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Abstract

  1. Top of page
  2. Abstract
  3. Method
  4. Results
  5. Discussion
  6. Acknowledgements
  7. References
  8. Supporting Information

The objective of this study was to characterize participation in leisure activities in children with cerebral palsy (CP) and identify determinants of greater involvement. Ninety-five children of school age (9y 7mo [SD 2y 1mo]) with CP were recruited, and participation was evaluated with the Children’s Assessment of Participation and Enjoyment in a subset (67/95; 42 males, 25 females) who could actively participate in completion of the assessment. Most had mild motor dysfunction (Gross Motor Function Classification System: 59% level I, 23% level II, 18% levels III–V) and had a spastic subtype of CP (23 hemiplegia, 17 diplegia, 16 quadriplegia, 11 other). Biomedical, child, family and environmental predictor variables were considered in the analysis. Results demonstrated that these children were actively involved in a wide range of leisure activities and experienced a high level of enjoyment. However, involvement was lower in skill-based and active physical activities as well as community-based activities. Mastery motivation and involvement in rehabilitation services enhanced involvement (intensity and diversity) in particular leisure activities, whereas cognitive and behavioral difficulties, activity limitations, and parental stress were obstacles to participation.

Children with cerebral palsy (CP) experience motor impairments, as well as deficits in other domains, which impact on their ability to move, solve problems, communicate, and socialize. These children may, therefore, also be at risk for less participation in leisure activities. Participation, defined as taking part or being involved in everyday life activities and roles, is a new concept brought to the forefront by the World Health Organization’s International Classification of Functioning, Disability and Health.1 Leisure activities are typically those in which an individual freely chooses to participate during their spare time because they find such activities enjoyable. Participation in leisure activities has emerged as an important ‘outcome’ for children with disabilities, with benefits that include fostering friendships, enhancing skill competencies, and developing personal interests and identity.2

A recent systematic review on participation in leisure activities in children and adolescents with CP has highlighted that very few studies have described this domain in this particular population.3 A Canadian study reported that the pattern of participation did not differ for children with CP in comparison with those with other physical disabilities.4 Another Canadian group found that children with CP exhibited important disruptions in their participation in life situations, particularly in recreational and community-based activities.5 Within the school setting, children with CP demonstrated limitations in their ability to participate in playground and recess activities.6 Evidence suggests that children with a variety of disabilities are involved in fewer activities than their peers, and that these activities tend to be home-based and less physically active, with fewer social engagements.4,7,8

Little evidence exists as to which attributes are facilitators or barriers to involvement in and enjoyment of leisure activities. Identification of these attributes is important in guiding future programs, services, and policies aimed at enhancing participation. Variables that are emerging as possible determinants are the following: child factors, such as severity of disability; personal factors, such as age, sex, and socioeconomic status; and environmental factors that include parents’ education, family preferences, social supports, and environmental resources.3,7,9–12 Further validation of these findings in children with physical disabilities is needed to determine which factors are generic (non-categorical) and which are disability-specific (categorical). Furthermore, exploration of other potentially modifiable attributes such as motivation, specific developmental problems, family function, and access to services is needed.

Traditionally, health care for children with CP focuses on early diagnosis, precise classification, and efforts to diminish motor impairments such as spasticity, muscle weakness, and decreased range of motion, and to manage associated challenging medical comorbidities. Rehabilitation programs have begun shifting focus from minimizing deficits to enhancing functional success and participation in spite of persisting deficits. Targeted interventions aimed at improving quality of life and participation are lacking, in part because of limited data on the factors that influence these outcomes.13 Further evidence is needed to identify attributes of the person and their environment that might potentially be modified to promote participation and community engagement. The primary objective of this study was, therefore, to describe the level of participation in leisure activities in children with CP and to identify factors that are associated with diversity, intensity, and enjoyment of these activities.

Method

  1. Top of page
  2. Abstract
  3. Method
  4. Results
  5. Discussion
  6. Acknowledgements
  7. References
  8. Supporting Information

Participants

Children were recruited from a database of all children referred to a single neurologist and seen either in the hospital’s neurology clinic, neonatal neurology follow-up clinic, private office, or a suburban community clinic. This sample is representative of children with CP from a local community who are routinely sent to a pediatric neurologist for diagnosis, etiological determination, and referral for rehabilitation services. CP was defined in accordance with Badawi et al.,14 whereby progressive processes, disorders of non-cerebral origin, and specific syndromes were excluded. Parents who could not easily read or converse in English or French were excluded from participation.

Procedures

A historical cohort of children diagnosed early in childhood (1991–2001) with CP by a neurologist (MS) and of school age during recruitment was approached for participation in this study. Baseline characteristics of this sample and the etiological profile have been reported.15 Once consent had been obtained, an appointment was made to perform assessments by evaluators at the Montreal Children’s Hospital. An occupational therapist conducted a semi-structured interview for the Vineland Adaptive Behavior Scale,16 and children completed the Children’s Assessment of Participation and Enjoyment (CAPE).17 In addition, the occupational or physical therapist administered the Gross Motor Function Measure and the Gross Motor Function and Classification System to document the level of gross motor ability.18,19 A psychologist administered the Leiter Intelligence test.20 Parents completed self-report measures of health-related quality of life Pediatric Quality of Life Inventory (PedsQL),21 child’s mastery motivation (Dimensions of Mastery Questionnaire),22 behavioral difficulties (Strengths and Difficulties Questionnaire),23 family coping (Impact on Family Scale)24, and stress (Parenting Stress Index).25 The above measures were selected because they are age-appropriate, have sound psychometric properties, and may be used with children who have physical limitations. Evaluators were blind to medical history, the specific objectives of the study and were not providing services to these children. Demographic information, type of schooling, and current services provided were also collected by using a formal questionnaire. A neurologist examined participants to validate the diagnosis and to classify the pattern of impairment. Assessments took 2.5 to 3 hours, with a break as needed. In all, 95 children were recruited. Predictors of quality of life have been reported.26

Measure of participation and predictor variables

The CAPE17 was administered only to those children in our sample who were able to participate actively in completing this measure, often with the assistance of their parent. An occupational therapist reviewed the pictorial items with the child, who indicated the intensity of involvement in each activity (how often, on a 7-point ordinal scale from once in the previous 4 months to daily), as well as their level of enjoyment (rated from 0 to 5, with a score of 5 indicating a high level of enjoyment). Items can be classified as formal activities (structured, preplanned) or informal activities (spontaneous). Furthermore, items may be categorized into five activity scales: social, recreational, active-physical, skill-based, and self-improvement. Scores for these subscales may be obtained for mean intensity (frequency) and mean enjoyment. In addition, the diversity (variety within a domain) may be calculated. Reliability estimates for the CAPE range from 0.75 to 0.93, and validity has been demonstrated.27 This instrument was forward translated and back translated to Canadian French. Factors considered in the analysis of variables that may be associated with involvement in and enjoyment of leisure activities appear in Table I.

Table I.   Predictor variables considered on univariate analysis and the mean performance on these measures for the sample (n=67)
CategoryPredictor variableMeasureProportion or mean (SD) rangePercentage below cutoff, if applicable
  1. GMFM, Gross Motor Function Measure; VABS, Vineland Adaptive Behavior Scales.

Biomedical factorsEtiological determinationYes/no (database) 
History of neonatal difficulties, gestational ageYes/no (database) weeks 
Pattern of motor impairmentSpastic subtypes (neurological examination)23 (35%) hemiplegia, 17 (26%) diplegia, 16 (24%) quadriplegia
Body function and activityBehavioral difficultiesStrengths and Difficulties Questionnaire12.1 (6.6) 0–2815.8 borderline; 28.1 abnormal
Intellectual abilitiesLeiter Intelligence ScaleBrief IQ: 82.2 (21.1) 38–14325.9<70 for both
  Fluid reasoning: 82.8 (18.7) 50–126 
Motor functionGMFM76.5 (23.5) 81–100
CommunicationVABS Subscales74.3 (25.9) 20–12353.1<78
Socialization 82.7 (19.9) 20–11734.4<78
Daily living skills 69.0 (26.3) 20–11256.3<78
Adaptive behavior 71.0 (23.9) 20–11656.3<78
Personal factorsSexMale/female42 (63%) male, 25 (37%) female
Age at assessmenty:mo9:7 (2:1) 6:1–12:11
IncomeTotal household income 
Child’s mastery motivationDimensions of Mastery ScaleTotal motivation: 3.3 (0.5) 1.8–4.5 Total persistence: 3.2 (0.5) 1.8–4.4
Environmental factorsFamily functioningParental Stress Index62.9 (34.9) 1–99 40%>85th centile; 15%<15th centile
 Impact on Family Scale28.6 (10.5) 15–55
School settingSegregated/integrated44 (66%) regular, 22 (33%) special school, 1 (1%) home schooled
Rehabilitation servicesYes/no (previous 6 months)51 (76%) yes, 13 (19%) no, 3 (5%) not specified

Statistical analyses

Descriptive statistics were used to characterize the sample. Given that there is limited direct evidence of the predictors of participation in leisure activities in children with CP, we could not confidently test a particular hypothesis by which specific predictor variables were identified. Univariate analyses were first conducted to determine which independent variables were associated with the CAPE scores. For continuous data, Pearson’s correlations were carried out, and simple linear regression analysis was performed for categorical variables. We also considered conceptual information from the literature to identify variables for the regression models. We then used a stepwise selection model to explore initially which variables seem to have the greatest association with the CAPE. Additional model selection methods based on adjusted r2, Mallows’ Cp, and Akaike Information Criterion, were simultaneously implemented as well. Finally, a multiple linear regression model was run that included those variables identified in the above procedures with redundant variables removed, to obtain the best model. Given the statistical concerns of using a stepwise selection process,28 we also further validated our final models using bootstrap methods, whereby we analyzed the models on observations with replacement on repeated samples of the same size as the original sample (2000 replications). Bootstrap estimates and Bias Corrected Accelerated confidence intervals are tabulated with the best predictive models for comparison. Although bootstrap methods may also be criticized, this provided more compelling evidence to reinforce the validity of the reported regression models.29

Results

  1. Top of page
  2. Abstract
  3. Method
  4. Results
  5. Discussion
  6. Acknowledgements
  7. References
  8. Supporting Information

Group characteristics

Of 95 school-aged children recruited to this study, 21/95 were untestable (cognitive and/or language limitations), and 7 were unavailable, leaving 67 children who were able to participate in completing the CAPE questionnaire. As expected, these children were more likely to have less limitations in motor function (Gross Motor Function Classification System: 59% Level I, 23% Level II, 18% Levels III–V). Most children (86%) had a spastic pattern of CP. Preterm birth was noted in 53.7%. Two-thirds of the children were integrated into regular schools, and most were receiving ongoing rehabilitation services. Demographic characteristics and performance on measures used for prediction appear in Table I. Although the sample primarily included children with relatively good gross motor function, developmental and functional assessments indicated that one-quarter of them had intellectual deficits and behavioral problems, and many had activity limitations across domains. More than half of the parents were either highly stressed or defensive, as measured by the Parenting Stress Index.

Performance on the CAPE

Mean scores on the subscales of the CAPE appear in Table SI (Supporting Information published on line). Children participated in a wide range of predominantly informal activities. With respect to intensity, children in our sample participated in recreational activities most often, and also in social and self-improvement activities. In comparison with a typically developing reference sample (M Law, personal communication, 2008), the intensity of involvement in leisure activities was lower in children with CP but was similar to that of a reference group of children with neurological impairments.4 Intensity for active-physical activities was lower in our sample than in reference samples with or without impairments. Children indicated a high level of enjoyment for formal and informal activities, with somewhat lower enjoyment of self-improvement activities. Enjoyment levels were as high as (or higher than) those of typically developing peers, with the exception of skill-based activities, which were slightly lower.

Table II lists all CAPE activities by domain, and highlights the activities that children in our sample most frequently participated in (at least weekly). Few children (6% or less) participated in martial arts, art lessons, played a musical instrument or had a paid job. In addition, 76% were not part of community groups, 85% did no volunteer work, and 87% were not in school clubs. Intensity of formal activities was highly associated with their diversity (r=0.94); however enjoyment of formal activities was only weakly associated with the frequency and number of these activities in which the child participated (r=0.25–0.28). Similarly, the intensity and diversity of informal activities were highly correlated (r=0.89); however, enjoyment of these activities was moderately related to the frequency (r=0.41) and number (r=0.33) of the activities.

Table II.   Children’s Assessment of Participation and Enjoyment activities by domain
Activity typeActivities
  1. Activities in bold type are those in which >50% of the sample participate, at least weekly; activities in italic type are pursued by 30 to 50%.

RecreationalDoing puzzles; Playing board or card games; Doing crafts, drawing or coloring; Collecting things; Playing computer or video games; Playing with pets; Doing pretend or imaginary play; Playing with things or toys; Going for a walk or hike; Playing on equipment; Watching TV or a rented movie; Taking care of a pet
Active-physicalDoing martial arts; Racing or track and field; Doing team sports; Participating in school clubs; Bicycling, in-line skating, or skateboarding; Doing water sports; Doing snow sports; Playing games; Doing a paid job
SocialTalking on the phone; Going to a party; Hanging out; Visiting; Going to the movies; Going to a live event; Going on a full-day outing, Listening to music; Making food
Skill-basedSwimming; Doing gymnastics; Horseback riding; Learning to sing (choir or individual lessons); Taking art lessons; Learning to dance; Playing a musical instrument; Participating in community organizations; Dancing
Self-improvementWriting letters; Writing a story; Getting extra help for schoolwork from a tutor; Doing a religious activity; Going to the public library; Reading; Doing volunteer work; Doing a chore; Managing an allowance; Doing homework; Shopping

Factors associated with participation

Involvement in a smaller number (diversity) of formal, structured activities was predicted by lower communication scale scores (Vineland Adaptive Behavior Scales; β=0.02, p=0.05) and hyperactivity (Strengths and Difficulties Questionnaire; β=–0.11, p=0.03), together explaining 12% of the variance. Intensity of participation in formal activities had no significant predictors identified. Enjoyment of formal activities was associated with conduct problems (β=0.29, p=0.006), no hyperactivity (β=–0.19, p=0.001), and female sex (r2 for the model, 0.34, p≤0.001). The number of different informal activities that the children participated in was predicted by higher IQ (β=0.08, p=0.006) and better Gross Motor Function Measure (GMFM) score (β=0.04, p=0.10), together explaining 21% of the variance (p<0.002. Greater intensity of involvement in informal activities was associated with higher IQ (β=0.01, p=0.02) and less impact of the health condition on the family (β=–0.02, p=0.05), with an r2 for the model of 0.26 (p=0.001). Greater enjoyment of informal activities was related to lower IQ, lower parental stress (child), female sex and a younger age at assessment (r2 for the model=0.45, p<0.001).

Multiple regression analyses were also carried out for each of the five activity subtypes. The best predictive models for intensity of involvement in each of these activities appear in Table III. Table IV documents the best models for diversity of involvement in these activity subscales, and Table SII (Supporting Information published online) describes the best predictive models for the enjoyment of each the activity subtypes. Overall, level of involvement (frequency, intensity) in recreational activities was predicted by conduct problems, mastery motivation, level of independence in everyday activities, and parental distress. Children with better motor function and no etiological determination were more involved in active-physical activities. Social involvement was greater in children with fewer functional limitations, and greater pleasure in mastery. Children who continued to receive rehabilitation services were more likely to participate in skill-based activities. Older children with better communication skills and less parental stress as a result of fewer child difficulties were more likely to be involved in self-improvement activities.

Table III.   Best predictive models for intensity of involvement in activity domains of the CAPE
Outcome measurePredictor variablesp (model)r2 (% variance)Parameter estimatep (variable)Bootstrap
EstimateBCa; 95% CI
  1. CAPE, Children’s Assessment of Participation and Enjoyment; BCa, Bias Corrected Accelerated; CI, confidence interval; GMFM, Gross Motor Function Measure; VABS, Vineland Adaptive Behavior Scales.

RecreationalMastery motivation (total)0.006180.670.0110.680.13; 1.16
Behavioral problems (conduct)0.170.0310.17−0.007; 0.31
Active-physicalEtiology<0.00142−0.680.004−0.69−1.21; −0.20
GMFM score0.02<0.0010.020.01; 0.03
SocialVABS (adaptive behavior)<0.001330.02<0.0010.020.007; 0.03
Mastery pleasure0.48<0.0010.480.21; 0.68
Skill-basedRehabilitation services0.01590.660.0150.660.29; 1.05
Self-improvementVABS (communication)<0.001440.010.0030.010.006; 0.02
Parental stress (difficult child)−0.030.017−0.03−0.06; −0.007
Age at assessment0.130.0070.130.05; 0.22
Table IV.   Best predictive models for diversity of involvement in activity domains of the CAPE
Outcome measurePredictor variablesp (model)r2 (% variance)Parameter estimatep (variable)Bootstrap
EstimateBCa; 95% CI
  1. CAPE, Children’s Assessment of Participation and Enjoyment; BCa, Bias Corrected Accelerated; GMFM, Gross Motor Function Measure; VABS, Vineland Adaptive Behavior Scales.

RecreationalVABS (daily living skills)0.001330.020.0810.02−0.003; 0.03
Mastery pleasure0.790.0070.810.33; 1.35
Behavior problems (conduct)0.360.0150.360.17; 0.58
Parental stress (parent distress)−0.050.035−0.05−0.095; −0.01
Active-physicalGMFM score<0.001230.03<0.0010.030.02; 0.04
SocialIQ (composite)<0.001360.03<0.0010.030.02; 0.05
Mastery pleasure0.570.0200.570.10; 1.05
Skill-basedRehabilitation services0.014101.170.0141.170.54; 1.82
Self-improvementVABS (communication)<0.001400.030.0030.030.01; 0.04
Age at assessment0.200.0260.210.04; 0.37
GMFM score0.020.0380.020.005; 0.04

The level of enjoyment was high overall for all types of recreational activity; nonetheless, several factors emerged as predictors of high enjoyment. Children with problematic peer relationships seemed to experience greater enjoyment of recreational and social activities; however, children with hyperactivity were less likely to enjoy skill-based activities. Children for whom parents reported high stress levels were less likely to enjoy most types of activity. Children with higher IQ were less likely to experience enjoyment of recreational activities, and males were less likely to enjoy skill-based and self-improvement activities. Older children were less likely to enjoy self-improvement tasks. Those receiving rehabilitation services were more likely to enjoy active-physical activities.

Discussion

  1. Top of page
  2. Abstract
  3. Method
  4. Results
  5. Discussion
  6. Acknowledgements
  7. References
  8. Supporting Information

So far, few studies have described participation in children with CP, with a paucity of information on leisure activities.30–32 In the present study, school-aged children with CP reported that they participate in a wide variety of leisure activities, although activities were less diverse and largely home-based, confirming reports on other groups with disabilities.4,7,8 The paucity of community-based activities would suggest that this might be an area to promote and encourage, so as to enhance community engagement. Involvement in active- physical and skill-based activities is diminished compared with other leisure activity types, a phenomenon reported in children with a wide range of physical disabilities.4 It is noteworthy that few children engaged in art lessons or learned to play musical instruments. Assistive technologies and virtual reality interventions may be approaches to consider in this regard. Enjoyment of leisure activities was as high as for typically developing peers,33 and was positively correlated with the number and frequency of involvement, particularly for informal activities.

The identification of determinants of participation is important because this helps guide effective health promotion strategies and policy initiatives that would enable children with CP to participate more fully in society, achieving greater life satisfaction. King et al.9,34 tested a model of determinants of participation in leisure activities for children with physical disabilities. Factors that influenced participation included aspects of the physical, social and attitudinal environment, family function and preferences, and child’s impairments and activity limitations. Using this model and the ICF as a framework, we examined several biomedical, body function and activity, and contextual factors as determinants of participation in leisure activities. A range of predictors were identified, underscoring the complex, multidimensional nature of participation. Overall, the factors associated with the five activity subtypes were similar, whether we were examining intensity (how often) or diversity (how many).

The only biomedical factor identified was knowledge of an underlying proximate cause for motor impairment being associated with diminished involvement in active-physical activities. Clinical evidence of etiology is related to severity of motor disability (GMFM score significantly lower in those with an etiology, p<0.001) and is thus indirectly related to participation. Previous studies have identified seizures as a predictor of participation,31 but, in general, biomedical factors do not seem to exert a strong influence on participation.

We examined several measures of body function and activity as possible determinants. Not surprisingly, motor function was associated with involvement in active physical and self-improvement activities. Others have noted that severity of motor dysfunction is associated with disruption in participation in recreation and other life habits;5,31 however, our study specifies particular leisure activities that are most affected. Lower IQ was associated with less involvement in social activities. Behavior problems were also predictive. Specifically, children with conduct problems were more involved in recreational activities, possibly providing an outlet for them. Functional domains such as communication and daily living skills were also associated with the intensity and diversity of involvement in leisure activities. These observations highlight the value of maximizing functional abilities at school age to enhance participation.

It is increasingly recognized that contextual (personal, environmental) factors exert a powerful influence on participation. Mastery motivation encapsulates the extent to which an individual will persist in solving a problem or mastering a challenging skill, and is associated with self-efficacy.22 We demonstrate that greater motivation was associated with more involvement in recreational activities, with a high level of mastery pleasure observed in children who were more involved in social activities. Child preferences predict participation intensity,9 which may in part relate to intrinsic motivation. Findings suggest that it is critical that children be provided with opportunities to engage in activities of their own choosing that are motivating, to increase participation.33 Older children were more involved in self-improvement activities such as homework or reading, which is developmentally appropriate.

In terms of environmental factors considered, receipt of rehabilitation services was associated with greater attention given to skill-based activities, suggesting that these services may facilitate confidence and competence in skilled tasks. It is also conceivable that clinicians inform families of adapted recreational activities available in the community, thus encouraging involvement. Elevated parental stress was correlated with diminished participation in self-improvement and recreational activities. The design precluded a determination of whether this is cause or effect; indeed, this may be bidirectional. Parents have a vital role in providing opportunities for leisure participation in this age group,33 emphasizing the importance of addressing family adaptation and coping to enhance the child’s well-being. We did not confirm the finding that family income was a determinant.4

A variety of factors were identified as determinants of enjoyment. Interestingly, impairments and activity limitations had little influence on enjoyment. Intelligence was the only variable that reached significance, suggesting that severity of disability is not an important determinant of satisfaction and pleasure in participating in leisure. Hyperactivity was associated with less enjoyment of skill-based activities, probably because these activities require greater focus and attention. Children with peer problems (few friends, bullied, prefer adults) were more likely to enjoy recreational and social activities, possibly because these leisure activities provided opportunities to socialize with peers and develop friendships. We validated the relationship between age and sex and participation reported by Law et al.4 Specifically, there was an association between older age and decreased enjoyment of self-improvement activities, and between female sex and greater likelihood of enjoying skill-based and self-improvement activities. This probably reflects patterns seen in typically developing peers. Enjoyment seemed more limited when parents were highly stressed, therefore warranting attention by health professionals. Children receiving rehabilitation services were more likely to enjoy active-physical activities, suggesting that these services may facilitate competences and self-assurance in these areas.

There are several limitations to this study. We did not include measures of environment. Recent qualitative and quantitative studies have demonstrated the important influence of the physical, social and attitudinal environment on participation.3,9 For example, district of residence, family preferences, and social supports are key predictors of participation for children with physical disabilities.9,30,35 These variables are potentially modifiable, and it will therefore be important to consider them in future studies. The CAPE asks about participation over the past 4 months, and there may be seasonal effects, with winter in Canada posing additional challenges. However, in general, children who are active in one season are likely to find comparable activities in other seasons. We recognize that using a stepwise selection model is an initial exploratory method, and therefore the results will require future validation.28 Nonetheless, additional bootstrap methods showed the same estimates with fairly small confidence intervals. Furthermore, bootstrap standard errors (not shown) approximated the standard errors of the original estimates in the best models by using stepwise selection methods. Sample size was small and focused on children with mild to moderate motor limitations; studies on larger samples with inclusion of children of all disability levels (with proxy report) are therefore needed. For some models, r2 was small, highlighting that there are as yet unknown variables that exert an influence on participation. This study provides initial evidence of several impairments, activity limitations and contextual factors that seem to influence involvement in and enjoyment of leisure activities that should be considered so as to promote participation.

Rehabilitation services focus primarily on function and skill development, with the expectation that this will translate into greater participation and enhanced quality of life.13,36 Our results suggest that access to rehabilitation services at school age continues to be important in enhancing functional autonomy in mobility and hand function, communication, and social development, because these areas exert direct influences on leisure participation. Adaptive strategies to promote functional success in these domains should be given high priority. Services focused on leisure domains should take advantage of what is intrinsically motivating to the child and should be directed at promoting the favorable situations for activities of a child’s choosing. Behavioral difficulties can have an impact on involvement in and enjoyment of leisure activities, and should be addressed by health professionals. Family-centered approaches to service delivery underscore the importance of considering priority issues for the family, such as coping and adaptation. Therefore, parental stress levels, which were shown to exert a negative influence on participation, should be evaluated intermittently by professionals, and interventions to optimize family well-being should be pursued. Advocacy for new policies and community-based programs is also clearly needed, to minimize barriers to participation.

The benefits of participation in leisure activities are numerous. Active engagement in meaningful activities of one’s own choosing is essential for promoting health and personal autonomy, skill development and productivity, community integration, and life satisfaction. The identification of possible determinants of participation is, therefore, essential, for the planning of effective rehabilitation programs and services, and health promotion initiatives that will contribute to a ‘better life’ for children with CP and for their families.

Acknowledgements

  1. Top of page
  2. Abstract
  3. Method
  4. Results
  5. Discussion
  6. Acknowledgements
  7. References
  8. Supporting Information

We wish to thank our research coordinator, Nicholas Hall, for his efforts in coordinating this project. We are grateful to the families and children who participated in this study. Thanks are due to occupational therapists Cynthia Perlman and Amy Brownstein and to psychologists Lisa Steinbach, Nancy Marget, Mafalda Porporino, Terry Viola, and Chantalle Martel for assistance in testing. This study was funded by the United Cerebral Palsy Research & Educational Foundation, USA. The results of this study were presented at the Annual Meeting of the American Academy for Cerebral Palsy and Developmental Medicine in Boston, September 2006.

References

  1. Top of page
  2. Abstract
  3. Method
  4. Results
  5. Discussion
  6. Acknowledgements
  7. References
  8. Supporting Information
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Supporting Information

  1. Top of page
  2. Abstract
  3. Method
  4. Results
  5. Discussion
  6. Acknowledgements
  7. References
  8. Supporting Information

Table S1 Group mean performance scores on the CAPE

Table S1 Best predictive models for level of enjoyment in activity domains of the CAPE

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