Thomas J. Huberty. Department of Counseling ... Neurology, and Pediatric Pulmonary Clinics at Riley Hospital, Indiana University Medical Center, the Medical ...
Journal ofPtdiatric Psychology. Vol. 18, No. 4. 1993, pp. 467-4SO
Development of the Child Attitude Toward Illness Scale1 Joan K. Austin2 Department of Psychiatric!Mental Health, School of Nursing, Indiana University
Department of Counseling and Educational Psychology, School of Education. Indiana University Received January 22. 1992; accepted August 12. 1992
Described the development of the Child Attitude Toward Illness Scale (CATIS), a short self-report instrument designed to provide a systematic assessment of how favorably or unfavorably children feel about having a chronic physical condition. Subjects were children (N = 269), ages 8-12 years, who had either epilepsy (n = 136) or asthma (n = 133). Results of confirmatory factor analysis and predicted relationships with scores on the Child Behavior Checklist and the Piers-Harris Children's Self-Concept Scale provided support for construct validity of the scale. Good internal consistency and test—retest reliability were also found. K E Y W O R D S : attitudes toward illness; attitude measurement; epilepsy; asthma.
•This research was supported by Grant No. R01 NS22416 awarded to Joan K. Austin by the National Institute of Neurological Disorders and Stroke. The authors thank the children and parents who participated in the research and acknowledge nuisance from the following: the Epilepsy, Pediatric Neurology, and Pediatric Pulmonary Clinics at Riley Hospital, Indiana University Medical Center, the Medical Research Committee of Methodist Hospital, Indianapolis; and the Pediatric Neurology and Pediatric Pulmonary Clinics at Methodist Hospital, Indianapolis. Toe following persons are acknowledged for their assistance: A. McBride, A. McNelis, M. S. Smith, J. CritchfieM, J. L. Austin, M. Zierdt, J. Zander. M. Michel, K. Thompson, E. Pencek, D . Strode, P. Pickering, J. Iacobsen, K. Gerkenstecker, B. Hale, O. Markand, D . Dunn, B. Garg, H. Eigen, A. Sorners, M. Wisen, J. Schaeffer, D . McDaniels, and J. Schecter. 2 A11 correspondence should be sent to Joan K. Austin, Indiana University School of Nursing, 1111 Middle Drive, Indianapolis, Indiana 46202. 467 0l46-S69J/9J/M0O-O4«7JO7.O(VO C 1993 Plenum PuWBtmq CorpmJoa
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Chronic illness presents may challenges for school-aged children and their families. Research has indicated that children with a chronic illness are at risk for the development of a variety of difficulties, such as behavior problems, poor selfconcept, and social withdrawal (Austin, 1989; Breslau, 1985; Rutter, Graham, & Yule, 1970). Recentresearchhas focused on identifying factors that account for this increased prevalence of mental health problems. One major approach in pediatric psychology is to view the chronic illness as a stressor for the family and use family stress theory to frame the research (Roberts & Wallander, 1992). Within family stress theory, a major concept proposed to influence coping and adaptation to chronic illness is the meaning that the illness holds for the family members (McCubbin & Patterson, 1983; Patterson, 1988). According to Patterson (1988), if family members' perceptions about the child's illness are primarily negative (e.g., the illness is viewed as a disaster), these negative feelings can contribute to the demands or stressors already placed on the family by the illness. If, on the other hand, family members' perceptions about the child's illness include positive feelings (e.g., the illness is viewed as making the family closer), these positive feelings can serve as a resource to help the family successfully adapt to the illness. Most research on adaptation to childhood chronic illness has focused on parents' perceptions and feelings about their children's illness and has failed to include perceptions about the illness from the children. Yet, based on the Double ABCX Model (McCubbin & Patterson, 1983) and literature on chronic childhood illness (Lefebvre, 1983), how children feel about having a chronic illness is believed to play a significant role in how they cope with and ultimately adapt to the chronic condition. Children who view their illness as making them different or less worthy than their peers are believed to withdraw and become more socially isolated (Lefebvre, 1983). In addition, Murphy (1974) found that children who were able to accentuate the positive aspects of their condition had a more favorable recovery from illness. Children's feelings about having a chronic condition are thought to be an especially important factor influencing adjustment when the condition has an attached stigma. For example, Bagley (1972) hypothesized that the stigma associated with epilepsy is the major reason for the high incidence of mental health problems found in children with epilepsy. Children who have negative feelings about having the chronic condition are more likely to engage in maladaptive coping behaviors and subsequently have a more negative adaptation to the condition than children who have positive feelings about having a chronic illness (Austin, Patterson, & Huberty, 1991). Despite the support for the importance of children's attitudes in their adjustment, no instruments could be found that measured children's favorable or unfavorable feelings (i.e., attitude) toward having a chronic physical condition. Therefore, a short self-report instrument, the Child Attitude Toward Illness Scale
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(CATIS), was developed to meet this need. It is the purpose of this report to describe the development, testing, and validation of the CATIS in two studies with samples of school-aged children with either epilepsy or asthma. Study 1 was carried out to obtain information about the internal consistency reliability of the CATIS. A second purpose was to examine the test-retest reliability from measurements taken approximately 2 weeks apart. Study 2 provided additional information about internal consistency reliability and preliminary information on construct validity. Construct validity was examined using confirmatory factor analysis and the testing of four hypothesized relationships among variables that would support the construct validity of the scale. The first hypothesis addressed differences in attitudes between children with epilepsy and asthma. Because children with epilepsy have been found to have more behavior problems and more social withdrawal than children with asthma, it was anticipated that children with epilepsy would have more negative attitudes toward having epilepsy than children with asthma would have toward having asthma. Our first hypothesis was that children with epilepsy will have more negative attitudes than children with asthma. The second and third hypotheses were based on family stress theory, especially the Double ABCX Model (McCubbin & Patterson, 1983). In that model the factors that predict positive adaptation to a chronic stressor, such as a chronic illness in a child, are decreased demands on the family, increased family adaptive resources, positive family definition of the stressor (attitudes), and adaptive coping behaviors. Consequently, it was anticipated that there would be a positive relationship between children's attitudes toward the health condition and adaptation. Our second hypothesis was that there will be a negative correlation between positive attitudes and children's behavior problems. Our third hypothesis was that there will be a negative correlation between positive attitudes and depression. The fourth predicted relationship was based on Massie's (1985) contention that a chronic illness in a child becomes melded into the child's identity. From this it was anticipated that feelings associated with having a chronic health condition would be positively correlated with feelings about self. Our fourth hypothesis was that there will be a correlation between positive attitudes and positive self-concept. The final predicted relationship focused on the association between the frequency of illness symptoms and attitudes. It was anticipated that less effective symptom control (e.g., more frequent seizures) would be associated with more negative attitudes about the condition because of the increased disruptions in the child's life. For example, illness symptoms can limit activities, increase visits to the physician, and increase medication levels. Also increases in episodes of illness can lead to negative reactions from other children. Our fifth hypothesis
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was that frequency of illness episodes will be negatively correlated with positive attitudes. The final relationships analyzed were more exploratory in nature and no directional hypotheses were specified. Relationships between attitudes and gender, age, age at onset of the illness, and socioeconomic status (SES) were investigated.
ITEM DEVELOPMENT
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The CATIS was designed to be a summated rating scale that measures children's feelings about having a chronic condition. We labeled the latent construct "attitude" because most contemporary social psychologists agree that the evaluative aspect (favorable-unfavorable) is the characteristic attribute of attitudes (Ajzen, 1988; Ajzen & Fishbein, 1980; Fishbein & Ajzen, 1975). Based on the conceptualization of attitude as a unidimensional construct (Fishbein & Ajzen, 1975) that reflects a positive or negative evaluation of an entity, items were constructed that measured how favorably or unfavorably children felt about having a chronic health condition. Initial items were generated by the authors based on the literature and on results from past research with chronically ill children and their parents (Austin, McBride, & Davis, 1984; Austin et al., 1991). Items were developed that measured children's feelings directly by asking them to rate their feelings about having the condition using bipolar adjectives (e.g., good to bad, fair to unfair, and sad to happy). A 5-point response format was used (e.g., very bad, a little bad, not sure, a little good, and very good). Items were also developed that measured feelings about having the condition. These items indirectly asked the children to rate how often (e.g., never to very often) they had feelings that would indicate positive or negative evaluations associated with having the condition. For example, the children were asked how often they felt that their chronic condition kept them from doing things they liked to do or made them feel different from other children, using the response format never, not often, sometimes, often, and very often. Sixteen items were developed at a reading level appropriate for an instrument that could be completed independently by children ages 8 through 12 years (i.e., about third-grade level). Because we were concerned about the children's consistency in responding to the items, one item (the first item in Table I) was repeated in the questionnaire, but with a reversal in the direction of the responses (i.e., very good to very bad the first time and very bad to very good the second time). The addition of the repeated item brought the total of items on the scale to 17.
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STUDY 1 Methods Subjects Subjects in tbe first study were 50 children (25 with epilepsy and 25 with asthma) ages 8 through 12 years. The mean age for the sample was 9.9 years. Criteria for selection into the study were that the children had had their condition for at least 1 year, bad been receiving daily medication for at least 1 year, had no other chronic conditions, and had an IQ of at least 70. No children were hospitalized at the time of data collection. The convenience sample was from outpatient clinics at one large medical center. All families approached for Study 1 agreed to participate.
The research was approved by tbe Institutional Review Boards of all institutions where data were collected for both studies. Informed consent was obtained from both parents and children. Before children were approached about being in the study, parents were informed about the study and asked for permission for the children to be asked about participation. Children were given $4 and parents were given $10 as incentive fees for their participation. The 17-item version of the CATIS was administered at two points in time, approximately 2 weeks apart. After the questionnaires were completed independently, children were asked questions to determine if they understood tbe items; these verbal responses were then compared with their written responses. For example, they were asked, "What was this question asking?", "Were any of the questions hard to understand?", and "What were you thinking about when you circled this answer?" Results From the open-ended questions, children were found to be able to discriminate among the 5 points on most of the response scales. The response scale using the terms lucky and unlucky, however, was found problematic. Even though children were able to understand what "being lucky" meant in a game, they were not able to connect "luck" with having an illness. This item was deleted. Intraquestionnaire Reliability The children were moderately consistent in their responses to the repeated item with the reversed response formats, with correlations between the two versions of the item being .51 at Time 1 and .62 at Time 2.
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Procedure
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Internal Consistency Reliability Internal consistency reliability was determined for responses at both administrations. One of the repeated items was omitted prior to the analysis of internal consistency reliability. Three additional items were dropped because they decreased the coefficient alpha. The coefficient alpha for die remaining items was .77 at Time 1 and .82 at Time 2. Tabte I. Lambda Values, I Values, aod Corrected Item-Total Correlations for CATIS*
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1. How good or bad do you feel it is that you have ?* (very good, a little good, not sure, a little bad, very bad) 2. How fair is it that you have ?* (very fair, a little fair, not sue, t little unfair, very unfair) 3. How happy or sad is it for you to have ? (very sad, a little sad, not sure, a little happy, very happy) 4. How bad or good do you feel it a to have ?* (very good, a little good, not sure, a little bad, very bad) 5. How often do you feel that your is your fault?* (never, not often, sometimes, often, very often) 6. How often do you feel that your keeps you from doing thing you like to do? (very often, often, sometimes, not often, never) 7. How often do you feel that you will always be tick?* (never, not often, sometimes, often, very often) 8. How often do you feel that your keeps you from starting new things? (very often, often, sometimes, not often, never) 9. How often do you feel different from others because of your ?* (never, DO* often, sometimes, often, very often) 10. How often do you feel bad because you have ? (very often, often, sometimes, not often, never) 11. How often do you feel sad about being lick?* (never, noc often, sometimes, often, very often) 12. How often do you feel happy even though you have (never, not often, sometimes, often, very often) 13. How often do you feel just as good as other Idas your age even though you have ?* (very often, often, sometimes, not often, never)
Lambda
t
Corrected item-total correlation
.59
8.1
.48
.46
5.7
.32
.59
8.1
.45
.38
5.4
.31
.56
7.2
.38
.68
7.9
.44
.58
7.0
.38
.64
8.0
.49
.82
10.2
.54
.85
11.2
.59
.76
10.0
.53
.32
3.9
.27
.46
5.2
.33
*Tbe chronic condition is placed in the blank area (e.g., asthma, seizures). Ratings are on 5-point scales. To scote, reverse items indicated and sum, then divide total by 13. 'Reversed for coding.
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Test-retest Reliability To examine test-retest reliability a total score was calculated. Items 1 , 2 , 4 , 5, 7, 9, 11, and 13 (Table I) were recoded so that 5 reflected a strongly positive attitude and 1 reflected a strongly negative attitude. The scores from the 13 items were summed and divided by the number of items or 13, so the total score would range between 1 and 5. A Pearson correlation coefficient was calculated between total scores at Time 1 and Time 2. The correlation was .80 (p < .001), which indicated good test-retest reliability. The difference between means at Time 1 (M = 3.09, SD = 0.65) and Time 2 (M = 3.30, SD = 0.75) was statistically significant, r(47) = 3 . 1 , p s .01, with scores slightly higher at Time 2. This increase in scores might be a result of a practice or familiarity effect.
Methods Subjects The sample was 269 children (136 with epilepsy and 133 with asthma) who were participants in a larger study on adaptation to chronic childhood illness. Criteria for inclusion were the same as for Study 1. Approximately 85% of the subjects were obtained from outpatient clinics at two large midwestern medical centers and about 15% from private physicians. Approximately 2% of the families approached to be in the study declined because of the time involved. The majority of the sample was composed of children either from outpatient clinics at two large medical center clinics or from the private practices of the specialists in these clinics. Because the children were referred to specialists for their medical care, it is likely that their medical conditions were more severe than children with asthma or epilepsy being treated by pediatricians or general family physicians. Furthermore, their health care was generally of the highest quality and was similar across subjects. The epilepsy sample was almost evenly divided between girls (n = 66) and boys (n = 70); the asthma sample had fewer girls (n = 46) than boys (n = 87). The children ranged in age from 8 to 12 years (M = 10.4 years, SD = 1.6). Socioeconomic status was measured using a scale developed by Green (1970) where mother's education and occupation of head of household are combined to obtain an overall score. The scores on the SES scale were similar for both samples. A SES score of 59 is reflective of a mother with 1 year of college and a head of household that is in a midlevel management position. Age at onset of the illness was also measured to the nearest year. Children with asthma had a signifi-
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STUDY 2
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Austin and Huberty Table II. Descriptive Statistics for CATIS ind Correlation* with Other Variables Epilepsy n = 136)
Child Attitude (CATIS)« Age at illness onset Socioeconomic status Behavior problems Mother's rating Father's rating* Depression Mother's raring Father's rating* Self-concept Frequency of illness episodes (1-8 scale)
Asthma ( n - 133)
M
SD
M
SD
Correlation with CATIS
3.2 5.1 59.4
0.6 2.0 7.8
3.4 3.1 59.5
0.7 2.8 8.4
.01 .15'
63.4 61.0
11.0 11.7
60.3 59.4
11.0 10.4
-.22/ -.43/
63.4 60.7 52.7 3.2
8.8 7.9 11.2 2.0
61.3 60.2 58.2 5.3
8.2 6.8 9.6 1.6
-.23/ -.32/ .48/ -.19" -.16*
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'Higher score indicates a more positive attitude/self-concept. •Epilepsy (n ~ 76) and asthma (n » 67). 'Epilepsy sample. 'Asthma sample. •p < .05. fp< .01.
cantly younger age of onset than the children with epilepsy, the average age being 5.1 years for the epilepsy sample and 3.1 years for the asthma sample, r(267) = 2.72, p < .01 (Table II). Procedure
The 13-item CATIS scale with no items repeated was administered one time as a part of a larger study on child and family adaptation to childhood illness. Even though children completed the questionnaire independently, an interviewer was available if the children had any questions. Other Measures As a part of the larger study, data were also collected on variables that could be used to investigate the construct validity of the CATIS. Child behavior problems and depression were measured by mothers' (n = 261) and fathers' (n = 143) ratings on the Child Behavior Checklist (CBCL; Achenbach & Edelbrock, 1983) a highly reliable and valid 118-item instrument on which parents rate the behavior of their children. Scores were converted to T scores using the norms for age and gender established by Achenbach and Edelbrock. Self-concept was measured using the total score on the Piers-Harris Children's Self-Concept Scale (PH; Piers, 1984) completed by the children. The PH
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is an 80-item scale that measures children's perceptions of themselves; it has been found to have good reliability and validity in past research (Piers, 1984). Scores were also converted to T scores based on norms presented by Piers. Seizure and asthma frequency were obtained from mothers and coded as follows: 1 = no episodes for 1 year or more; 2 = no episodes for 6 months to 1 year, 3 = no episodes for 3 months to 6 months; 4 = no episodes for 1 month to 3 months; 5 = 1 to 9 episodes in past month; 6 = 10 to 16 episodes in the past month; 7 = 20 to 29 episodes in the past month; and 8 = 30 or more episodes in the past month.
Results Reliability
Validity Confirmatory Factor Analysis. Confirmatory factor analysis was carried out using the measurement model of the LISREL VI computer program to determine if the scale had only one dimension as planned. The measurement model specifies how hypothetical constructs are measured in terms of observed variables and is used to examine the validity of instruments (Bagozzi, 1981; Long, 1983). The chi-square statistic was significant, x*(65, N = 262) = 250.87, p < .01, and the root mean square residual was 0.129. Because chi-square is sensitive to sample size and departures from assumptions are difficult to avoid, it is difficult to achieve a chi-square that is not statistically significant (Long, 1983). Consequently, fit should be examined using other criteria (Boyd, Frey, & Aaronson, 1988; Long, 1983). A good fit for a one-factor solution was found based on criteria described by Boyd, et al. (1988). The goodness-of-fit index (GFI), which is a measure of the relative amount of variance and covariance accounted for by the factor, was .86. The coefficient of determination, which is an estimate of the proportion of variance accounted for by the factor, was .53. In addition, the t values, which test the relationship between each item and the latent variable, were all over 2.0, indicating a good fit (Boyd et al., 1988). Lambda values,
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The coefficient alpha for the total scale was .80. Corrected item-to-total score correlations ranged between .27 and .59 (see Table I). No items were dropped because doing so decreased the coefficient alpha. To determine if younger children were less consistent in their responses, coefficient alpha was computed separately on two subsamples based on age. Adequate internal consistency reliability was found both for those children less than 11 years (n = 165, a = .74) and for those age 11 years or over (n = 100, a = .86).
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which are viewed as factor loadings, ranged from .33 to .84. See Table I for / values and lambda values. In general, results supported one unitary construct in the scale. Sample Scores on Other Measures. Based on norms for the CBCL (Achenbach & Edelbrock, 1983) for total behavior problems and depression, children in both samples were experiencing more problems than children from the general population. The mean for the mothers' ratings of 63.4 for the epilepsy sample is at the cutoff for the clinical range (T > 63) and is clearly above the range for normal behavior (i.e., mean was at the 90th percentile for the general population). Approximately 48% of the children with epilepsy had T scores above 63 based on the mothers' ratings. Scores for the fathers' ratings on the CBCL for the epilepsy sample, though lower, are still approximately 1 standard deviation above the mean for the general population (i.e., T = 50). In the asthma sample, the mean T scores for the behavior problems and depression are also approximately 1 standard deviation above the mean for the standardization norms. In addition, approximately 35% of the children with asthma had T scores above the clinical cutoff of 63 based on the mothers' ratings. Furthermore, based on the mothers' ratings, children with epilepsy were experiencing significantly more behavior problems, r(260) = 2.3, p < .025, and more depression, /(260) = 2.02, p < .05, than children with asthma. Using the norms for self-concept established by Piers (1984) for the PH, the mean T scores for children's total scores were well within 1 standard deviation of the mean for the general population. These results indicate that children in both samples had self-concepts similar to children in the general population. Children with asthma were having more frequent illness episodes (M = 5.2, SD = 1.5 [1 to 9 episodes per month category]) than the children with epilepsy (M = 3.2, SD = 2.0 [seizure-free for 3 months category]), r(267) = 9.55, p < .001. Construct Validity. The total attitude score was calculated using the same procedure as described in Study 1 with higher scores indicating more positive attitudes. All hypothesized relationships were in the predicted directions and provided support for the construct validity of the scale. The hypothesis that children with epilepsy would have more negative attitudes toward having epilepsy than children with asthma would have toward having asthma was supported. Children with epilepsy were found to have significantly lower scores on the CATIS (fit = 3.21, SD = 0.68) than children with asthma (M = 3.44, SD = 0.64), r(267) = 2.72, p < .008. Differences between the groups were significant even when age, age at onset, and frequency of illness episodes were controlled using analysis of covariance. As hypothesized, child attitude was significantly negatively correlated with both measures of psychosocial adaptation, depression, and behavior problems. This was true for both mothers' and fathers' ratings. See Table II for correlations.
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DISCUSSION Results of this preliminary step in the development of the Child Attitude Toward Illness Scale (CATIS) are encouraging. There is evidence for internal consistency reliability in both studies. Evidence .for test-retest reliability over a 2-week period was also found in Study 1. Further assessment of test-retest reliability is desirable,however, because the sample for Study 1 was small. InStudy 2 attitude scores were not found to vary by gender, age, or age of onset of the illness. Although the correlation with socioeconomic status was statistically significant, the magnitude was very low and minimal variance was accounted for. Overall, the findings in Study 2 lend support for the construct validity of the CATIS for the measurement of children's attitudes toward having a chronic health condition. As expected, children with epilepsy have more negative attitudes than children with asthma. These results were expected both because of the stigma that is associated with epilepsy (Bagley, 1972) and because children with epilepsy have more behavioral problems, more social withdrawal, and more anxiety than children with asthma (Austin, 1989). Likewise, significant negative correlations between children's attitudes and parents' ratings of behavior problems and depression were found and provide support for the validity of the scale. The direction of effects between attitudes and psychosocial adaptation is not known and cannot be specified from these data. Most likely there is a circular feedback loop where positive attitudes about having the condition help to maintain a positive adjustment; this positive adjustment, in turn, contributes to a positive attitude about having the condition. Positive attitudes toward having the condition could be viewed as one factor associated with better outcomes in chronically ill children. Positive attitudes toward an illness could also be viewed
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The hypothesis that attitude scores and self-concept scores would be positively correlated was also supported. The correlation between the total CATIS score and the total score on the PH (r = .48) was the highest of all correlations. The final hypothesis that there would be a low negative correlation between child attitude and frequency of illness episodes was also supported both forcpilepsy (r = - . 19, p = .029) and, to a lesser degree for asthma (r = - . 16, p = .070). Relationships with Other Variables. There was no significant difference between scores for girls (M = 3.31, n = 112) and boys (M = 3.34, n = 157) on the CATIS. Furthermore, no significant relationships were found between illness attitudes and age of child or age at onset of the illness. A low correlation, however, was found between attitudes and SES (r = .15, p < .05), indicating that the more positive the attitudes the higher the SES (see Table II). Although significant, the amount of variance accounted for is minimal (2%).
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from a different perspective, that is, the child may not feel that it is good to have a chronic illness, but that she or he is not significantly negatively affected by it. The strong relationship between children's attitudes and self-concept also provides support for the construct validity of the instrument. This relationship provides support for Massie's (1985) contention that long-term chronic illness in childhood becomes a part of one's identity. It should also be noted that the average length of time since onset was approximately 5 years for the epilepsy sample and approximately 7 years for the asthma sample. In this sample feelings about the chronic condition were related to feelings about the self. The final hypothesized relationships between children's attitudes toward having the condition and frequency of illness episodes are supported for both the epilepsy and asthma samples. The magnitude of the correlations was expected to be low, however, because past research has consistently found a weak relationship between severity of the illness and child adaptation (Drotar & Bush, 1985). In addition, past research on parent adjustment to epilepsy also indicated that perception of seizure control was a stronger predictor of parent adaptation to childhood epilepsy than the actual number of seizures the child was having (Austin et al., 1984). Past experience with frequency of illness episodes might influence feelings and perceptions. For example, if the child has been experiencing no or rare illness episodes, then an increase to monthly episodes would be perceived as negative. On the other hand, if a chijd had been experiencing weekly illness episodes, a decrease to monthly episodes would be viewed as positive. Certainly more work is needed to further develop the scale. Three of the items (i.e., 2, 4, and 12) have corrected item-to-total correlations below .33. If these remain low in future research, these items may need to be revised or dropped. Cross-validation is also needed with different samples of chronically ill children to determine if the findings are valid and reliable for these samples. It might be that because epilepsy and asthma are both episodic conditions where symptom-free periods are interrupted by sometimes embarrassing and frightening episodes, feelings about having these conditions are different than for other chronic illnesses. In this study the ratings of behavior problems and depression were obtained from parents. In future research it would be important to compare the child's response on the CATIS to self-report measures of behavior problems and depression to determine if therelationshipsare similar. The instrument could be further validated by administering it before and after interventions to change children's attitudes toward their illness. The significant increase in scores found between Time 1 and Time 2 in the first study, however, underscores the need for control subjects when the CATIS is used in an intervention study. Even though the CATIS was originally developed for use in research with children, with further development it appears to have potential for use in the clinical setting. Therelationshipsfound between attitudes and measures of psy-
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chosocial adaptation in this study suggest that it is important to be able to assess how children feel about having a chronic physical condition. The CATIS provides a short self-report scale that can be used in the clinical setting to assess children's attitudes about having a chronic medical condition. For example, nurses and health psychologists could use the children's responses to the items as a starting point for discussions about their feelings in relation to their illness. The CATIS could also be used to determine if educational programs designed to help children cope with chronic conditions change these feelings.
REFERENCES
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Achenbach, T. M., & Edelbrock, C. (1983). Manual for the child behavior checklist and revised child behavior profile. Burlington: University of Vermont Department of Psychiatry. Ajzen, I. (1988). Attitudes, personality, and behavior. Chicago, IL; Dorsey. Ajzen, I., St. Fishbein, M. (1980). Understanding attitudes and predicting social behavior. Englewood Cliffs, NJ: Prentice-Hall. Austin, J. K. (1989). Comparison of child adaptation to epilepsy and asthma. Journal of Child and Adolescent Psychiatric and Mental Health Nursing, 2, 139-144. Austin, J. K , McBride, A. B., & Davis, H. W. (1984). Parental attitude and adjustment to childhood epilepsy. Nursing Research, 33, 92-96. Austin, J. K., Patterson, J. M., St. Huberty, T. J. (1991). Development of the Coping Health Inventory for Children. Journal qfPediatric Nursing, 6, 166-174. Bagley, C. (1972). Social prejudice and the adjustment of peqple with epilepsy. Epilepsia. 13. 33-45. Bagozzi, R. P. (1981). An examination of the validity of two models of attitude. Multtvariate Behavioral Research. 13. 323-359. Boyd, C. J., Frey, M. A.,
