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Aim The objective was to describe leisure activity preferences of children with cerebral palsy (CP) and their relationship to participation. Factors associated with greater interest in leisure activities were identified.
Method Fifty-five school-aged children (36 males, 19 females; mean age 9y 11mo; range 6y 1mo–12y 11mo) with CP (Gross Motor Function Classification System [GMFCS]) level I 62%, level II 22%, level III–IV 16%; 33.3% hemiplegia, 29.6% diplegia, 25.9% quadriplegia, 11.2% other) who could complete the Preferences for Activities of Children (PAC) were recruited.
Results Social and recreational activities were most preferred, and self-improvement activities were least preferred. Younger age, higher motivation, and IQ predicted interest in active–physical activities (r2=0.39). Negative reaction to failure was associated with less preference for social activities (r2=0.16), whereas increased prosocial behaviours were related to greater preference for recreational (r2=0.13) and self-improvement activities; the latter is also predicted by older age (r2=0.24). Interest in skill-based activities was greater in females and in children who were highly motivated, younger, and had greater motor limitations (r2=0.51). The findings suggest that personal factors and functional abilities influence leisure activity preferences. High preference for certain activities was not always associated with involvement in these activities.
Interpretation Determination of preferences is inherent to child-centred practice and should, therefore, be part of the evaluation process. Rehabilitation strategies can minimize barriers to leisure participation, such as fear of failure, low motivation, or environmental obstacles.
Cerebral palsy (CP) is a disorder of movement and posture causing activity limitations arising from a lesion or abnormality of the immature brain.1,2 Rehabilitation is primarily directed at minimizing motor impairments and maximizing functional independence. Recently, there has been greater emphasis on promoting participation; however, while remediation and adaptive strategies to diminish limitations in mobility and self-care are well established, targeted interventions to promote participation in leisure activities are less well developed.
Participation is defined by the World Health Organization as taking part or being involved in life situations. Specifically, everyday activities within particular domains are grouped into life habits, such as mobility, communication, or self-care. Evaluation tools typically include a range of these activities, which are then combined to represent participation in these related activities. Participation is a concept that is receiving considerable attention, particularly with the adoption and usage of the International Classification of Functioning, Disability, and Health.3 The level of participation in life roles is probably modified by health condition, functional limitations, and personal and environmental factors.4 Leisure is regarded as the time designated for freely chosen activities, performed when not involved in self-care or work (school). Participation in leisure activities is essential in the development of skill competencies, socializing with peers, exploring personal interests, and simply enjoying life.5 Therefore, recognition of the factors that promote leisure participation would assist in developing health promotion strategies.
There is a paucity of studies that have described participation in leisure activities in children with CP. Preliminary studies suggested that these children experience some restriction in their involvement in leisure activities, particularly those that are physical, social, or in the community setting.6–11 A recent review has highlighted several determinants of participation in leisure activities that include activity limitations (difficulties in one or more activities in particular participation domains), personal factors such as age, sex, and socioeconomic status, and environmental factors such as family preferences, and social and resource supports.12
Preference is defined as having a choice between alternatives and the opportunity to choose those alternatives that are most satisfying. It is linked to motivation, with greater motivation associated with a greater likelihood of performing activities of one’s own choosing.13 Children with disabilities may demonstrate interests or preferences in particular leisure activities, but several obstacles may limit actual participation. Personal choices and preferences of activities may, in turn, be influenced by a child’s level of persistence, perception of the task, activity limitations, and past experiences, as well as by environmental barriers.13–15 To date, few studies have described the personal preferences for leisure activities in children with disabilities. Evidence about the preferences of children with CP may help promote child-centred therapeutic approaches. Understanding the incongruities between preference and actual involvement is important, so that rehabilitation professionals can address barriers that limit participation. The objective of this study was to describe leisure activity preferences in school-aged children with CP and to determine the relationship between preferences (‘would like to do’) and actual involvement (‘does do’) in these activities. Factors associated with greater preference for activity subtypes (social, physical, skill-based, recreational, self-improvement) were ascertained.
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Participation in leisure-time physical, social, and recreational activities has well-established health benefits, in terms of both physical health and social–emotional well-being.9,30,31 Recent studies on children with physical disabilities emphasize that personal preferences in leisure activities directly predict level of participation in these activities.4,32 However, few studies have described leisure activity preferences of children with CP. An appreciation of the interests of children with CP, and of the factors that influence preferences, is important in the development of health promotion initiatives that optimize leisure participation.
Children in our sample most preferred social and recreational activities, and indeed we have previously reported that the intensity of actual participation in these activities is greater than for other leisure activity domains.10 Therefore, these children are most involved in the leisure activities that they prefer. In one study that used the PAC on typically developing school-aged children, preference for social activities was also high.33 Not surprisingly, the lowest preference scores in our sample were for self-improvement activities; nonetheless, intensity of actual participation in these activities (homework, chores, reading) is similar to that of social activities (CAPE intensity 2.9 [SD 0.9] vs 3.1 [SD 0.9]). Preference for active–physical activities was only slightly lower than for social and recreational activities; however, we, and others, have reported that children and young people with CP have lower levels of participation in physical activities than their peers without disability.6,9,10 Correlations between preferences (PAC) and actual involvement in these leisure activities (CAPE) in our study highlight the significant association between high interest in particular activity types (recreational, skill-based) and involvement in these activities. However, these associations were modest for active–physical, social, and self-improvement activities. Similarly, King et al.4 found modest correlations between PAC and CAPE scores for formal (r=0.28) and informal (r=0.31) leisure activities. Of note, high preference for active–physical activities was weakly correlated with enjoyment of these activities, perhaps implying that these children’s physical activity experiences need to be augmented or modified. Collectively, these findings suggest that, for some children, there may be a high interest in particular activities (physical, social) that is not linked with high involvement in these activities. Conversely, greater involvement in particular activities (self-improvement) may be associated with lower personal preference. Therefore, leisure participation may not be optimally based on personal preferences and desires because of particular obstacles limiting participation. Furthermore, children are expected to participate in certain activities, even if they prefer not to.
The child’s age influenced leisure preferences, with older children showing less interest in active–physical, skill-based, and self-improvement activities. It is conceivable that as they get older children become more aware of their difficulties and differences on potentially physically challenging tasks than their peers. Increasing age has been reported to have a similar effect on decreased actual participation in leisure activities in children with physical disabilities.7
Sex also influenced activity preferences, with females indicating greater interest in skill-based activities. Studies that have reported sex effects on leisure participation further emphasize that females participate more than males in more formal, structured activities10 and in a wider diversity of skill-based activities.7 Another study used the PAC test to evaluate preferences on typically developing Israeli and Druze children. Sex was significantly associated, such that Israeli females preferred skill-based activities more than did males.33 Interestingly, this was mediated by cultural context, as this sex effect was not documented in Druze children, although greater preference for social activities in females was noted in both groups.
Children with more severe motor limitations, and those attending special schools, also demonstrated a greater preference for skill-based activities (e.g. swimming, dancing, horseback riding). It is possible that children in segregated schools are provided with greater opportunities and resources to pursue these activities. Perhaps these interests could be further augmented in children with mild motor dysfunction, if given the opportunity, with greater awareness created of adapted community programmes that are available.
Intrinsic motivation is related to our personal beliefs of how well we expect to perform an activity and how much we value that activity, and it is closely linked with our desire to engage in a particular task.13 Mastery motivation is defined by the DMQ developers as the intrinsic drive to explore and master one’s environment. There is an instrumental aspect (the level of motivation to attempt to master a task that is at least moderately challenging) and an expressive aspect (the expressive reactions while working on or upon completing a task). Results indicate that children who persist in doing challenging motor tasks are more likely to prefer active–physical and skill-based activities. Furthermore, children who react negatively to failure show low preferences for social activities. Perception of competency (i.e. ‘Can I do it?’) influences motivation and interest in activities. Gaining confidence in one’s abilities, confronting fear of failure, and allowing failures to occur are avenues that can be pursued by rehabilitation specialists, with respect to promoting greater involvement in physical activities that are important for overall health.34
The value of leisure activities in supporting physical and psychological health in children with disabilities is recognized; nevertheless, the primary focus of rehabilitation for school-aged children with CP is on independence in self-care and mobility and productivity in the school environment.35 Within schools, rehabilitation specialists are mandated to develop educational goals; thus, the importance of promoting home- and community-based leisure participation in children with disabilities may be overlooked or given lower priority. Key barriers to participation in leisure activities for children with physical disabilities include functional limitations, sociodemographic factors, family adaptation, costs, accessibility, programs available, and family and child preferences.4,7,10,12,30 Rehabilitation specialists need to elicit a child’s own preferences and interests when assessing participation in leisure activities, given its importance to actual involvement in these activities.7,33 Once preferences are identified, clinicians should ascertain whether there are modifiable barriers to involvement in the ‘most preferred’ activities. Second, it is important for clinicians to understand the factors that can modify leisure activity preferences when developing strategies to promote participation. For example, the importance of positive social behaviours in promoting interest in recreational activities and of good reasoning skills in enhancing interest in active–physical activities would suggest that efforts to facilitate ongoing skill development in psychosocial domains may enhance preferences for more physically or socially challenging leisure activities. Improving intrinsic mastery motivation by addressing environmental barriers (e.g. access, awareness of adapted programs, peer/teacher/family support) and personal obstacles (e.g. low confidence and expectancy for success, low priority) to choosing to do more challenging leisure activities needs greater consideration.4,30,34
There are a number of limitations to this study. Our sample included children who could actively assist in completion of the PAC test, therefore children with lower cognitive and language abilities were excluded. Future studies may consider using parents as proxy respondents, to better appreciate the leisure preferences of children with more severe limitations. Our results indicate that parental stress and activity limitations across domains were not important predictors of the PAC domains overall. It is possible that with a larger, more heterogeneous sample, these variables may be associated.