Asamblea general

As shown in Table 9, three concepts were identified from the interview data of the psychosocial effects of the 'Skeleton-in-the-cupboard. The first was concerned with effects on education and was comprised of five dimensions: academic attainment, school attendance, academic problems, family problems and attitudes towards learning.

The dimension o f academic attainment

The majority (59 per cent) of the diabetic group was successful in passing at least one national examination at A level. This was only achieved by 16 per cent (N=3) of those with CAH, with 63 per cent (N=12) of this group leaving school without any O or A level examination passes. The two groups were similar in

the types of schools attended, with a high proportion of both groups attending non-selective secondary schools (see Table 10).

TABLE 10: Types of schools attended by both groups

GROUP SELECTED SCHOOLS N (%) NON­ SELECTED SCHOOLS N (%) TOTALS N (%) CAH 3(16) 16 (84) 19(100) DIABETIC 6(35) 11(65) 17 (100) TOTALS 9(25) 27 (75) 36 (100) Chi square = 0.9288, d.f. = 1 N.S.

The type of school attended was not therefore a significant factor in the considerable differences between the groups in the levels of final educational attainment. The differences are unlikely to be directly related to the regimen demands of the chronic conditions. The demands for those with diabetes would seem to be greater during school days, and as already reported they recalled that the demand of the need for regular meals at school was felt to be considerable. The interview data suggested a number of other factors that may have contributed to school achievement.

The dimension o f school attendance

The presence of a chronic condition may necessitate absences from school due to ill health or attendance at hospital for inpatient and/or outpatient treatment. About a third of the women in each group recalled fi'equent absences during their school years, with the reason commonly given as their chronic condition:

I wish I could start school again, I've missed out on quite a lot o f things. I was in and out o f hospital, so I didn't go often, and not being well. (CIO)

I rejused school. I kept getting colds, I was always ill. (Cl 5)

I went to hospital a lot due to the fa c t that I was going through adolescence- I wasn't too well. I worked it out, it's about seven years o f my life I've spent in hospital. (C4I)

I missed so much schooling. In the sixth, I had less than one third attendance. I used to say (it was) cos o f the diabetes- it was awful. (D24)

By [the] end o f the fifth form, it was the equivalent o f one year o ff school with sickness. A t the time I never realised

it.(D26)

For the diabetic group, absences from school did not appear to be related to achievement; those reporting frequent absences did not also report educational difficulties and perceived themselves as achieving well in their schoolwork. It would seem that the diabetic group achieved their higher examination successes in spite of their frequent absences. In contrast, for those with CAH their frequent absences were associated with both self-perceptions of poor academic achievement and considerable academic problems.

The dimension o f academic problems

A further difference in the reports of school progress was the recall of experiences of academic learning problems. Although two (12 per cent) of the women with diabetes remembered 'examination nerves', no member of this group recalled any specific academic problems. All seven of those women in the CAH group who were frequently absent recalled learning difficulties with five of them having had difficulties in both reading and numerical skills, the remaining two in numerical skills:

I don't know any maths. Reading is a problem, I get bored 'cos I can't read it quickly enough. People were

getting on and I wasn't,- I thought, what's the point?(C04)

I was in and out o f hospital, so I didn't go [to school] very often, and not being well 1 fourni it very hard to cope at school, it was all too much. (CIO)

1 was ill so much when I was young. It was alright 'til I was about fourteen, then I didn't like it at all, I never used to go. 1 wasn't very bright, I didn't get on too well I had a special tutor, I can add up and take away, but anything like 'yards' and things I can't do. I regret not getting on at school very much. (C33).

I missed a lot o f school [I got on] very well actually. I didn't take any exams, but that was my own choice. I would say I was middle to top [in class position]. (D28)

The dimension o f family problems

The women raised a number of issues connected with their families that they felt had contributed to school difficulties. These were variable both in the type of problem and the characteristics of those recalling them. The problems ranged from constant house moves, deaths of family members, parental marital problems, and either a lack of or too much parental pressure to achieve at school. In both groups, such attributions were made by those who found it difficult at school, had specific learning problems, and did not obtain any nationally recognised examinations (low achievers) and also by those who obtained either ordinary or advanced level certificates of education (high achievers). Therefore little support was provided for a perception of family problems as major contributors to academic school achievement.

The dimension o f attitudes towards learning

The final dimension to be considered was the recall by the women of general attitudes towards academic learning. Rutter (1983) proposed that the

experience of attending school should promote more than academic achievement; school attendance should also develop positive attitudes towards learning and social skills. Both of these areas were discussed during the interviews and the data suggested differences in attitudes between the women with CAH and those with diabetes.

Women with CAH recalled holding negative attitudes towards learning, attitudes of a low level of commitment and co-operation:

1 was very argumentative-1 didn't want to learn. (C04. low achiever)

I didn't do a lot o f work,...I had a 'laid back' attitude to

school.(COS.high achiever)

I wasn't happy there, I was used to getting by on my brains alone-1 didn't work. (COJ.high achiever)

I couldn't be bothered. (C09.low achiever)

In comparison, although women with diabetes expressed regret that they had not made more of their opportunities, they recalled a commitment to learning:

I wouldn't say the school was highly academic, but it was nice- 1 wish I'd concentrated more, but I did my best. (D09.high achiever)

I didn't enjoy my time there at all. I regret I wasn't wise enough to make the most o f the opportunities, I kept on with it. (D24. high achiever)

I had a few problems with maths, but nothing I couldn't sort out, I found it difficult to understand, but I got my GCSE, (DlS.low achiever)

I was always near the bottom o f the class- I'm not a brilliant person, but I think I'm quick at picking things up. I didn't let school work get me down. (D29. low achiever)

In general, the women with diabetes, both good and poor attenders at all levels of a c ^ d w c achievement, .perceived themselves as having, coped adegu^ely. The CaH group women dfcT not recall school as easy am a(%)earea ro nave

lacked the determination to overcome any academic difficulties. Explanations for such differences in educational achievement might be through two classes of factors. One would be either the direct effects of the medical condition or the proposed effects of hormone levels both on general intelligence and on cognitive profiles, and the second the psychological effects of an early diagnosed chronic condition.

The first set of attributions needs to be examined on two issues: on the question of the reliability of the reported findings and on the direct attribution of the results of hormone levels.

The evidence from post-mortem studies has implicated hypoglaecemic attacks as a major cause of cerebral lesions even when the attacks themselves are not fatal (Brierley,1981). It is therefore possible that chronic diabetes could be associated with impairment on a variety of cognitive tasks although the results of studies attempting to directly test this association by comparison of those with diabetes and those without have been ambiguous (Franceschi et al, 1984;

Holmes, 1986; Ryan et a/, 1984). Prescott et al (1990) compared poorly

controlled to well controlled adult diabetics on a memory test, but failed to find any effect of the degree of glycaemic control upon cognitive performance. A highly significant correlation between memory performance and duration of illness was found, although the magnitude was very small and was considered

unlikely to give rise to any material handicap in daily life. The authors agreed with Ryan (1988) who suggested that the demands of diabetes were likely to result in a response style of cautiousness, and that this was the best overall explanation for their findings.

The results of the studies examining the effects of CAH on general intelligence (Sinforiani et al, 1994; Resnick et al, 1986; McGuire and Omenn, 1975) are

also ambiguous. The review of cognitive characteristics of CAH patients by Nass and Baker (1991) gave support for four findings: that CAH patients have a cognitive advantage; that this advantage is reversed to a disadvantage in CAH salt losers; that there is a possible increased risk of learning difficulties especially in connection with calculation abilities; and finally that post-pubertal CAH women may show an advantage in spatial ability. The conclusion that those with CAH may have a cognitive advantage has not been consistently replicated (Helleday et al 1994), and Nass and Baker (1991) reported increased

frequencies of learning difficulties for those with CAH. The results of studies comparing salt losers to simple virilisers show lower scores for salt losers (Helleday et al, 1994; Ehrhardt and Baker, 1974; Money and Lewis, 1966;

Wentzel et al, 1978). It was not possible in the present study to compare salt

losers with simple virilisers due to the small sample sizes. Given the high proportion of salt losers in the sample and the self-report of both general and specific educational difficulties, together with the lower final achievement levels compared to those of the women with diabetes, it might be considered that support for a cognitive disadvantage for those with severe levels of CAH has been supported. However, the educational outcome for this sample of women

with CAH may be a function of psychological factors. The difficulties reported by them in establishing and maintaining social relationships at school may have been an important factor.

The second issue to be considered concerns explanations for any cognitive profile differences. Cognitive characteristic have been attributed to the effects of hormone levels especially pre-natal levels, on the developing brain (Hampson and Kimura, 1992), but such attributions based upon biological essentialism have not received universal support (Vines, 1993; Kelly, 1991), and alternative factors may account for finding of any cognitive differences. It is proposed here that experiences contributing to the development of a 'Skeleton-in-the-cupboard' and its maintenance may be indirectly responsible for the patterns of low school achievement.

The relationship between frequent absences, family problems, attitudes towards learning and educational achievement were complex. Frequent absences and family problems were experienced by high and low school achievers of both groups; however attitudes towards learning suggested group differences with the diabetic group recalling a coping and the CAH group a 'can't be bothered' approach. It would be expected that those who held this latter attitude would not achieve highly at school, however both CAH achievers and non-achievers recalled a non-committal approach. It is proposed that a complex interaction of these factors may have been important in the levels of achievement attained in school. Frequent school absences resulted in poor progress with academic subjects and this, combined with the need to keep hidden the experiences of

CAH and therefore the reasons for their absences, may have had effects on school social relationships. Failure to establish school friendships has been found to result in low self-esteem, and low self-esteem has, in turn, been shown to be associated with poor achievement levels (Rutter, 1983; Asher and Coie, 1990). These proposed relationships will be further considered after the effect of the ‘Skeleton-in-the-cupboard’ on social relationships, has been examined.

The concept of the effects of the ’Skeleton-in-the-cupboard* on