                            <div id="ubcOpenCollectionsWidgetDisplay">
                            <script id="ubcOpenCollectionsWidget"
                            src="{[{embed.src}]}"
                            data-item="{[{embed.item}]}"
                            data-collection="{[{embed.collection}]}"
                            data-metadata="{[{embed.showMetadata}]}"
                            data-width="{[{embed.width}]}"
                            async >
                            </script>
                            </div>
                        
                    
IIIF logo Our image viewer uses the IIIF 2.0 standard. To load this item in other compatible viewers, use this url:
http://iiif.library.ubc.ca/presentation/dsp.831.1-0098694/manifest

Comment

Related Items