WOMEN AND CHI LDREN

Self-concept: comparison between school-aged children with congenital

heart disease and normal school-aged children
Chi-Wen Chen MScN, RN
Lecturer, Department of Nursing, College of Medicine, Fu-Jen Catholic University, Taipei, Taiwan
Chung-Yi Li PhD
Professor, Department of Public Health, College of Medicine, Fu-Jen Catholic University, Hsin-Chuan, Taipei, Taiwan
Jou-Kou Wang MD, PhD
Professor, Department of Pediatrics, National Taiwan University Hospital, Taipei, Taiwan
Submitted for publication: 10 February 2004
Accepted for publication: 13 August 2004
Correspondence:
Chi-Wen Chen
School of Nursing
College of Medicine
Fu-Jen Catholic University 510
Chung-Cheng Road
Hsin-Chuan,
Taipei
Taiwan
Telephone: 886 2 29053459
E-mail: Nurs1010@mails.fju.edu.tw
CHEN C- W, LI C- Y & WANG J- K ( 2005) CHEN C- W, LI C- Y & WANG J- K ( 2005) Journal of Clinical Nursing 14, 394402
Self-concept: comparison between school-aged children with congenital heart dis-
ease and normal school-aged children
Aims and objectives. The aim of this study was to evaluate and compare the self-
concept of school-aged children with congenital heart disease to those of normal
school-aged children. The primary objective was to analyse results of the Self-
Concept Scale questionnaire administered to children with congenital heart disease
aged 912 years. Sixty-four children with congenital heart disease (study group), and
71 without congenital heart disease (control group), completed the questionnaire.
Background. Little attention has focused on school-aged children with congenital
heart disease who are in the important stages of developing self-concept.
Results. The mean score on the Physical self-concept of the Self-Concept Scale was
signicantly lower for the study group than the control group (P < 0.05). No sig-
nicant differences were observed between children with congenital heart disease and
normal children in terms of family self-concept, school self-concept, appearance self-
concept, emotional self-concept and general self-concept for the Self-Concept Scale.
Conclusions. Nurses should use the study ndings to encourage positive self-concept
development and improve their patient education about physical activity before the
child is discharged. Thus, children with congenital heart disease could leave the
hospital with a clear understanding of their body and condition, and how it affects
daily life.
Relevance to clinical practice. The results of this study may provide more holistic
views on self-concept for clinical nurses working with children who have congenital
heart disease and their families and for school nurses working with elementary
school children.
Key words: children, congenital heart disease, nursing, self-concept
Introduction
Self-concept is the nucleus of personality development for
children and leads to individualistic thinking and behaviour,
as inuenced by interactions with their environment and
other people. School-aged children are at a critical juncture
when they begin to develop self-concept through socialization
(Yan et al. 1999, Santrock 2002).
394 2005 Blackwell Publishing Ltd
Congenital heart disease (CHD) ranks among the three
leading causes of hospitalization in school-aged children in
Chinese societies (Yan et al. 1999). The incidence of CHD is
estimated at between 8 and 10/1000 in Taiwan (Kao et al.
2000). Although improvements in cardiac surgery and
postoperative cares have reduced mortality for children with
CHD and lead to a better survival, children with CHD may
still develop unfavourable cognitive and psychosocial char-
acteristics, which adversely affect their quality of life (Salzer-
Muhar et al. 2002). According to Yan et al. (1999), children
with chronic illness have the additional burden of physical,
psychological and emotional threats, including difculties in
the development of self-concept. The important demands of
holistic care are to teach children and their families the
necessary skills for home care and self-care and help them
achieve a healthy self-concept (Alderman 2000, Vessey &
OSullivan 2000).
In Taiwan and other countries an increasing body of
research is focusing on self-concept (Hung 1993, Chen &
Hsiang 1997, Bai 1999, Greenwald et al. 2002, Marsh et al.
2002). In the paediatric nursing literature, self-concept has
been discussed for adolescents with CHD, children with
asthma and school-aged children with a chronic illness (Yan
et al. 1999, McNelis et al. 2000, Salzer-Muhar et al. 2002).
However, scant attention has been given to school-aged
children with CHD who are in the important stages of
developing self-concept. This study provides data on self-
concept and its subconcepts in Taiwanese school-aged
children with CHD and may help nursing professionals
provide better holistic care for such children.
Literature review
School-aged children are at a stage during which they break
away from the egocentric subjective period and begin devel-
oping an objective self-image to form a complete self-concept.
Childrens self-concepts become more complicated as they
mature (Hung 1993). An important research concern is howto
choose a proper tool to evaluate self-concept of Taiwanese
children. The theoretical construction models of self-concept
can be divided into two categories: unidimensional perspec-
tives and multidimensional perspectives. The unidimensional
models have been criticized for oversimplifying the idea of self-
concept. In addition, repeated measurements are usually found
in the results provided by unidimensional perspectives. As for
the total score of the evaluation, it canbe considered toobroad,
producing results that are scattershot (Hou1998). Onthe other
hand, the multidimensional perspectives include the following
models: (1) the independent model in which each dimension is
considered independent and irrelevant; (2) the correlated-
factor model in which the dimensions are highly interrelated;
(3) the compensatory model in which negative correlations are
found between some dimensions; (4) the taxonomic model in
which the self-concept is a series which consists of independent
factors from different dimensions and (5) the hierarchical
model is organized or structured. It is multi-dimensional, with
each dimension reecting an individual or groups self-referent
category system. It is hierarchical, with personal behaviour in
specic situations at the base, broad inferences about the self in
the middle and global/general self-concept at the apex. Self-
concepts of different elds are correlated but can also be
individually explained. The hierarchical model is believed tobe
the most thoroughandhas beenvalidatedby studies inWestern
countries. Therefore, the hierarchical construction of self-
concept has become a new trend in studying self-concept
(Byrne & Shavelson 1996, Hou 2001, Byrne 2002). The
hierarchical constructionproposedbyShavelsonet al. (1976) is
levelled by hierarchical orders. The highest level is general self-
concept [similar to Spearmans (1927) G factor for general
intelligence] and is subsequently divided into Academic self-
concept and Non-academic self-concept. The Non-academic
self-concept includes social, emotional and physical self-
concepts. Each of these categorizations is divided into several
domains that are more concrete and specic. Finally, the most
detailed, discrete level under each domain includes the
performance of specic behaviours. The design of this study
applied Hous (2001) self-concept model for Taiwanese
children based on the multidimensional and hierarchical self-
concept models explained by Shavelson et al.s (1976) theor-
etical constructs (Fig. 1).
In the literature investigating the self-concepts of children
with CHD, Vessey and OSullivan (2000) stated that the
concepts children had believed about their internal bodies
played a signicant role in their self-concept. Pre-school
children have relatively undeveloped views of their internal
bodies, which are often based more on fantasy then fact.
School-aged children can name several organs and their
functions, but do not understand how different organs work
together to form an organ system. Adolescents, however, can
construct a complex understanding of organs and how the
body functions (Neff 1990). Vessey and OSullivan (2000)
compared concepts of internal bodies among 50 children with
cardiac disease and 50 healthy children aged 515 years.
They found no differences between the two groups in
knowledge of body parts, bodily function, or the values that
were assigned. However, 96% of the participants with CHD
were classied as having no permanent dysfunction. Seventy-
ve per cent had never had a cardiac catheterization and 82%
had never undergone surgery. In addition, Salzer-Muhar et al.
(2002) investigated Viennese adolescents with CHD and
Women and children Self-concept
2005 Blackwell Publishing Ltd, Journal of Clinical Nursing, 14, 394402 395
found that males with CHD had low self-esteem and believed
themselves to be generally incompetent. This negative self-
image expressed by adolescent males with CHD may, in part,
be explained by their reduced capacity for physical activity,
thus interfering with the development of healthy relation-
ships, particularly in cultures where a high premium is placed
on athletic prowess.
Similarly, Yan et al. (1999) investigated selected factors
inuencing self-concept among 122 Chinese school-aged
children hospitalized with chronic illnesses, including neph-
rotic syndrome, leukaemia and CHD. The majority of study
participants had at least an average level of self-concept. In
addition, academic achievement (grade point average) was a
strong predictor of self-concept. Thus, the authors suggested
that the continuing academic achievement of hospital-
ized chronically ill children could also enhance their self-
perception, physical attributes and popularity. Age, gender,
duration of illness and the type of illness were predictors of
self-concept and its subconcepts such as social behaviour,
anxiety, popularity or physical appearance and attributes.
Based on this literature, we decided to use the multidimen-
sional and hierarchical self-concept models and compare the
self-concept of school-aged children with CHD to those of
normal school-aged children.
Aims
The aims of this study were to examine (1) self-concept of
school-aged children with CHD and normal school-aged
children and (2) the comparison of self-concept between
school-aged children with CHD and normal school-aged
children.
Methods
Participants and procedures
A total of 135 children, 64 with CHD and 71 unaffected,
constituted the sample for this exploratory, descriptive study.
Patients with chromosomal aberrations or extracardiac mal-
formations were excluded. Inclusion criteria for the study
group were (1) diagnosed with a cyanotic or acyanotic heart
condition within the rst two years of life; and (2) aged
912 years. Cardiac function was assigned using the classi-
cation system from the Cardiology Committee of the
Pediatricians Society of the Republic of China: (1) normal;
(2) previous CHDdiagnosis but current good cardiac function
and no symptoms; (3) mild symptoms; (4) moderate symp-
toms; and (5) severe symptoms. The control group partici-
pants could not have had any chronic disorder and/or major
illness requiring hospitalization/surgery after one year of age.
Children with CHD were recruited from the paediatric
cardiology outpatient departments at two large medical
centres in Taiwan, one in Taipei and one in Taoyuan, from
July 2002 to February 2003. Before conducting this study,
institutional review board approval was obtained. To select a
sample of control children who reected the geographic
distribution and age range similar to the study children,
nursing students visited the classes that the study children
attended and asked parents of children without CHD in the
General factor
Subareas
of SC
Specific
behaviours
General SC
Person SC Emotion SC Interperson SC
Family
SC
Appearance
SC
School
SC
Specific
emotional SC
Physical
SC
Figure 1 Non-academic self-concept (SC)
hierarchical model for children in Taiwan
(translated from Hou 2001, p. 147).
C-W Chen et al.
396 2005 Blackwell Publishing Ltd, Journal of Clinical Nursing, 14, 394402
same class to participate. All study children were aged
912 years and selected voluntarily. The study was explained
and informed consent from all parents/guardians was
obtained. Parents completed the demographic form, and the
children completed the self-concept scale. After completing
the questionnaires, they immediately returned the forms to
the researcher and received a token gift.
The Self-Concept Scale
The Self-Concept Scale (SCS) for elementary school children
was used in this study. This scale was based on multidimen-
sional and hierarchical self-concept models (Hou 2001). In
addition to the Whole Scale, this inventory consists for ve
subscales: family, school, appearance, physical, and emo-
tional. Each subscale contains 917 items and the Whole
inventory consists of 61 items. A ve-point response scale
was used, from not t totally to t totally, with scores ranging
from 1 to 5. Administration of the questionnaire required
about 2030 min. The percentile rank and T-score norms for
the SCS were based on a larger, representative sample of
1544 boys and girls in grades 46. Reliability studies of the
ve subscales of SCS have yielded Cronbach a coefcients
ranging from 0.83 to 0.89, and testretest reliability coef-
cients over a 2-week period ranging from 0.76 to 0.91. The
content-related validity, criterion-related validity and
construct-related validity were satisfactory (Wu & Hou
2000, Hou 2001).
Data analysis
The SPSS software (version 10.0, Chicago, IL, USA) statis-
tical analysis program was used with P < 0.05 considered
statistically signicant. To understand further the meaning of
the participants scores, the SCS also provides the T-score
norms. T-score is a standard score of linear transformation.
By the T-score, we could determine to what extent each
individuals score shifted above or below the mean and for
how many SD. The theoretical equation is: T 10Z 50.
That is, the mean is 50 and the SD is 10 (Wu & Hou 2000).
Fishers exact test was used to compare the differences of
demographic data between the two groups. Multiple regres-
sion and logistic regression analyses were used to analyse the
differences of overall self-concept and its subconcepts in
school-aged CHD children and normal children.
Ethical approval was obtained from the Human Research
Ethics Committee of the hospitals. The purpose and method
of this study were explained to the primary caregiver of each
participant. All participants were informed of the voluntary
nature and condentiality of their participation.
Results
Research participants
The study participants ranged in age from 8.6 to 12.7 years,
with the average age approximately 10 years (Table 1). The
CHD group included more girls (57.8%; 37/64) and the
control group included more boys (50.7%; 36/71), but these
differences were not statistically signicant. About 90% of
the children in both groups had siblings. More than 60% of
the children in both groups were in the fourth and fth
grades. Most of the children in both groups, about 90%, had
at least fair school performance. In both groups, more than
90% of parents were married. Parents ages and educational
levels were not signicantly different between the two groups.
In 78.3% of children with CHD, the diagnosis was left to
right shunt, including patent ductus arteriosus, atrial septal
defect and ventricular septal defect. At least half of the
children in the CHD group had never undergone a heart
operation. About 40% of the children who had undergone an
operation did so when still a toddler. Just over one-third
(36.8%) of the children underwent their rst heart operation
at school age. Most children, about 60%, had a previous
CHD diagnosis, but good cardiac function and no symptoms
at the time of the study.
Self-concept differences between school-aged CHD
children and normal children
The mean score (Table 2) on the physical self-concept of the
SCS was signicantly lower for CHD children than for
normal children (Crude effect; P 0.007). No signicant
differences were observed between CHD children and normal
children in terms of Family self-concept, school self-concept,
appearance self-concept, emotional self-concept and general
self-concept for the SCS. Furthermore, when multiple regres-
sion analysis was used to control for the childrens attributive
variables, the mean score of physical self-concept was also
signicantly lower in children with CHD than in normal
children (P < 0.05).
Results indicated that both groups scored higher means in
the T-score norms of School self-concept, but children with
CHD scored lower in the T-score norms of physical self-
concept, and normal children scored lower in the T-score
norms of family self-concept (Figs 2 and 3). Logistic
regression analysis was used to control for variables such
as the childrens personal attributes before self-concept
differences were compared (Table 3). Fewer CHD children
scored more than 50 in physical self-concept (OR: 0.51,
P 0.096).
Women and children Self-concept
2005 Blackwell Publishing Ltd, Journal of Clinical Nursing, 14, 394402 397
Discussion
Although the study children were not randomly sampled, we
selected the control group to match the age distribution and
geographic area of the CHD group, which increased com-
parability between the two groups. Our data showed that
except for the signicantly lower score of physical self-
concept in the study children, no other signicant differences
Table 1 Demographic characteristics of the
study sample (n 135)
Variable
Children with CHD
(n 64)
Non-CHD children
(n 71) P-value
Age (years) 10.85 0.97 (8.612.7) 10.78 0.85 (9.312.7) 0.635
Age of father (years) 42.37 4.02 (3554) 43.09 5.23 (3163) 0.386
Age of mother (years) 40.13 4.24 (3252) 39.79 3.95 (3047) 0.632
Gender
Male 27 (42.2) 36 (50.7) 0.388
Female 37 (57.8) 35 (49.3)
Siblings
Only child 6 (9.4) 6 (8.5) 1.000
With siblings 58 (90.6) 65 (91.5)
Grade
Fifth grade or below 43 (68.3) 46 (64.8) 0.716
Sixth grade or above 20 (31.7) 25 (35.2)
Academic performance
Fair or above 57 (91.9) 69 (97.2) 0.250
Fair below 5 (8.1) 2 (2.8)
Marital status
Married 58 (92.1) 66 (94.3) 0.735
Others 5 (7.9) 4 (5.7)
Educational level of father
Senior high school or below 33 (53.2) 40 (58.0) 0.602
University or above 29 (46.8) 29 (42.0)
Educational level of mother
Senior high school or below 41 (64.1) 40 (57.1) 0.480
University or above 23 (35.9) 30 (42.9)
Diagnosis
Left to right shunt 47 (78.3)
Right to left shunt 7 (11.7)
Other 6 (10.0)
Number of heart operations
None 32 (53.3) 71 (100)
1 19 (31.7)
2 7 (11.7)
3 1 (1.7)
4 1 (1.7)
Age for rst time undergoing heart operation
Before toddler 9 (47.4)
Preschool 3 (15.8)
School-age 7 (36.8)
Functional level of heart
Normal function 0 (0) 71 (100)
Whole heart function
without symptoms
41 (66.1)
Mild heart symptoms 15 (24.2)
Moderate heart symptoms 4 (6.5)
Severe heart symptoms 2 (3.2)
Values are presented as mean SD (range) or n (%).
Summation of number of subjects not equal to the total number of subjects for certain variables
was because of missing information.
C-W Chen et al.
398 2005 Blackwell Publishing Ltd, Journal of Clinical Nursing, 14, 394402
were observed between the two groups for the other SCS
scores.
Various scales can measure self-concept. For example,
Salzer-Muhar et al. (2002) chose the Frankfurter
Selbstkonzeptskalen (FSKN) to assess the self-concept of
adolescent subjects with CHD in 10 dimensions. Yan et al.
(1999) used the PiersHarris Self-concept Scale (PHSCS) to
collect data on self-concept among children with chronic
illness. This scale was designed to assess how children aged
616 years perceive themselves as well as provide a multi-
dimensional measure of self-concept and yield a full-scale
score with the six sub-concept scores. We used the Self-
Concept Scale (SCS) originally developed by Hou (2001) to
measure self-concept in the study group children for the
following reasons. Firstly, this scale was based on the
hierarchical self-concept model that was described above.
Secondly, the percentile rank and T-score norms for this scale
were estimated from a larger, representative sample of 1544
boys and girls in grades 46 in a Taiwanese cultural setting.
Thirdly, the SCS showed satisfactory reliability and validity
(Hou 1998, 2001).
After transformation to T-score norms, the General self-
concept and all its subconcepts of normal children were higher
than the mean (mean 50), with the lowest score in the
Family self-concept (Fig. 3). For school-aged children, their
interactions with their families or their relationships to family
members are weaker. This nding is inconsistent with that of
Hungs (1993) study 10 years ago, which found that students
scored highest in the Family self-concept. In Hungs study, the
sample included 4730 randomly selected Taiwanese students
from third to sixth grade. Two possible explanations for his
ndings are that children in fourth to sixth grade are in late
childhood about to enter early adolescence. Thus, they may
have a greater need for autonomy and more parentchild
conicts occur (Santrock 2002). Secondly, the family pattern
of 10 years ago differs widely from current family patterns.
The family is a dynamic system and, in the 21st century,
several dramatic changes have inuenced the components and
patterns of traditional family life changes in family life include
reduced birth rates, increased numbers of working mother,
divorce, single parent families and blended families (Shaffer
Table 2 Comparison of the self-concept scale (SCS) between children with CHD and non-CHD children
Variable
Children with CHD
(n 64)
Non-CHD children
(n 71)
Crude effect Adjusted effect
B R
2
P-value B R
2
P-value
Family SC 70.30 9.40 68.62 11.61 1.68 0.006 0.361 1.28 0.125 0.511
School SC 58.91 6.69 59.23 7.74 0.32 0.000 0.799 0.601 0.072 0.668
Appearance SC 34.92 7.59 34.24 6.84 0.68 0.002 0.583 1.08 0.102 0.433
Physical SC 41.16 9.37 45.46 8.91 4.31 0.053 0.007** 3.33 0.211 0.046*
Emotional SC 33.59 5.73 32.68 6.67 0.92 0.005 0.395 1.50 0.135 0.201
General SC 238.87 27.81 241.45 26.22 2.58 0.002 0.581 0.92 0.134 0.855
Values are expressed as mean SD.
SC, self-concept.
*P < 0.05; **P < 0.01.
Adjustment for sex, age, siblings, grade, school performance, marital status, fathers age and education, mothers age and education.
0
10
20
30
40
50
60
70
80
Family
SC
School
SC
Appearance
SC
Physical
SC
Emotional
SC
General
SC
T(N)
0
10
20
30
40
50
60
70
80
T(N)
min max mean
Figure 2 T-score norms of SCS in children with CHD.
0
10
20
30
40
50
60
70
80
F
a
m
i
l
y

S
C
S
c
h
o
o
l

S
C
A
p
p
e
a
r
a
n
c
e

S
C
P
h
y
s
i
c
a
l

S
C
E
m
o
t
i
o
n
a
l

S
C
G
e
n
e
r
a
l

S
C
T(N)
0
10
20
30
40
50
60
70
80
T(N)
min max mean
Figure 3 T-score norms of SCS in normal children.
Women and children Self-concept
2005 Blackwell Publishing Ltd, Journal of Clinical Nursing, 14, 394402 399
1999). Although more than 90% of parents in this study were
married, the dynamics of family life in two-parent families
may have also changed. Similarly, for children with CHD, in
addition to the lowest score in Physical self-concept, their
scores in Family self-concept were the second lowest, a
reection of how school-aged children perceive themselves in
interactions with their family members.
The nding that both groups scored higher means in the
T-score norms of School self-concept indicates that they
perceive themselves as having better relationships with their
teachers, friends and classmates than those of other subcon-
cepts. When children enter the transition to elementary
school, they experience a change from being a home child to
being a school child. Children in middle and late childhood
particularly benet from this transition, as school and a new
life outside the home help them develop a new sense of self
(Santrock 2002). Peer relationships, interactions with teach-
ers, and achievement orientation comprise this new sense of
self. It is interesting to note, however, that the children tend
to gravitate towards peers who are usually associated with
their parents values. If the parents emphasizes education and
works to improve their childrens achievements, children are
likely to choose friends with whom they can study, share class
notes, and pursue academic achievement (Shaffer 1999).
According to reports in the literature, Asian American and
Chinese children tend to have peer groups that value
academic achievement (Chen et al. 1997, Fuligni 1997).
Yan et al. (1999) also mentioned that academic achievement
(grade point average) was a strong predictor of self-concept.
The sense of industry vs. inferiority is developed during
middle and late childhood. Therefore, in addition to appre-
ciating academic achievement, children should be encouraged
in their efforts to increase their knowledge and skills in areas
where they have the most interest. In Taiwan, parents also
value academic achievements highly. Most of the children in
both groups, about 90%, had at least a fair academic
performance in this study, which seems consistent with the
ndings reported in the literature. However, the inuence of
academic performance on School self-concept needs further
investigation.
The Physical self-concept was signicantly lower in the
children with CHD despite that (1) we controlled for
personal attributive variables; (2) most of the children with
CHD (78.3%) had acyanotic heart disease; and (3) most of
the children with CHD (66.1%) had heart disease but were
asymptomatic. These ndings revealed that the perception of
exercise and physical condition in children with CHD was
lower than that of normal children. We surmise that during
middle and late childhood, children engage in active not
passive activities. Furthermore, most children are excellent
health during this period (Santrock 2002). However, chil-
dren with CHD may resent restrictions on their physical
Table 3 Logistic regression analysis of
higher T-score norms (50) for the self-
concept scale (SCS) between children with
CHD and non-CHD children
Variable
Children with CHD
(n 64)
Non-CHD
children (n 71) Crude effect Adjusted effect
n (%) n (%) OR (95% CI) OR (95% CI)
Family SC
<50 25 (39.1) 28 (39.4) 1.0 1.0
50 39 (60.9) 43 (60.6) 1.02 (0.512.03) 1.12 (0.492.57)
School SC
<50 15 (23.4) 17 (23.9) 1.0 1.0
50 49 (76.6) 54 (76.1) 1.03 (0.472.28) 1.12 (0.442.80)
Appearance SC
<50 20 (31.3) 28 (39.4) 1.0 1.0
50 44 (68.8) 43 (60.6) 1.43 (0.702.92) 1.57 (0.703.51)
Physical SC
<50 38 (59.4) 27 (38.0) 1.0 1.0
50 26 (40.6) 44 (62.0) 0.42 (0.210.84)* 0.51 (0.231.13)
Emotional SC
<50 21 (32.8) 30 (42.3) 1.0 1.0
50 43 (67.2) 41 (57.7) 1.50 (0.743.03) 1.82 (0.784.24)
General SC
<50 23 (35.9) 19 (26.8) 1.0 1.0
50 41 (64.1) 52 (73.2) 0.65 (0.311.36) 0.57 (0.251.31)
SC, self-concept; OR, odds ratio; CI, condence interval.
*P < 0.05.
Adjustment for sex, age, siblings, grade, school performance, marital status, fathers age and
education, mothers age and education.
C-W Chen et al.
400 2005 Blackwell Publishing Ltd, Journal of Clinical Nursing, 14, 394402
activity especially those children with clubbing of the ngers,
cyanosis and small, thin frames. These conditions may force
children with CHD to confront issues of disease and death
long before their peers (Yan et al. 1999). Based on the same
reasoning, Salzer-Muhar et al. (2002) indicated that male
adolescents with CHD had lower self-esteem than female
adolescents. Another possible cause of the lower School self-
concept may stem from a more sheltered upbringing where
the main caregivers who are more protective than those
guardians of healthy children. Kao et al. (2000) conducted a
study of 51 children with CHD aged 1012 years who had
completed surgical correction and found that 54.9% of their
parents were overprotective. The caregivers method of
childrearing should be considered when physical activities
are evaluated or restricted. Lastly, at this stage of develop-
ment, children begin to understand the relationship between
illness and the body. However, they still cannot understand
the interrelationships between organs or construct an integ-
rated view of organ systems (Vessey & OSullivan 2000).
They may still perceive their bodies as passive and need
guidance in adjusting after completing surgical corrections.
The General self-concepts between the two study groups
were not signicantly different. Similar ndings have been
reported by Yan et al. (1999) who found that the majority of
hospitalized school-aged Chinese children with a chronic
illness, including CHD, had at least an average level of self-
concept. Specically, the ndings indicated that children with
CHD scored higher than normal children in Family, Appear-
ance, and Emotional self-concepts, although the differences
did not achieve statistical signicance. Therefore, further
analysis on the ndings of SCS subconcepts of could provide
more meaningful interpretations.
Conclusions
This study provides important implications for nursing
practice. Our ndings support the need for clinical nurses
to be knowledgeable about the self-concept of hospitalized
school-aged children with CHD and for school nurses to
consider childrens self-concept development in elementary
school. Furthermore, nurses may use the study ndings to
encourage positive self-concept development. For hospital-
ized children with CHD, the institution should provide age-
appropriate information such as books, models or computer
software about the body to help them understand CHD,
cardiac catheterization and open heart surgery. Teaching
about physical activity before discharge is vital to ensure the
children are discharged from hospital with a clear under-
standing of their body and condition, and how it affects daily
life. In addition, the hospital could offer e-mail facilities to
allow the children to remain in contact with their friends.
The patient-mate could learn this information with a friend
with the same condition. The continuing academic achieve-
ment of hospitalized children can also enhance their positive
school self-concept. In school, the nurses and teachers may
encourage children with CHD to participate in peer activ-
ities, especially in physical exercise. For example, the
children may be assigned to be a timekeeper or a judge,
even if they are unable to participate actively. As for Family
self-concept, the nurses should observe family interactions
and understand how the children perceive themselves in the
family structure.
We recognize reviewer that the number of children with
CHD in the study is small, and generalization of the study
results is limited. Because of the limited sample size, any
attempt to perform stratied analysis by childrens age or
cardiac functional level would not yield statistically mean-
ingful data. In addition, other possible inuencing factors,
such as academic achievement in a cultural context,
individual family function, and family characteristics should
be explored in future studies.
Acknowledgements
This study was supported by grants from Division of
Academic Research, Ofce of Research and Development,
Fu-Jen Catholic University (4102-20021). We are grateful
to the children who participated in the study.
Contributions
Study design: CWC; data collection and analysis: CWC,
CYL, JK; manuscript preparation: CWC, CYL.
References
Alderman LM (2000) At risk: adolescents and adults with con-
genital heart disease. Dimensions of Critical Care Nursing 19,
215.
Bai BJ (1999) The investigation of elementary school childrens sex
role and the relationship between sex role and self-concept. The
Research of Elementary Education (Chinese) 4, 243279.
Byrne BM (2002) Validating the measurement and structure of self-
concept: snapshots of past, present, and future research. American
Psychologist 57, 897909.
Byrne BM & Shavelson RJ (1996) On the structure of social self-
concept for pre-, early, and late adolescents: a test of the Shavelson,
Hubner, and Stanton (1976) model. Journal of Personality and
Social Psychology 70, 599613.
Chen CY & Hsiang PT (1997) The relationship between sex, self-
concept and interpersonal relationship in 5th grade school-aged
children. Chuan-Shi (Chinese) 15, 120.
Women and children Self-concept
2005 Blackwell Publishing Ltd, Journal of Clinical Nursing, 14, 394402 401
Chen X, Rubin KH & Li D (1997) Relationship between academic
achievement and social adjustment: evidence from Chinese chil-
dren. Developmental Psychology 33, 518525.
Fuligni AJ (1997) The academic achievement of adolescents from
immigrant families: The roles of family background, attitudes, and
behaviors. Child Development 68, 351363.
Greenwald AG, Banaji MR, Rudman LA, Farnham SD, Nosek BA &
Mellott DS (2002) Aunified theory of implicit attitudes, stereotypes,
self-esteem, and self-concept. Psychological Review 109, 325.
Hou YL (1998) New theoretical trends in self-concept: multifaceted
hierarchical structure. Guidance Quarterly (Chinese) 34, 1123.
Hou YL (2001) The development of the self-concept scale for
elementary school children. Psychological Testing (Chinese) 48,
141166.
Hung RH (1993) The relationships study of elementary school chil-
drens self-concept. The Guide Report (Chinese) 1, 243279.
Kao YL, Wang RH, Pai L & Hwang BT (2000) Life adjustment of
school-aged children with congenital heart disease after corrective
surgery. The Journal of Nursing (Chinese) 47, 4354.
Marsh HW, Ellis LA & Graven RG (2002) How do preschool chil-
dren feel about themselves? Unraveling measurement and multi-
dimensional self-concept structure. Developmental Psychology 38,
376393.
McNelis AM, Huster GA, Michel M, Hollingsworth J, Eigen H &
Austin JK (2000) Factors associated with self-concept in children
with asthma. Journal of Child and Adolescent Psychiatric Nursing
13, 5568.
Neff JA (1990) Body knowledge and concerns. Nursing Times 86,
6771.
Salzer-Muhar U, Herle M, Floquet P, Freilinger M, Greber-Platzer
S, Haller A, Leixnering W, Marx M, Wurst E & Schlemmer M
(2002) Self-concept in male and female adolescents with con-
genital heart disease. Clinical Pediatrics 41, 1724.
Santrock JW (2002) Life-Span Development. McGraw-Hill Co.,
New York.
Shaffer DR (1999) Developmental Psychology: Childhood and
Adolescence. Brooks/Cole Publishing Co., Pacic Grove, CA.
Shavelson RJ, Hubner JJ & Stanton GC (1976) Self-concept:
validation of construct interpretations. Review of Educational
Research 46, 407441.
Spearman C (1927) The Abilities of Man. Macmillan, New York.
Vessey JA & OSullivan P (2000) A study of childrens concepts of
their internal bodies: a comparison of children with and without
congenital heart disease. Journal of Pediatric Nursing 15, 292298.
Wu YY & Hou YL (2000) Manual: Self-Concept Scale for
Elementary Children. (Chinese). Psychology Co., Taipei.
Yan H, Kantawang S & Yinghua Y (1999) Selected factors influen-
cing self-concept among hospitalized Chinese school-age children
with a chronic illness. International Journal of Nursing Practice 5,
3846.
C-W Chen et al.
402 2005 Blackwell Publishing Ltd, Journal of Clinical Nursing, 14, 394402