Participation of children with cerebral palsy in leisure activities supports the current ICF health paradigm


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In 2001, the World Health Organization’s (WHO) adoption of the International Classification of Functioning, Disability and Health (ICF) triggered a shift in international medical paradigms and led to a perceptual change in our understanding of the importance of participation and function on health. The need to emphasize components of health as opposed to consequences of disease is intrinsic in this biopsychosocial model, yet it raises numerous questions regarding the required ingredients for successful participation.

According to the ICF, participation has been described as involvement in life situations and is understood to represent the highest level in the hierarchy of functioning, yet we are still only on the cusp of understanding the diverse elements intrinsic in this construct.

In this issue, Majnemer et al. report on a commendable investigation into the participation and enjoyment of leisure activities in children with cerebral palsy (CP). Majnemer et al.’s findings that children with CP are actively involved in a wide range of activities and that they experience a high level of enjoyment despite their activity limitations support previous claims that the defining factor of optimal participation and quality of life of the child with CP is not the extent of the child’s disability per se.1 Thus, it is vital within this population to assess not only the child’s disability but also the extent to which the child is able to and enjoys participating in meaningful domains, including leisure activities. However, findings of this study raise the question of whether increased participation in a range of domains automatically results in an improvement in quality of life.

While the findings comparing children with CP to typically developing children should be considered with reservations, since the comparison group is not described, certain findings of this study are particularly intriguing and open doors for further investigation and for guiding intervention for children with CP. As noted by the authors, the finding that children with problematic peer relationships were those who appeared to most enjoy social and recreational activities indeed has implications for rehabilitation services. It might be possible to provide children experiencing these limitations with increased social opportunities in order to attain the skills necessary for success in an area which is clearly meaningful yet lacking, as reflected by their enjoyment of these activities despite their difficulties with them.

It might seem obvious to assume that enjoyment of leisure activities is a given when one participates in them. Yet Majnemer et al.’s findings seem to imply that we should question this assumption, particularly among children with CP. One of the most interesting results regarding this issue was that, while a higher IQ was found to predict participation in a greater number of informal activities, it was also found to predict reduced enjoyment in leisure activities. This raises two important issues.

First, there is a need to consider the role of the IQ of the child with CP in facilitating their enjoyment from leisure activities. A higher IQ might facilitate performance of a wider range of activities, but it might also lead to a greater awareness of difficulties and thus result in decreased enjoyment from the activity performance itself. Thus the findings concerning the predictive power of IQ seem to open doors to investigate issues such as self-esteem in this population as a means of encouraging increased enjoyment and more meaningful participation. While the issue of the role of intelligence in the participation in, and enjoyment from leisure activities amongst children with CP is one which the authors could perhaps have further explored.

Second, this finding raises doubts regarding conventional outlooks on what constitutes leisure activities among children with CP, and whether this construct can be tested in this population using a tool not developed specifically for children with this diagnosis. The authors define leisure activities as ‘those in which an individual freely chooses to participate during their spare time because they find such activities enjoyable’. Since the notion of enjoyment is inherent in their definition of leisure activities, one could ask why there was then a need to investigate the level of the child’s enjoyment at all. The impetus to assess the level of enjoyment of leisure activities, together with the interesting findings of the study, implies that these leisure activities need to be redefined in this population.