"Just make friends, that's the most important thing!" School transition and making friends. The concerns and worries of children with illness and disability.

Anne McMaugh and Ray Debus, University of Sydney.

The study of psychosocial adjustment has frequently subsumed the study of specific areas of social adjustment while the study of children's actual peer relationships has been subsumed within broader studies of social competence. It has been within the last decade that significant reviews of research have resulted in calls to study peer relations directly and specifically as a unique dimension of the broader social adjustment construct (see Spirito, DeLawyer and Stark,1991; LaGreca, 1990). The area of peer relationships has been particularly acknowledged as a potential area of difficulty for children with chronic conditions (La Greca, 1990; Spirito, DeLawyer and Stark, 1991). It is suggested that certain problems that arise along with having a condition or disability may affect peer relationships. In particular, Spirito, DeLaywer and Stark (1991) point out that conditions that affect the physical appearance or restrict activities may be most likely to impact upon relationships. Similarly, La Greca (1990) suggested that restrictions to physical activity, interruption of daily activities, altered or unusual physical appearance and forced lifestyle changes might influence the peer relationships of children with chronic conditions.

Marked methodological deficiencies within the field of social adjustment studies have however, also been highlighted. Common criticisms have included the failure of research studies to examine social adjustment specifically (Spirito, DeLaywer and Stark, 1991; Nassau and Drotar, 1995; Thompson and Gustafson, 1995). Often claims about social adjustment have been made as an aside to a general study of psychosocial adjustment. Multiscale diagnostic tools such as the Child Behaviour Checklist [CBCL] (Achenbach & Edelbrock, 1984), which contains a small subscale of items regarding social competence, have been used widely to report social maladjustment among this population of children (Thompson and Gustafson, 1995). Perrin, Stein and Drotar (1991) point out that this instrument may not adequately conceptualise or represent social adjustment due to the small subscale of items and the tendency of the items to assess actual functioning rather than competence. This tendency to assess social functioning rather than competence has also led to the suggestion that this form of assessment of social adjustment may be inappropriate for children with disabilities (Perrin. Stein and Drotar, 1991; Thompson & Gustafson, 1995). Items on the scale that reflect school attendance, participation in physical activities and participation in household chores may be inappropriate estimates of adjustment for a sick or disabled child. In using such scales, many studies have not specifically assessed peer relationships.

Few studies have used multiple informants or multiple methods and few studies have used child or peer reports. The main method of assessment has relied upon parental ratings, usually from mothers, and sometimes teacher ratings. Direct assessment of peer relationships is rare with multiscale diagnostic tools such as the CBCL dominating the method of assessment (Thompson and Gustafson, 1995).

A lack of focus on developmental stages has led to the use of samples of children that vary dramatically in terms of age. Relevant age and developmental differences may be obscured if studies do not specifically focus on these factors. Several reviewers have also pointed out that the frequent practice of comparing the adjustment of children with physical conditions to the adjustment of their healthy peers is problematic (Harper, 1991; Lemanek, 1994). These reviewers suggest that such comparisons promote a "difference/deficit" approach to the study of adjustment and do little to identify factors that promote positive adjustment within the population.

It would appear then that the study of social adjustment among children with chronic illness is limited by both methodological and operational shortcomings. Methodological shortcomings are not entirely due to poor choice in designing studies but may be due to the nature of the study population itself. The low incidence rates of most condition groups necessitate combining wide age ranges and a diverse range of condition groupings within a single study. The demand for research that is considered empirically robust with wide generalisability drives concerns for larger sample sizes with the accompanying problems of loss of clarity. It is true too that the study of specialised populations is complicated by difficulty in identification and gaining access, hence the number of studies conducted in clinical settings on convenience samples, rather than the use of groupings in natural settings.

Operational shortcomings are however more a result of the selection of instruments and the conclusions drawn from ensuing results. The wide use of multiscale diagnostic instruments provides a case in point, whereby specific conclusions about social adjustment are drawn from a measure designed to assess behavioural maladjustment or competence or some other broad, clinically relevant term. Operational shortcomings are evident too in the number of studies relying on comparisons between healthy children and disabled children to draw conclusions about appropriate levels of adjustment. It is indeed questionable to assume that indicators of social adjustment in healthy, non-disabled children may be the same as those in disabled or ill children. If we take for example indicators of participation in sports, participation in group activities or outings, attendance at school, communication with peers, it becomes apparent that all are areas that some children with disability or illness may quite reasonably be expected to differ from their healthy peers. It may be the case that it is not appropriate to compare adjustment between populations without closely considering our operational definition of adjustment in both populations.

Despite such concerns for method and operational clarity, the suggestion of peer relationship vulnerability within this population demands scrutiny. A most productive and positive line of enquiry would appear to be towards examining social adjustment issues that are particularly relevant to students with chronic illness (La Greca, 1990). One such avenue of investigation suggested by La Greca (1990) concerns the ability of the individual to develop illness specific social skills. Such skills might entail coping with teasing or questions related to the disability and ultimately the need to "tell" or disclose information about the illness to one's peers. Just as it is pertinent to understand illness specific social adjustment issues, it is also important to construct a broader picture of salient concerns and issues confronting students more generally.

In light of these two suggested directions, this paper reports on findings from Stages One and Two of a year long study with 24 young adolescents with chronic physical conditions as they move from Year 6 into Year 7. The paper aims to illustrate briefly the nature and type of concerns raised by students when talking about their concerns and worries both prospectively and in actuality as they make the transition to high school. Secondly, the paper discusses the particular relevance of highly specific concerns relating to the task of self-disclosure of illness to peers and friends in the high school environment.

Table 1: Categories and thematic clusters- Year 6 interviews.

Note: Each cluster illustrated here represents preliminary emergent themes which are expanded upon in Year 7 interviews.

An initial overview of transcripts revealed several key categories of student concerns and worries, each of which contained several thematic clusters. In presenting such a thematic structure, the aim is to acknowledge both the interviewer's (my own) conceptual groupings and categorisations but also to acknowledge through specific thematic clusters the students' own contributions to these overall categories. It became apparent very early in the research process that several student insights were to set the scene for subsequent thematic investigations into the role of self-disclosure, teasing and concern for the perceptions of others.

Students consistently reported concerns for both the maintenance of and the making of friendships during the transition to high school. The exciting possibility of "making new friends" and "meeting new people" was matched by concerns for losing old friends, being left alone and worry about not knowing anyone:

Chloe: I'm afraid that if my friends go off and find new friends and then I'm left there.

Lee: Because I know people here and I don't really know anybody over there, hopefully I'll make a few friends, to keep in touch with my friends here.

Nick : Yeah well I guess, well there is another thing [that worries me], like cause half of my friends like these guys are going to private schools and stuff like that, so I won't see them, and making new friends I don't know.. (nervous laugh).

Although students almost universally declared their excitement and concerns for making new friends, it was within this excitement that students first broached the issue of specific concerns and worries about their ability to cope in the new social milieu. Students' concerns largely focussed upon fear of teasing and harassment from the new peer group. In several cases it became apparent that fears of teasing were largely based on prior and current experiences of teasing in the primary school environment and the student's worry that such harassment would worsen or recommence in an unfamiliar peer group (see Appendix 1). Thus, the fear of reliving or revisiting past school experiences posed a disconcerting dilemma for some students. Largely the dilemma can be seen to centre on other thematic issues within the category Aspects of Self.

Students' concerns and worries about the impending transition to high school were often related to concerns and worries in other thematic areas. In particular, student concerns about peer relations and harassment about their condition were frequently associated with references to the perceptions of their self held by other students and the dilemma of whether to self-disclose about their condition in the high school environment (see Appendix 2). These aspects of self-concern highlight concerns for the impending vulnerability of the self in the high school environment but importantly student comments also highlight concern for the preservation of the self in the new environment:

Jim: I'm just worried about that there might be a bully there, where there's not one in this school really. It might get a bit rough [later in conversation] Just as long as I don't tell them anything about me...

Jim: Like if I tell them that I'm slow at running and stuff, then they can chase me and stuff. But as long as I don't go near people like that and don't tell people...[JS0198]

Students discuss ways to circumvent or mediate the potential affront to the self, discussing ways to ward off teasing (by being up front and disclosing or talking about their condition) or by ignoring and not responding to teasing and harassment. Interestingly, just as students worry about the challenge to the self, they also perceive high school as a time of personal change and growth, they describe their selves as more grown up, more responsible, even "cooler"!

Some students perceived the transition event to be a time of personal change and growth; other students also described the transition in terms of affective impact and expectations for school culture, process and environment. Students responded to the question of "How do you feel about going to high school?" by talking about feeling excited, nervous and somewhat scared. Other students considered the question carefully and qualified their answers:

Although students were able to perceive the transition event as a time of personal change and growth, they were scared about other aspects of change, feeling "smaller", having a lower status and being youngest again. Students are concerned about keeping up with work and expect large homework burdens. A number of students referred to the fact that they write slowly or work slowly, others comment on a loss of understanding from teachers, fear diminishing support from teachers and a general sense emerges from the interviews of a feeling of 'forced independence' (see Appendix 3). This sense of a forced independence was clearly articulated in one student's comment: "That you've got to be very punctual that you've gotta look after yourself, so there's no teachers gonna be there to help you, although there's the school nurse....".

Of all comments reflecting student thoughts about the changing nature of schooling, by far the most common were thoughts about new subjects and an expanding school curriculum. Student comments commonly reflected a desire to break away from the primary school system of being in a single classroom with just one teacher to moving into a larger curriculum with multiple teachers. In some cases, an expanded curriculum led to concerns about home work and keeping up with work. Students with a history of long term or frequent hospitalisation were particularly concerned about keeping up and catching up with work. Interestingly most comments relating to concerns about workload were in reference to subject areas such as Mathematics and English. In contrast, students extensively reported an excitement and willingness to take on new subjects in creative and practical areas, such as woodwork, metalwork agriculture, and sports (see Appendix 4).

Across the four categories it is apparent that students concerns are, at face value at least, rather typical of the types of student concerns reported in other studies. In particular the general sense of slight anxiety and the paradoxical problems of a gain in maturity coupled with "being youngest again", are similar to the types of issues identified by Yates and colleagues (1999) in their studies of school transition. Yates (1999) questions the assumption that transition is a time of disruption where change is necessarily bad, suggesting instead that many students have already faced at least one school transition in the primary years. Similarly, student comments in both the Yates (1999) studies and the current study do not necessarily reflect a negative perception of the new environment, but rather a blend of prospective hopes and fears. The purpose of this discussion then, is not to suggest that such student concerns as expressed in the current study are either trite or of no concern at all. However, the apparent commonality or 'ordinariness' of these concerns does highlight two issues: firstly, that the general concerns and worries of students with chronic conditions and disabilities appear to be more similar to those of their peers than they are different. Secondly, that the presence of such ordinary concerns highlights the presence of more unusual, and possibly more disability-specific concerns.

Most critically, the insights gained from Year 6 interviews allowed for the later investigation of highly specific concerns including the act of self-disclosure and its association with other thematic issues including teasing and self-perceptions.

In seeking social validation, the individual may disclose information for the purpose of gauging the correctness or appropriateness of beliefs or views and by disclosing such information invite responses from those around them. During the adolescent years, seeking social validation may be linked to emerging self-awareness and particular concerns for acceptance and conformity in the peer group. It is probable adolescents are able to use the act of disclosure as a means of social control by manipulating and selecting the types of information revealed in order to promote the desired social outcome (Derlega and Grzelaks, 1979). In seeking group membership and adapting to group dynamics the individual may selectively choose to disclose information to enhance status or may hide information that will diminish status in the eyes of peers. Such heightened concern for self-representation during the adolescent years may also allow self-disclosure to act as a means of self-clarification whereby the individual seeks dialogue and discussion which allows for development and clarification of beliefs and ideas (Burhmester and Prager, 1995). Although self-disclosure may function as a means of clarifying and sharpening ideas, it also serves a vital function in allowing for self-expression of personal problems, feelings of distress or happiness. When used as a means of self-expression, it is likely that the motivation lies largely in seeking a cathartic release of emotions (Burhmester and Prager, 1995). However, the motivation in such self-expression is likely influenced by the nature of the stressor that may indicate not only the need for self-expression but also for feedback and assistance in coping with stressors.

It is clear that self-disclosure exists within the bounds of communicative links between individuals. In this way, the act of self-disclosure is thought to play a significant role in enhancing relationship development. Although many researchers consider self-disclosure and intimacy as key features of adolescent friendships, it is clear that self-disclosure is but one of a number of features that lead to intimacy in friendships. In particular, Berndt and Hanna (1995) point out that where intimacy refers to the quality of a relationship, self-disclosure describes a behaviour that may or may not necessarily enhance the quality of a relationship. In essence, self-disclosure can be considered any level of self-revelation ranging from the mundane to the highly personal. In general, it is recognised that adolescents not only disclose to various significant people in their lives, ranging from parents to peers and friends, but they may disclose differentially to these various people (Papini et al, 1990). In particular, it is suggested that less intimate types of information may be widely revealed, whereas highly intimate personal information may be guarded for a selected few. In this way, low-level information may not necessarily lead to intimate relations between individuals whereas high-level disclosures may increase a sense of knowing, closeness and ultimately intimacy between individuals.

Although self-disclosure is manifest of an individual's cognitive state, it is indeed a social activity consisting of the discloser on one hand and the recipient of disclosure on the other. The act of self-disclosure involves the choosing of a recipient of the message while choosing is in turn limited by the constraints of the environment in which the individual exists (Buhrmester and Prager, 1995). Self-disclosure may equally be prompted or inhibited by socio-cultural boundaries that either convey expectations of disclosure or convey expectations of inhibition. Adolescents for example may choose differentially between parents and peers as targets for self-disclosure. Papini et al (1990) noted that while younger adolescents felt quite free to describe an emotional state to their parents, older adolescents preferred to disclose emotions to their friends. Differential levels of self-disclosure may also be related to sex-role orientation with several reports illustrating that boys report less instances of sharing personal thoughts and feelings than girls, possibly suggesting that a traditional masculine sex-role discourages the telling of personal, intimate details (Berndt and Hanna, 1995). In seeking the social support offered by self-disclosure Frydenberg (1997) suggests that boys and girls do indeed utilise social-support differently. Where girls use social support freely and directly and rely on friends for support, boys tend to use social support on an 'as needed basis', preferring to keep problems to themselves and choosing family support rather than peer support when necessary.

Although boys and girls may indeed choose to "do it differently" (Frydenberg, 1997) when seeking social-support through disclosure, it is apparent that children and adolescents who lack social-support suffer similar consequences regardless of gender. In particular, an inability to establish close and meaningful relationships has been associated with feelings of loneliness, peer rejection and dissatisfaction in the school environment. Although the development of close and meaningful relationships is widely regarded as a normal developmental task of the adolescent period, it is apparent that the peer group actively rejects around 10% of children (see Newcomb, Bukowski and Pattee, 1993; Asher, 1990). Similarly, an extensive body of literature within the field of pediatric psychology has suggested that children with disability and other chronic physical disorders present a higher risk of poor social adjustment and lower peer acceptance. Peer relationship vulnerability among this group may be related to the difficulties associated with managing and living with a severe and debilitating condition. The potential for a condition to restrict opportunities for play or engagement with peers, or the number of days absent from school, along with the psychosocial consequences of living with illness, may all play a role in shaping such peer relationships. Unfortunately a much less frequently examined concept is the possibility that peer relationship problems among such children are not manifest in isolation nor are they products of individual 'maladjustment'. Rather, peer relationships and associated problems are manifest and often created in the social worlds of school classrooms and playgrounds and are as such a social issue not an individual problem. It is unfortunate too, that the study of actual peer relationships and friendships among these children has been secondary to the study of behavioural deviancies from the "norm", leading to widespread conclusions that children living with chronic illness and disability are maladjusted and socially incompetent.

Just as less is known about the actual peer relationships and friendships of children with disability and illness, so too is little known about the intricacies of self-disclosure among children in general. Little is known for example, about the actual association between issues, concerns, and the types of social input and provisions sought through self-disclosure (Buhrmester & Prager, 1995). It is pertinent and timely that the current study seeks to address these questions within the highly specific context of disclosure of disability within a new peer environment. In particular the nature of the data gathered in the current study questions the underlying assumptions of the act of self-disclosure being both voluntary in nature and existing within the bounds of friendship.

It was during students Year 6 discussions of "things that concern or bother me" about going to high school that student thoughts of disclosing or 'telling' about illness, emerged as an important theme:

Although students such as Jim expressed concern for concealing their condition, it became clear that concealment was not an option for other Year 6 students:

It was with these student concerns in mind that interviews in Year 7 sought out student reasons for such concealment and in students for whom concealment was not an option, how they dealt with the range of questions confronting them in the new peer milieu. Subsequently, Stage Two interviews included specific questions about the act of self-disclosure. The material in this paper is drawn from questions such as: "So have you told anyone here at school about your condition?", "Can you tell me how much people here at school know about CF?" "How did your friends come to know about you having CF?" "Can you remember what led to you telling your classmates about having CF?".

Seventeen students reported their decision to disclose or conceal information about their condition in the high school environment. Another seven students were not considered in this analysis because the act of self-disclosure was either not necessitated by their environment or the student was unknowledgeable about the nature of their condition. Students in highly supported environments reported that disclosure of their condition was 'not an issue' because most other children in their environment also had a visible and disabling condition. Among these students, the question "Have you told your friends about your condition?" was met with surprise and rejection of the concept as unnecessary. Among other students, an inability to actually describe their condition or perhaps an unwillingness to acknowledge their condition also accounted for instances where a discussion of self-disclosure was not appropriate or relevant. As such, it has been possible to examine seventeen cases of both disclosure and concealment and query the events or environmental constraints leading to such decisions (Table 2). Likewise, it has also been possible for students to recreate the disclosure event and describe the type of information they reveal or choose not to reveal. Students' own thoughts on the meaning and importance of the process are illustrated in several cases, and serve to highlight the interplay between other aspects of self-perceptions and the impact of teasing.

Table 2: Student self-disclosure to peers and friends

Table 2 reflects the decision to tell either friends or peers as well as the decision to conceal the presence of a condition. It is apparent that friends are marginally more likely than peers to be chosen as recipients of self-disclosure, the rates of disclosure however, are similar across both peers and friends. Children who disclose to friends are also likely to have disclosed to peers with only three students opting not to tell peers and only tell friends. It is notable too, that a considerable association exists between children who have chosen not to tell either peers or friends and peer rejection. Each student identified in Table 2 as having 'no friends' experiences significant dissatisfaction in the school environment, reporting teasing, bullying and overall inability to form close relationships. Similarly, students identified as having 'problematic peer relations' do not report the presence of close and mutual friendships and do not appear to enjoy reciprocated relationships at the classroom level.

A noticeable difference is also evident in the disclosure styles of male and female students; girls are far more likely to disclose to both peers and friends whereas boys seldom choose to disclose to peers. Graph 1 further describes this discrepancy in terms of boys and girls disclosure to either peers or friends. It is apparent that when girls choose to disclose or conceal information about their condition they do so universally telling or not telling both peers and friends. Boys on the other hand are far more likely to tell only friends with just two reported instances of universal disclosure to both peers and friends.

In cases of universal disclosure to both peers and friends, the inability to conceal a condition played a major role in motivating disclosure:

In Matthew's story it is apparent that part of the motivation for disclosing information lies in the fact refusal to disclose sends a negative message to peers about the type of person you are:

In Kylie's story too, self-disclosure acts as a means of self-representation:

The decision to tell or not to tell and its association with self-representation is a vexed and unclear issue for some students. Students are torn between the risk of telling and exposing oneself to teasing or bullying as exemplified by Jim's Year 6 concerns. Similarly, the act of disclosure may not always have a desirable outcome:

Earlier in this interview, Abby had described the type of harassment she receives from peers:

The possibility that self-disclosure may not be received positively by peers is a risk that clearly accompanies any form of self-disclosure. It is clear however that in these cases self-disclosure is not always voluntary and occurs in the context of impersonal and sometimes rude questions. In such cases, students with disabilities do not experience the potential for self-disclosure to act as a meaningful form of self-expression or self-representation in the manner referred to by Derlega and Grzelak (1979) and others:

The misrepresentation of a disclosure is a very real concern for students like Kim who, having survived cancer, must now survive peer beliefs of contagion and infection:

The possibility that peers may get the 'wrong' impression of students remains the greatest motivating factor in the decision not to disclose. Boys almost exclusively report concern for peer group impressions as a factor in deciding not to disclose:

It is also apparent however, that choosing not to disclose may make one vulnerable to further harassment:

Despite Liz's best efforts not to tell about her disability, her peer group has chosen to exploit her desire for privacy and use knowledge of her disability as a method of teasing and harassment. In each case where students without friendships have opted not to tell either peers or friends there is clear evidence of problematic peer relationships whereby students are teased and perhaps inappropriately respond to teasing by telling peers to "Shut up", or replying "So what?" rather than disclosing the true nature of their condition.

The consequences of the decision not to tell either peers or friends can be contrasted with the positive outcomes for students who have confided in peers and friends. Students who have disclosed within close friendships report that their friends provide physical and emotional support by comforting them when teasing occurs or by encouraging them to take their medication.

The current research has provided two important insights into the process of social adjustment over the transition to high school. Firstly, the current study has illustrated that the concerns and worries of children with illness and disability can be considered, for the most part, very similar to those of their non-disabled and healthy peers as reported in other literature. In listening to students prospective and current reports on the transition to high school one is struck by the very practical, very 'ordinary' nature of their concerns for new subjects, different teachers and the paradoxical concern for 'growing up' from the bottom of the high school hierarchy. It is important that this 'ordinariness' is illustrated, because it is evidence that children with disabilities and chronic illness are not simply adjusting to their illness but they are indeed adjusting and growing up with their illness or disability. To restore some emphasis to the process of growing up with an illness or disability is to restore some emphasis to the individual as an active agent in shaping his or her own adjustment trajectory despite the presence of a chronic or disabling condition.

At a second level, this investigation of student concerns has highlighted some very specific and illness-related concerns. Just as La Greca (1990) suggested, it seems apparent that students with chronic conditions do indeed acquire disability-specific social skills. Student reports have illustrated that teasing, harassment and questions are almost a routine feature of growing up with a disability. A student's report that telling "comes naturally to a disability..."[MS0299] may indeed be the most honest way in which to explain the process of acquiring disability-specific skills such as self-disclosure.

Clearly, in the social world of the school playground choosing not to tell about a condition is a risky decision. Boys who choose not to tell are largely able to do so because of the relatively invisible nature of their condition. Students who choose not to tell and have clearly visible conditions cannot escape peer scrutiny and curiosity. Students without friends however do not appear to have either the reserve to ignore peer comments or the social skills to respond in an appropriate manner. These students also lack the buffering protection of best friends and essentially have no form of social support in the school environment, often failing to report harassment to teachers or experiencing negative responses from teachers.

Choosing to disclose or not to disclose has proven equally important to adjustment depending on environment and own perception. Boys in particular have expressed concerns that not telling is important to the establishment of peer relationships, whereas girls who have told close friends express that this is important and meaningful to them and their friends. In such cases, the disclosure has acted as means of tangible support in coping with illness. In one case, the deliberate choice not to tell is associated with a Year 7 experience of loneliness and misery, teasing and harassment.

Although there is evidence among these reports that self-disclosure has provided students with a means to control self-representation and has acted as a form of social-support, there is also evidence that self-disclosure has not functioned in the manner reported in other literature (see Rotenberg, 1995). Clearly, the act of self-disclosure as experienced by students in this study has largely occurred as an involuntary response to questions or provocation. It is also apparent that disclosure is not necessarily linked with close and intimate relationships; rather self-disclosure functions at a general peer-level as a self-protective mechanism.

Self-disclosure operates it seems, as a self-protective mechanism according to the student's sense of perceived risk to the self. A history of teasing and bullying, or fear that this may occur, may lead to students attaching a negative meaning to self-disclosure. Where students associate self-disclosure with high-perceived risk to the self, it likely leads to the decision not to disclose. Conversely, where students have a low-perceived sense of risk as in the context of close relationships they tend to disclose freely across peers and friends. A sense of perceived risk to the self may also account, in some part, for the suggestion that "boys do it differently" (Frydenberg, 1997) when it comes to seeking social support. It is apparent that boys are most likely to voice concerns for the perceptions of peers as a reason for not disclosing information about their condition. Girls on the other hand seem to enjoy and rely upon the support of close relationships when disclosing freely across peers and friends.

Thus, it is clear that for some students, school is a difficult place to disclose illness and as such may also be a difficult place to develop a sense of self that incorporates this aspect of identity. On the other hand, it is also apparent that the transition to high school incorporates so much more than adjusting to high school with a chronic illness or disability. The reports of 24 young adolescents in the current study highlight that student concerns also centre on routine aspects of transition including adapting to a new school culture, studying new subjects and simply growing up and gaining independence.

The current study represents an attempt to understand social adjustment processes among children with chronic conditions, and to understand how children's peer relations contribute to this adjustment. Methodologically, it has been critical that the current study has sought out student insights into the adjustment process and as such has highlighted the complex interplay between individual social adjustment and the dynamics of the peer environment. As a result, the study has not been limited by typical constraints relating to identification and testing among small populations; rather the study has been strengthened by the knowledge gained from close attention to students' insights and collaboration with students to identify the meaning and value of these insights.

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Chloe: I dunno, just people not knowing me as much, and they think "oh its all right to tease her", so they tease her.

Kylie: That's what really scares me, it's not just that, I don't care if they tease me, it's that I'm going to get there and I'm never going to have a boyfriend. I'm down there, than the other pupils and no ones going to like a short person [later in interview] ...it all revolves around being small, everything!

Nick: That like, the adult books, cause I like reading books. And the Internet, computers.

Ady: Well you get to do pottery and art... [later in interview] like we're gunna learn more stuff and like for Religion and that we've got that