Pediatric Annals

Psychological Problems of Disabled Adolescents and Young Adults

Thomas E Strax, MD

Abstract

The psychosocial and psychosexual development of an adult appears in a succession of stages. Each of these incorporates the preceding stage and builds new framework. There can be arrest of this maturaprocess at any point from a variety of causes. disability certainly has a high potential for arrest in development.

Adolescence is a period of "storm and stress" characby biological, social, and emotional changes. Adolescents have four major developmental tasks. They must consolidate identity, achieve independence from parents, establish new love objects outside of the family, and find a vocation.

The actual time varies from culture to culture. the poor, this can be an extremely short with the adolescent becoming independent ages 15 and 18. In the middle class, adolesmight extend through college, even graduate with the individual still being controlled and by the family.1

Achieving the four major developmental tasks dura period of biological stress is extremely difficult for able-bodied individual; these tasks are even more arduous for those with a physical disability. This article will be limited to physically disabled children of normal intelligence with intact families.

The disabled individual almost always has a prolonged adolescence for which there are several reasons:

* The child has been overprotected and sheltered.

* Most growth occurs within the nuclear and extended family because experiences with peers are limited.

* The identity crisis is even more profound because of a dearth of appropriate role models.2-5

This maturation and the achievement of adolescent goals does not occur smoothly but progresses in a jerky, chaotic fashion. This causes stress, which is manifested by typical adolescent behavior such as new hair styles, musical tastes, and dress codes. Too much anxiety results in antisocial acting out behaviors, such as delinquency, truancy, sexual promiscuity, and drug abuse.

Disabled adolescents are at a great disadvantage in attempting to deal with the developmental demands of adolescence. Their limited mobility and the excessive care that they may have received can lead to passivity. In contrast, disabled adolescents may become rebellious, performing antisocial acts as a way of overcompensating for psychological passivity or turn to fantasy and denial. Depending upon their intensity and frequency, these defense mechanisms need not be pathological.6,7

To find one's identity, one must first have an intact image of one's own body, be able to fantasize different identities, and see how these roles fit. The first identity figures are parents. As the adolescent's horizons enlarge, the choice of identities goes beyond the family. The number of figures available depends upon culture, mobility, economic status, and experience. The disabled child in a wheelchair does not often go to baseball games or wander around downtown. The number of individuals a disabled child can fantasize being and still relate to reality is also limited - someone in a wheelchair cannot be a baseball player.

Tringo,8 in 1970, investigated the attitudes of nondisabled high school, college undergraduate, college graduate students, and rehabilitation workers toward 21 specific disabilities. He found that subjects with higher educational levels showed less rejection of disabled persons. There were nine possible ratings from which to choose ranging from "would marry" to "would put to death." The highest ranking brain injured type disability was epilepsy, which ranks 13 out of 21. Familiarity and experience with specific disabilities may have been responsible for the assigned ratings. Cancer, stroke, and heart disease are common in many families, and thus were accorded high ratings. Alcoholism and criminal experiences tended to have a low position in the study. Yucker, Block, and Young9 found that close personal contact with a disabled person resulted in greater acceptance of a particular disability. However, persons…

The psychosocial and psychosexual development of an adult appears in a succession of stages. Each of these incorporates the preceding stage and builds new framework. There can be arrest of this maturaprocess at any point from a variety of causes. disability certainly has a high potential for arrest in development.

Adolescence is a period of "storm and stress" characby biological, social, and emotional changes. Adolescents have four major developmental tasks. They must consolidate identity, achieve independence from parents, establish new love objects outside of the family, and find a vocation.

The actual time varies from culture to culture. the poor, this can be an extremely short with the adolescent becoming independent ages 15 and 18. In the middle class, adolesmight extend through college, even graduate with the individual still being controlled and by the family.1

Achieving the four major developmental tasks dura period of biological stress is extremely difficult for able-bodied individual; these tasks are even more arduous for those with a physical disability. This article will be limited to physically disabled children of normal intelligence with intact families.

The disabled individual almost always has a prolonged adolescence for which there are several reasons:

* The child has been overprotected and sheltered.

* Most growth occurs within the nuclear and extended family because experiences with peers are limited.

* The identity crisis is even more profound because of a dearth of appropriate role models.2-5

This maturation and the achievement of adolescent goals does not occur smoothly but progresses in a jerky, chaotic fashion. This causes stress, which is manifested by typical adolescent behavior such as new hair styles, musical tastes, and dress codes. Too much anxiety results in antisocial acting out behaviors, such as delinquency, truancy, sexual promiscuity, and drug abuse.

Disabled adolescents are at a great disadvantage in attempting to deal with the developmental demands of adolescence. Their limited mobility and the excessive care that they may have received can lead to passivity. In contrast, disabled adolescents may become rebellious, performing antisocial acts as a way of overcompensating for psychological passivity or turn to fantasy and denial. Depending upon their intensity and frequency, these defense mechanisms need not be pathological.6,7

To find one's identity, one must first have an intact image of one's own body, be able to fantasize different identities, and see how these roles fit. The first identity figures are parents. As the adolescent's horizons enlarge, the choice of identities goes beyond the family. The number of figures available depends upon culture, mobility, economic status, and experience. The disabled child in a wheelchair does not often go to baseball games or wander around downtown. The number of individuals a disabled child can fantasize being and still relate to reality is also limited - someone in a wheelchair cannot be a baseball player.

Tringo,8 in 1970, investigated the attitudes of nondisabled high school, college undergraduate, college graduate students, and rehabilitation workers toward 21 specific disabilities. He found that subjects with higher educational levels showed less rejection of disabled persons. There were nine possible ratings from which to choose ranging from "would marry" to "would put to death." The highest ranking brain injured type disability was epilepsy, which ranks 13 out of 21. Familiarity and experience with specific disabilities may have been responsible for the assigned ratings. Cancer, stroke, and heart disease are common in many families, and thus were accorded high ratings. Alcoholism and criminal experiences tended to have a low position in the study. Yucker, Block, and Young9 found that close personal contact with a disabled person resulted in greater acceptance of a particular disability. However, persons having disabled family members and professionals working with the disabled showed little change in their attitudes with increased contact. It was felt that a rehabilitation and family setting provided information which stressed the limitations of the disabled. Friedman2 studied the effects of modeling on choosing acceptable playmates among nondisabled, disabled children in wheelchairs, and facially disfigured children. He used children from the 7th to the 11th grade. Nondisabled, wheelchair bound, and facially disfigured children all modeled identically - they chose as friends nondisabled first, wheelchair bound next, and facially disfigured last of the three groups.

These studies demonstrate a reluctance of physically able-bodied children to accept the physically disabled child into their peer groups. Therefore, the disabled adolescent is deprived of a valuable tool in working out problems. Normal adolescents appear to ostracize the disabled based, in part, on lack of experience with the persons with disabilities and fear of becoming disabled. By the time physically disabled children become adolescents, they are aware of society's ideal physical image. Like their able-bodied peers, they will reject themselves. An individual's selfimage is usually based on society's norms. l0,12 We look better and more perfect in our dreams.

It is difficult to deny a physical disability when one walks toward a reflecting image or enters a crowd of people with similar disabilities. Many paraplegics and other disabled individuals with marked gait problems see themselves in their dreams as walking normally.

Independence from parents has two elements: emotional independence and financial independence. Disabled children are usually pitied and coddled more than able-bodied children, and, therefore, are much more dependent upon their parents. They are more afraid of loss of parental love and of eventual loss of their parents than are the able-bodied. Parents who encourage a certain amount of independence in ablebodied adolescents often overprotect their physically disabled adolescent.5,13

Children who have been overprotected grow into adults who feel that they need special protection. They may not have to live up to the same rules and regulations that control the lives of other family members.10,14 The combination of real and imagined needs of the physically disabled may create an infantile and immature personality.

When disabled children finally enter the outside world, schools segregate them into special classes. Peer groups will not admit them; without friends they find life extremely lonely. In an attempt to find friends and attract attention, the disabled are more prone to turn toward inappropriate behavior such as loud talking and foolish behavior. The able-bodied individual who turns to this type of behavior usually receives instant feedback from family, teachers, and peer group members. This is not the case with the physically disabled.

Children who are considered disabled by their parents and have not been admitted to peer groups have a great deal of difficulty in school. The perceptions of others coupled with their inability to be accepted within a peer group lead these children to complete withdrawal. They feel that they are inferior.

Many parents of disabled children are afraid to allow them to be integrated into society. They feel that their children can only be hurt. The parents of able-bodied children expect them to leave home eventually. This is not so with the parents of physically disabled children. These children are forever protected.

Segregation versus integration of the disabled is a difficult problem. Neither special schools nor isolated environments are advocated. Studies show that disabled children learn better when they are with a homogeneous peer group and are not exposed to the demands of a 40-pupil class which is moving at a rate they cannot handle. The problem with this type of isolation is that at some point these children must be integrated into society. Integration is difficult if it has not been occurring all along.

Able-bodied children have additional contact with the world when they start to walk and talk, between ages 1 and 2. Lessons learned during early play are needed for later maturation. By age 5 or 6, able-bodied children are ready for school and know how to make friends and play with other children. Physically disabled children may not be walking until age 5 or 6, and are, therefore, denied the outside influence of a peer group. It is agonizing for physically disabled or uncoordinated children who have trouble dancing, conversing, or participating in sports activities to join in with other teenagers.

At the onset of puberty, a child's life is centered in the family, but the focus is soon transferred to an influential peer group. Intense friendships are made first with members of the same sex and later in adolescence with members of the opposite sex. Family-centered orientation is diminished and peer values become more important. Assimilation into the peer group provides the adolescent with a vehicle for separation from the home. The earlier the entry into a peer group, the more quickly the emotional milestones needed for independence will be met.1,6,10,15

Williams,16 in 1970, discussed the alienation syndrome in adolescence. He pointed out that our society reinforces narcissistic, competitive individualism with emphasis on performance, achievement, and productivity at the expense of relationships between young people. Unless there are successful relationships both in the family and within peer groups, successful relationships in adult life cannot be established.

A fast moving, high achievement, need-oriented society does not have a place for slow individuals. It is not fashionable to have disabled friends or to slow down for someone who needs help.

Dorner,17 in his study of children with spina bifida, found that the nonhandicapped friends of preadolescents were lost during adolescence. About half of his adolescents were judged to be severely socially isolated. In his group, the more mobile spina bifida adolescents experienced less social isolation. Depression was extremely common: 31% of the girls and 15% of the boys had persistent periods of depression or suicidal ideation. Anxiety about the future was extremely common, primarily over employment, independence from the family, and the possibility of marriage.

The function of late adolescence and adulthood is to establish new love objects outside of the family and to establish a vocational goal. These functions cannot be undertaken until the adolescent has been able to:

* consolidate a personal identity;

* achieve a semblance of independence from the family; and

* gain acceptance into a peer group.3,8,10,18

Disabled individuals enter adulthood socially deprived and immature. They do not know how to approach someone of the same sex, let alone someone of the opposite sex. The social aspect of school and peer group activities has usually been absent.

In addition to the above problems, disabled individuals are outcasts who are not acceptable to society, are usually full of self-pity and egocentric ity, and have also rejected themselves.

Subconsciously, they wonder if their defective bodies will function sexually. A feeling of general physical incompetence may lead to a feeling of genital incompetence. The physically disabled are less mobile and, therefore, have less of a chance to meet and court appropriate mates. Once disabled persons have developed the emotional maturity, self-esteem, and confidence needed to find a mate, they must then deal with the problem of not being acceptable to people of the opposite sex.

In addition to the social stigmata of having a physical disability, there are some real practical problems. One study, conducted in 1977 by the Social Security Administration, found that of the 18 million disabled adults between ages 18 and 64, 40% needed some help in their activities of daily living. This assistance was usually provided by an immediate member ot the household. In half of the cases, help was being provided by a spouse or child. Only 10% had paid help, usually only for one day a week at most. Twenty-seven percent of those who needed help received none. Most found it difficult to be a lover, provider, and also a patient at the same time.19

For the disabled, finding a vocation, and with it economic independence, is extremely difficult if not impossible; many employees with disabilities are turned down simply because they are physically disabled. Of 7 handicapped individuals of employment age only 1.5 are employed. This number excludes those in institutions or in military service. Women constitute 51% of this group.

Employers give many reasons for not considering handicapped people, usually based on myths such as "our insurance rates will skyrocket" or "we would have to treat them differently, giving them special privileges" or "our present employees would not accept them." These statements should be evaluated in light of a study conducted by Dupont, which has had extensive programs for hiring handicapped employees. They found no increase in the workmen's compensation costs as a result of hiring the handicapped. One study, by the US Chamber of Commerce and the National Association of Manufacturers, found that 90% of 279 companies experienced no increase in their insurance costs as a result of hiring handicapped individuals. Adjustments to the workplace have been minimal in most companies that hire the handicapped. These adjustments usually consist of simple changes, such as lowered work space, special desks, entrance ramps, or doorway modification. Dupont found that the disabled are safe workers; 96% of the 1,400 handicapped employees had better safety records than their ablebodied counterparts. They did not find that their disabled employees wanted to be treated differently than the able-bodied employees. The disabled employee was competitive with the unimpaired worker in productivity, attendance, job stability, safety, and cost of employment. Seventy-nine percent of the disabled employees had better attendance records, and 93% had average or better turnover rates. 20

In summary, for the disabled, adolescence and young adulthood is a period of self-examination and rejection. It is hoped that this period will be followed by a healthier, more realistic acceptance of themselves, their handicaps, limitations, and strengths. This hope can be realized with a supportive family unit, the understanding of peers, and adequate medical, social, and vocational services.

REFERENCES

1. Oerttinger K; Normal Adolescence. New York, Charles Scribner and Sons. 1968.

2. Friedman RS : Modeling behavior of nondisabled and disabled adolescents based upon social preference for and similarity to nondisabled and disabled models, dissertation. Hofstra University. Hempstead. Long Island, NY. 1974.

3. Waldhorn HK: Rehabilation the Physically Handicapped Adolescent New York. John Day. 1972.

4. Marrim HP: Parental response to handicapped children. Dev Med Child Neurol 1975; 17:251-252.

5. Richmond IB: The family and the handicapped child. Clinical Proceedings. Children's Hospital National Medical Center 1971; 25:156-164.

6. Freeman RD. Psychiatric problems in adolescents with cerebral palsy. Dev Med Child Neurol 1970: 12:64.

7. Domer S: Psychological and social problems of families of adolescent spina bifida patients: A preliminary report. Dev Med Child Neurol 1971; 29(suppl):24-26.

8. Tringn J: The hierarchy of preference toward disability groups. J Special Ed 1970; 4:295-106.

9. Yunker HE. Block JR. Young JH: The Measurement of Attitudes Toward Disabled Persons. New York. Albertson. 1970.

10. Brutten M. Richardson S. Manuel C: Something's Wrong with My Child. New York. Harcourt Brace Jovanovich, Inc. 1973.

11. Schooler JC: (ed): Current Issues in Adolescent Psychiatry. New York. Brunner-Mazel. 1973.

12. Seidel UP. Chadwick OFD. Rutter M : Psychological disorders in crippled children. A comparative study of children with and without brain damage. Dev Med Child Neurol 1975; 17:561-571.

13. Caplan G. Lebowitz S: Adolescence. Psychosis and Perspective. New York. Basic Books. Inc. 1969.

14. Grunberg: L. Grinberg R: Pathological aspects of identity in adolescence. Contemporary Psychoanalysis 1974; 10:27-40.

15. Blaine CB Jr: Meeting: the challenge of today's adolescent. Delaware Medical Journal 1971; 45:191-196.

16. Williams SS: Alienation ol youth as reflected on the hippie movement. J Am Acad Child Psychiatry 1970; 9:251.

17. Dornet S: The relationship of physical handicap to stress in families with an adolescent with spina bifida. Dev Med Chid Neurol 1975; 17:765-776.

18. Centers L. Centers R: Peer group attitudes toward the amputee child. J Sci Psychol 1963: 61:127-131.

19. Hershkowitz: M: One in Eleven Handicapped Adults: A Survey Based on 1970 Census Data. Government Printing Office. 1977.

10. Wolfe J: Disability is no. Handicap for Dupont. Presidents Committee on Employment of the Handicapped, 1974.

10.3928/0090-4481-19881201-07

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