JOURNAL OF ADOLESCENT HEALTH 2003;32:456 458

ADOLESCENT HEALTH BRIEF

Factors Associated With Self-Esteem in Preadolescents and Adolescents With Cerebral Palsy
JANEEN C. MANUEL, Ph.D., RAJESH BALKRISHNAN, Ph.D.,
FABIAN CAMACHO, M.S., M.A., BETH PATERSON SMITH, Ph.D., AND
L. ANDREW KOMAN, M.D.

Abstract: Predictors of self-esteem were examined in 50

pre-adolescents and adolescents with cerebral palsy. On
average, self-esteem was high, although 30% scored below a cut-point for low self-esteem. Self-esteem was
bivariately associated with female gender, better physician-assessed functional ability, greater perception of the
impact of the disability, and higher perceived parent
overprotectiveness. In a multivariate model, only perceived impact of the disability remained significant.
Society for Adolescent Medicine, 2003

previous literature, we hypothesized that: (a) youth

with cerebral palsy would have similar self-esteem
scores as samples of non-disabled youth; (b) youthperceived disability, but not physician-rated severity
and functional status, would be associated with
decreased self-esteem; and (c) higher maternal optimism, more social participation, a more positive
perception of the impact of the disability, and less
perception of parental overprotection would predict
increased self-esteem.

KEY WORDS:

Adaptation
Adolescents
Cerebral palsy
Disability
Self-esteem

Throughout adolescence, young people develop a

less dependent relationship with parents, a greater
reliance on their peer group, and a greater emphasis
on education and career development [1]. Physical
disabilities like cerebral palsy may have an impact on
these events, with resulting reduction in self-esteem.
This study explored the self-esteem in pre-adolescents and adolescents with cerebral palsy. Based on

From the Department of Public Health Sciences (J.C.M., R.B., F.C.)

and the Department of Orthopaedic Surgery (B.P.S., L.A.K.), Wake
Forest University Health Sciences, Winston-Salem, North Carolina.
Address correspondence to: Janeen Manuel, Ph.D., Wake Forest
University Health Sciences, Department of Public Health Sciences,
Medical Center Blvd., Winston-Salem, NC 27157. E-mail:
jmanuel@wfubmc.edu.
Manuscript accepted November 30, 2002.
1054-139X/03/$see front matter
doi:10.1016/S1054-139X(03)00050-8

Methods
Procedures
After obtaining Institutional Review Board approval,
we screened pre-adolescents and adolescents (ages
9 18 years) with cerebral palsy (CP) whose parents
were participating in an on-going study of cerebral
palsy outcomes at a private orthopaedic clinic. CP
was defined as a nonprogressive injury to the developing central nervous system producing spasticity,
motor dysfunction, movement disorders, weakness,
and/or impaired sensitivity. Seventy-four of the children were thought to have adequate mental and
communication ability to understand the questionnaires (i.e., functional ability scores of at least 5 on
the communication and social cognition subscale
items of the Functional Independence Measure for
Children (WeeFIM)) [2]. However, owing to time
constraints and missed appointments, only 50 (68%)
were approached, all of whom agreed to participate.
There were no differences in demographic characteristics in participants vs. eligible nonparticipants ex Society for Adolescent Medicine, 2003
Published by Elsevier Inc., 360 Park Avenue South, New York, NY 10010

June 2003

SELF-ESTEEM AND CEREBRAL PALSY

457

Table 1. Adolescent and Maternal Characteristics and Their Relationship to Adolescent Self-Esteem
Characteristic
Physician-assessed CP severity
Physician-assessed functional status
Social participation
# close friends
# activities
# chores
Adolescent disability perception
Perceived disability severitya
Perceived impact of disability
Perceived parent overprotectivenessb
Maternal optimism

Mean (SD)

Range (Possible Range)

1.7 (.54)
115.3 (17.28)

13 (13)
61126 (18 126)

.44
.07*

7.0 (5.09)
1.5 (.93)
2.2 (.82)

120
1 4
13

.10
.05
.17

1.9 (.56)
11.0 (1.63)
2.7 (.71)
22.0 (3.28)

1 4 (1 4)
8 16 (4 16)
1 4 (1 4)
1531 (0 32)

1.03
1.39***
2.06**
.22

Note: Values for beta derived from univariate linear regression with Rosenberg Self-Esteem scores as the dependent variable.
* p .05; ** p .001; *** p .0001.
a
Based on a scale from 1 (not at all disabled) to 4 (highly disabled).
b
Based on a scale from 1 (strongly agree that parent is very overprotective) to 4 (strongly disagree that parent is very
overprotective).

cept that the latter tended to be younger (mean age

12 years vs. 13 years in participants).
Participants completed questionnaires in a quiet
area away from parents. In 17 cases, the questions
were read aloud by a research assistant to insure
understanding. Demographic, CP severity/functional status scores, and maternal optimism information were obtained from the larger study.
Subjects
Subjects ranged in age from 9 18 years (M 13
years; SD 3.02), and about half (52%) were male.
About 70% were white; 26% were African-American
(4% indicated other). Fifty-seven percent had diplegia, 27% had hemiplegia, 14% had quadriplegia, and
2% monoplegia. About half (49%) came from families
reporting incomes of less than $40,000/year, and
most mothers reported being high school graduates
or more (90%).
Measures
The Rosenberg Self-Esteem scale (RSE) [3] assessed
self-esteem. This measure and the WeeFIM [2] have
previously been shown valid for use with older
children and adolescents, as has the Life Orientation
Test (optimism) [4] for use with adults. For the
current sample, alpha reliabilities were .84 for the
RSE and .64 for the Life Orientation Test. The Global
Rating Scale is a measure of CP severity created for
the larger CP study. Scores on this scale range from
1 (mild) to 3 (severe).
Participants were also asked about their perceptions of disability (not at all disabled to highly

disabled), social participation (number of close

friends, activity participation, chore participation),
and parent-overprotection (not at all overprotective to very overprotective). Finally, based on the
work of Ireys et al [5], the following questions
assessed perceived impact of the disability: (a)
When it comes to my disability, my family always
tells me what to do; (b) My disability makes a lot of
other people nervous; (c) I get angry whenever
friends give me advice or express their opinions
about my disability; (d) Because of my disability,
people often treat me like a child.

Statistical Analyses
Descriptive statistics were calculated on all variables.
Bivariate analyses determined associations with the
RSE. Finally, a multivariate regression was completed including all bivariately significant variables
(p .10 or less). The power of the multivariate
analysis was .93 for a sample size of 50 (2-tailed
alpha .05), assuming an R2 of .30.

Results
The mean self-esteem score was 30.63 (SD 3.96;
range 22-40) out of 40; 30% of the adolescents fell
into the low self-esteem category ( 28). Of the
demographic characteristics (age, gender, ethnicity,
family income, maternal education), only gender was
significantly related to self-esteem, with girls having
lower scores on average (mean scores of 27.74 versus
30.59 for boys). This variable was controlled in the
multivariate model.

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MANUEL ET AL

JOURNAL OF ADOLESCENT HEALTH Vol. 32, No. 6

Table 2. Regression of Significant Variables on Adolescent

Self-Esteem
Variable
Adolescent
gendera
Physicianassessed
functional
status
Perceived parent
overprotectiveness
Perceived impact
of disability

Standard
Error

Partial
F

2.26

1.00

5.06*

.02

.03

.31

.29

.72

.69

1.17

.31

13.92**

Note: Self-esteem was assessed with the Rosenberg Self-Esteem Scale

Overall F(4,41) 8.45, p .0001, R2 .45.
* p 0.05; ** p 0.001.
a
Gender was added to the model as a covariate owing to its
significant association with self-esteem scores.

Table 1 shows variable characteristics and their

relationship to self-esteem. The variables significantly associated with self-esteem at the bivariate
level (greater physician-assessed functional status,
perceived impact of disability, and perceived parent
overprotectiveness) were entered into a multivariate
model. In this model, only perceived impact of the
disability remained significant (partial F 13.92, p
.0001) (Table 2), with those perceiving a greater
impact of the disability reporting lower self-esteem.

Discussion
The pre-adolescents and adolescents surveyed had
mean self-esteem scores comparable to samples of
healthy adolescents [6] and young adults with
chronic illness [5]. The percent of participants with
lower levels of self-esteem (i.e., scores 29), however, was slightly higher than in the sample of young
adults with chronic illness (30% vs. 26%) [5]. Although not examined for this study, this finding
might be owing to the high visibility of the condition
and to the tendency of participants to have speech
and learning disabilities, which have been associated
with lower self-esteem in previous studies [5,7].
While this study was limited by its small sample
size, it extends previous research on self-esteem in
adolescents with disabilities. First, it corroborates

previous studies that physical disability is not necessarily associated with low self-esteem in adolescents [8 10]. Second, these findings demonstrate the
importance of the youths perception of the impact of
the disability to self-esteem, as opposed to physicianassessed severity/functional variables; because impact and self-esteem were only moderately correlated (r .59), it is unlikely that they are measuring
the same construct. Although confirmation of results
is necessary, professionals who work with pre-adolescents and adolescents with cerebral palsy are
encouraged to be aware of the youths perceptions of
the condition when determining those at risk for
self-esteem difficulties.
We thank Gloria Hairston for her assistance in recruiting participants for this study.
This research was aided by a grant from the Richard J.
Reynolds III and Marie M Reynolds Foundation, the Orthopaedic
Research and Education Foundation, the United Cerebral Palsy
Research and Educational Foundation (#R-613-94), and Allergan,
Irvine, CA.

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