The role of loneliness in quality of life among children

Loneliness in children and adolescents is explained as an emotionally obtrusive experience arising from sadness and anxiety coming out of quantitative or qualitative deficiencies in social relationships of the child. Loneliness which is expression of general well-being and gratification obtained from life of individual as a whole effect the life quality of a child. In this research a cross-sectional and correlational study out of quantitative research methods was designed and conceptual model constituted in the direction of aim of research was examined by structural equation modeling. According to result of study, loneliness predict life quality negatively. This situation is quite important because social workers, psychological counselors, teachers and administrators would determine students’ feelings of loneliness and would develop and implement programs for these children to establish deeper and more stable relationships with their friends and families.


Introduction
Life quality is expression of general well-being and gratification obtained from life of individual as a whole.WHO (1996) describes life quality as perceiving manner of life position within the culture and values system together with goals, expectations, standards and anxieties of individual.Many studies were held to determine life quality of adults and elderly so far.In recent years, studies were developed to evaluate life quality of children.It is important to investigate the concept of life quality during childhood, because childhood experiences affect level of welfare in coming ages (Wallander & Koot, 2015).
There are six dimensions determined to measure life quality: physical health, psychological condition, level of independence, social relationships, environment, religion/spirituality/personal beliefs (WHOQOL group, 1995).When scales revealing life quality of children are reviewed, there are items related to physical, social, emotional, school functionality.Dimensions suggested by WHO (1993) to measure life quality of children and characteristics related to these dimensions are as follows; family/social relationships: role within family, valuable adults, parent relationships, family dynamics, family life style, animals, friends; physical conditions: mobility, function, sleep; psychological (inner): signification to himself/herself, perceived control, crime, mood, confidence, physical appearance: body image, hair, height, psychosocial relationships with social and material environment: security, future expectations, value given to important people, game, choices, options, acceptance; environment: school, meal, housework, place, financial security.It is found that physical functionality in children is evaluated by activities like having bath, running, doing daily routine at home; social functionality is measured with activities like meeting with peers, adapting to peers, stepping with peers (Uneri & Memik, 2007).At this juncture, it is beneficial to mention the concept of loneliness which is one of the concepts able to influence social and emotional functionality of children and by this way, would determine level of life quality.Because loneliness is a factor affecting life quality negatively being a feeling making individual far from others, cutting off communication and as a result, feeling sadness (Parkhurst & Hopmeyer 1999).
Loneliness in children and adolescents is explained as an emotionally obtrusive experience and this situation arise from sadness and anxiety coming out of quantitative or qualitative deficiencies in social relationships of the child (Bucholz & Catton, 1999;Hymel et al, 1999;in Juntila, 2010).Primary school students' social and emotional wellness and situation of loneliness is explained depending on social relationships and social skills (Vauras & Junttila, 2007).Children suffering loneliness have underdeveloped social skills and their interactions with other people are weak and negative both in their childhood and in later periods (Stoeckli, 2010).
Research studies show that feeling of loneliness results in negative consequences in lives of children (Juntila, 2010); loneliness is related to risk of dropping out in children (McWhirter et al., 2002;Page & Scanlan, 1994), depression and anxiety disorders (Boivin et al., 1995;Buchholtz and Catton, 1999;Moore & Schultz, 1983;Storch et al., 2003), social avoidance of children (Nurmi et al., 1996), deficiency in self-confidence (Goswick and Jones, 1982;Inderbitzen et al.,1992) and experiencing adaptation problems by developing a negative style (Ireland and Qualter, 2008;Pavri, 2001;Milsom et al., 2003).Therefore, loneliness should be evaluated as a factor influencing life quality both in childhood and in coming years.Demos (1974) conducted a study on children aged between 9 and 12 and found that children feel lonely when "they are alone (e.g. when nobody plays with them), when they do not have a group of friends they have good communication with, when they are mentally isolated (e.g. when they travel alone, when they are ill, etc.), when they are rejected by friends and when they are fed up or bored (e.g., when they do not want to do anything)".As it is seen, social functionality of children determines the condition of loneliness and as a result, this influence level of life quality.
On the other hand, it is seen that in scales developed to measure life quality, the reality that the individual is in a dynamic interaction is taken into account and the individual's physical, emotional and social wellness is investigated as dimensions (Gumus, 2010).Satiation out of life is affected by physical health, mental health, social relationships and personal beliefs and attitudes (Asut, 2014).
At that point, it is necessary to draw attention to the importance of social work occupation which evaluates applicants within the system they are in with an understanding of "individual in its environment", focuses on individuals' interactions with those systems, social functionality and wellness situation on life quality studies.Social workers make studies in level of individual, family, group, society with an ecological perspective and clear up problems arising from interactions of systems the individual is in and develops interventions for solutions (Zastrow, 2013).By this way, applications at the micro, mezzo and macro levels have an important effect on life quality of individual.In the field of children, which is one of the basic domains of social work occupation, professionals look at problems of children on a multidimensional frame by investigating the child within levels of family, school context, peer groups, neighborhood and community and make positive contributions to general well-being of children and as a result, to life quality with interventions they developed.
Social workers evaluate many factors would cause in feelings while dealing with subject of loneliness as a factor affecting life quality.These factors can be listed as child's losing of a liked friend or subject, divorce of parents, rejection by peers, starting a new school, being deprived of necessary social skills for making friends (Bullock, 1998).As it could be seen, when such factors are focused on, studies could be made at the levels of family, friends, school and teachers, factors causing child's loneliness can be determined correctly and so effective solutions can be produced.
Most of research studies conducted about life quality is related to children and adolescents in literature.This study aims to search for life quality and loneliness of healthy children.In this context, aim of this study is to determine relationship between loneliness level and life quality of children.

Material and Method
In this research, a cross-sectional and correlational study out of quantitative research methods was designed.Correlational studies are studies by which relationship between two or more variables are investigated without intervening to these variables.It can be said that correlational studies are important in terms of examining relationships between variables, effective in determining levels of relationships and revealing necessary data in order to make upper level studies about these relationships (Buyuk Ozturk, Cakmak, Akgun, Karadeniz & Demirel, 2008).

Procedure
Data analyzing was made by LISREL 8.8 package program.Structural Equation Modeling is a comprehensive statistical method used to test models containing hypothesis directed to causal and correlational relationships among observable and non-observable (hidden) variables (Hoyle, 1995).According to Kline (1998), together with use of structural equation modeling for similar aims to multiple regressions, multiple indicator variables, two or more implicit variable, associated error term, measured independent implicit variables are used more strongly in interactive modeling of measurement errors.In order to examine relationships between variables, structural equation model has been used in this study.
In this research study, loneliness scale for children and life quality scale was used.Loneliness Scale for Children is a 24-item, 5-degree likert type assessment tool developed to measure perceived loneliness of children by Asher, Hymel, Renshaw (1984).During progressing of the original scale, after a factor analysis made by 16 items, a one-factored structure has been emerged.There are 16-items to measure loneliness of children and 8 filling items (2, 5, 7, 11, 13, 15, 19 and 23) asking about hobbies in the scale.Scores those could be obtained from the scale is between 16 and 80.In reliability study of 16 items in the scale, Cronbach alpha is found to be .90.Totally 10 of Loneliness Scale have negative meanings (items 3, 6, 9, 12, 14, 17, 18, 20, 21 and 24).Scale adaptation study has been conducted by Duyan, Calik Var, Kilic (2015) and reliability score (Cronbach Alpha) was found as 0.82.Confirmatory factor analysis results for validity found the scale to be valid and reliable for Turkish society.Increment of scores obtained from the scale show the increment in loneliness.
Life quality scale for children was developed by Varni et al. (1999) in order to measure life qualities of children and adolescents between ages of 2 and 18.This scale consists of 23 items and 4 subdimensions.There are 8 items measuring physical functionality, 5 items measuring emotional functionality, 5 items measuring social functionality, 5 items measuring functionality at school.Scale is a 5-degree likert type (0= never, 1= rarely, 2= sometimes, 3= often, 4= almost always) assessment tool.Reliability of scale was found to be 0.93 (Cronbach alpha) and it is determined that the scale is valid, reliable and sensitive (Varni et al., 1999).In the Validity and Reliability study of Memik et al. (2008), Childhood Form, Ages 8-12 of Life Quality Scale for Children, inner consistency of scale was found to be 0.86.

Statistical Analysis
Multivariate statistical techniques including Structural Equation Modeling are based on some assumptions and reliability of statistical tests obtained by related techniques depend on procuring of these assumptions (Kalayci, 2009).When the data is examined, it is found that missing data is coincidental and there is no assignment.After that, one-way and multiple extreme value analysis was made.It is seen that the values are in desired range.Then, coefficient of skewness and flatness coefficients were examined for one variable normality, it is found that values are in between ±1.0 and data set provides one-variable normality.It is investigated by using graphics whether variables meet linearity and multiple normality assumptions and it is found that the assumption is met.In multiple variable analysis made by structural equation model, sample size should be between 200 and 500 people.The closer this value to 500, the better the reliability of the model (Kline; 2005).In the light of that information, size of data set is found to be appropriate for analysis.

Result
Conceptual model constituted in the direction of aim of research was examined by structural equation model.Results are given in Table 1 and Figure 1.When the figure and table are examined, it is seen that loneliness affects life quality negatively.After analysis, when we look at the proportion of chi square value of conceptual model to degree of freedom (‫/2א‬sd), it can be seen that this value (‫/2א‬sd=2.50) is in between acceptable limits (‫/2א‬sd ≤ 5).This finding can be interpreted as model has good fit index a.Also, one of the fit indexes, RMSEA is found 0,069.When we look at other fit indexes (GFI; 0.88 and AGFI; 0.85 and SRMR; 0,072) it is seen that the model shows acceptable adaptation.In addition, values as CFI; 0.94, NFI; 0.90 show that model has good fit index.That is, conceptual model provide acceptable fit of model.

Discussion
Today, with changing world and diversification of family structures and school contexts and with increasing individualism with technology, children experience loneliness more (Rokach & Shick, 2014).Perceived loneliness of children affects academic and social lives of children (Rokach, 1996).Perception of loneliness that could develop as a result of different variables influence many fields in life of child and this negative effect show itself within school environment that the children spend most of their life.
In a study held in children of sixth grade by Stoeckli (2009), almost two third of children (%38) stated that they experience loneliness in the school environment.A similar study was conducted by Galanaki (2004) and children described their lonely times as when they are rejected by peers; when they make low-quality friendships and when they avoid school.In addition, in the study, it was found that loneliness is related to difficulties like anxiety, shyness, aggressiveness and cognitive problems.
Studies attract notice to relationship between physical health problems, depression, rejection of peers, situation of being aggressive or victim, anxiety, low level of self-esteem, low social status and degree of loneliness in children (Bakkaloglu, 2010;Qualter, Brown, Munn, & Rotenberg, 2010).In Vellymalay (2013)'s study on loneliness and social dissatisfaction in children, children answer the question "Do you feel lonely at school?" as yes to 52.8% and "Are you alone at school?" as yes to 44.4% and by this way report their condition of loneliness and social dissatisfaction.Edward et al. (2002) investigated life quality of adolescents by qualitative research methods.In this study, adolescents were asked which themes affect their life quality most and it is found that mostly chosen themes are friendship, family, believing himself/herself, school respectively and least chosen themes are freedom, health, spirituality.Therefore, it can be inferred that friendship and family relationships are determinant on life quality of children and life quality of children far away from human relationships would be affected negatively.Studies in literature coincide with findings of the study.
When life quality studies in children are interviewed, it is seen that life quality of children who has a disorder is measured mostly.Di Battista et al. (2014) found that, in adolescents with traumatic brain damage, depression is a determinant of life quality in these adolescents.In a study by Houben-van Herten et al. (2015), they conducted a study to determine life quality determinants about health in children aged 4-11 and they found that socio-economical, demographical, family/environmental factors have a contribution to life quality of children.Kupeli (2009), in the study assessing life quality of children with cancer, found that the disorder influence especially school functionality negatively.These results show the effect of illnesses on life quality.Erturan et al. (2014) found in their research study that acne affect negatively adolescents' life quality, loneliness and life satisfaction levels.
According to results of this study, life quality and life satisfaction of adolescents with acne decrease significantly compared to controls and their levels of loneliness increase significantly.
In the study of Eser et al. (2008) in which the life quality scale developed for children; Kid-KINDL was adapted to Turkish; it was found that being a male, wellness of perceived health condition, having a high family income level, being from upper social class, mothers' being more educated, not working in a job after school and high level of school success was higher significantly compared with opposites both in total life quality and sub-dimensions.
The fact that loneliness result in depression, peer bullying, low sense of self, academic failure, rejection, negative perception of future, acquisition of harmful habits, influence the children with these emotional situations in terms of their life quality and social adaptation.As a result, this situation is quite important because social workers, psychological counselors, teachers and administrators would determine students' feelings of loneliness and would develop and implement programs for these children to establish deeper and more stable relationships with their friends and families.

Figure
Figure 1.Conceptual Model