myTREEHOUSE Self-Concept Assessment: preliminary psychometric analysis of a new self-concept assessment for children with cerebral palsy

According to a number of systematic reviews and meta-analyses, children with a physical disability or chronic illness have lower self-concept than children with typical development; including children with cerebral palsy (CP),1 developmental coordination disorder,2 asthma, diabetes, epilepsy, and juvenile arthritis.3 However, concerns have been raised over the meaning of these findings, as all have used self-concept assessments designed for children with typical development. Our systematic review4 and others5, 6 have indicated that self-concept assessments designed for children with typical development are unsuitable for children with disabilities. In addition, these assessments may present children with constructs that do not reflect their differing life experiences, or omit other important constructs. In support of this, our Delphi consensus survey7 showed that while clinicians/researchers, parents, and children with CP agreed that some items from commonly used self-concept assessments for children with typical development were appropriate for children with CP, they also proposed several additional items critical for reflecting self-concept of children with CP. Measures specific to CP are internationally supported for accurate assessment of quality of life,8 gross motor,9 and upper limb performance.10 We therefore propose this approach as a mechanism to improve self-concept assessment for children with CP.

In response to this challenge, we designed a new CP-specific self-concept assessment, called the ‘myTREEHOUSE Self-Concept Assessment’ (myTREEHOUSE). myTREEHOUSE is based on the developmental theories of ‘self’ that propose that self-concept development is dependent on the interaction between socialization experiences and cognitive processes.11, 12 In the paediatric context, Harter11 proposed that cognitive development impacts two areas of self-development. First, ‘differentiation’ involves the ability to compare one's performance between the real and ideal self. Second, ‘integration’ involves the ability to conceptualize one's overall self-worth based on various performance areas. (It is important to differentiate self-concept from self-esteem. Although still debated, self-esteem is commonly defined as the evaluation of self.13) In contrast, self-concept is the (evolving) product of this evaluation. Applying the developmental theory of ‘self’, we developed myTREEHOUSE to provide a child-reported evaluation of self-concept across three Performance Perspectives: (1) Personal – children's evaluation of their performance against their own personal standards; (2) Social – children's evaluation of their performance against the performance of their peers; and (3) Perceived – children's perception of how significant others like parents or teachers might evaluate their performance.

myTREEHOUSE then assesses each Performance Perspective across eight domains, including five domains from assessments for children with typical development13 that have been employed for children with CP,4 and three additional CP-specific domains derived from our Delphi consensus survey.7 The domains identified from existing assessments that were supported by Delphi survey participants are Physical Appearance, Learning Abilities, Social Skills, Emotional Regulation, and General Self. The new CP-specific domains are Physical Abilities, Personal Agency, and Ability to Participate.

In addition to evaluating performance, myTREEHOUSE also asks children to provide an Importance Rating – where children rate the importance they place on each item. Items viewed as more important are rated higher.11 Using the Importance Rating, a Personal Concern Score is derived, which highlights the difference between each child's Personal Performance Score and their Importance Rating, and flags key items or domains that are adversely impacting the child's self-concept. Self-report on constructs of self-concept is considered effective from the age of 8,11 which is the lower limit we recommend for using myTREEHOUSE.

This paper provides a preliminary psychometric analysis of the myTREEHOUSE Self-Concept Assessment for children with CP aged 8 to 12 years. Objectives were to evaluate its (1) validity, including face and content validity, and (2) reliability, including internal consistency and test–retest reliability.

Method

Ethical approval was obtained from the National Health & Medical Research Council registered Human Research Ethics Committees of the Cerebral Palsy League (EC00417) and the Australian Catholic University (EC00205).

Discussion

This is the first study reporting on the development of the myTREEHOUSE Self-Concept Assessment for children with CP aged 8 to 12 years, which measures self-concept using three Performance Perspectives and an Importance Rating over eight domains. Before this study, self-concept assessments developed for children with typical development were used for children with CP; however, those assessments did not fully capture the self-concept of children with CP. myTREEHOUSE was developed in response to the need for population specific self-concept assessments for children with physical disability,6 like CP,7 and the lack of well-validated assessments for this population.4, 5

myTREEHOUSE showed strong internal consistency across Performance Perspectives, with values comparable to existing self-concept measures validated for children with typical development20-22 or for children with CP, such as the Self-Description Questionnaire-I (Cronbach's α=0.76–0.94).23 Values were also comparable with those reported for other CP-specific measures of psychological constructs, such as the CP Quality of Life Questionnaire for Children (Cronbach's α=0.80–0.90).8

myTREEHOUSE showed moderate to good test–retest reliability. This finding is comparable with other CP-specific measures of psychological constructs, such as the CP Quality of Life Questionnaire for Children (ICC=0.76–0.89).8 Test–retest reliability is a recommended inclusion in psychometric testing13 but has not been consistently reported in evaluations of other self-concept assessments.4, 5 The current findings indicate that the myTREEHOUSE self-concept constructs are fairly stable and can be reliably assessed over time.

Impairments caused by CP may limit a child's access to their environment, resulting in a different life experience compared with children with typical development. myTREEHOUSE was constructed to include several CP-specific areas identified as important contributors7 under the domain names of Physical Abilities, Personal Agency, and Ability to Participate. Their inclusion provides a more comprehensive evaluation of self-concept for children with CP.

myTREEHOUSE has the unique ability to provide clinicians with a measure of self-concept from three Performance Perspectives (i.e. Personal, Social, and Perceived). Personal and Social Performance Perspectives are common features in most self-concept assessments for children with typical development13 but they are not evaluated as individual components, making it difficult to ascertain their relative contribution. Measuring these components separately, myTREEHOUSE allows clinicians to assess the relative weight of these perspectives to assist with determining appropriate intervention programmes to target the core difficulties for children with low self-concept.

Moreover, myTREEHOUSE has introduced a new evaluative perspective, the Perceived Performance Perspective, which evaluates a child's perspective of how others might view their performance. To date, this perspective has not been evaluated as an independent construct in self-concept instruments. Unlike their typically developing peers, children with CP are consistently exposed to evaluation by clinicians and caregivers, often being commented on in their presence, about their proficiency related to various areas of impairment. This reality for children with CP makes the Perceived Performance Perspective more important for their sense of self. By preadolescence, children have mastered the ‘role-taking’ skill (i.e. being able to step into another's shoes),24 which enables them to take in the judgement of others and incorporate this knowledge into their evaluation of self-concept.11, 12 Thus, the myTREEHOUSE Perceived Performance Perspective can provide clinicians with an insight into the best approach for discussing treatment progress to protect or promote each child's self-concept.

Furthermore, myTREEHOUSE also incorporates a Personal Concern Score that provides clinicians with the ability to identify domains of particular concern to the child. Harter22 introduced a similar scoring format in the Self-Perception Profile for Children and stressed its significance in interpreting self-concept,11 but this type of rating has not been included in other self-concept assessments used with children with CP.4 The myTREEHOUSE Personal Concern Score allows clinicians to target specific domains that are negatively impacting a child's overall self-concept.

Lastly, myTREEHOUSE includes two administration methods to facilitate the participation of children with a wide range of abilities: a Questionnaire Version and a pictorial Game Version. Stone and Lemanek25 emphasized the importance of designing self-report assessments for children to suit their capacity (e.g. attention span, reading and writing skills) and maintaining their interest using pictorial cues. Our Game Version, which uses not only pictorial cues but is presented in a game format, received favourable responses from both allied health professionals in the expert reference group and children with CP who participated in this study. Children indicated that they enjoyed the interactive nature of the game with the ramps making rating scales easy to comprehend.

This study introduces preliminary psychometrics for myTREEHOUSE. Sample size in this study was modest because of strict inclusion criteria for functional communication and cognitive ability, which resulted in a reduction in eligible participants. However, these criteria are important to ensure that participants have the language and cognitive ability to perceive the self and to engage in self-concept evaluation.5 Further investigation with a larger sample would allow for evaluation of construct validity using factor analysis to confirm the domains.