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Comparing participation in physical recreation activities between children with disability and children with typical development: A secondary analysis of matched data
Research in Developmental Disabilities 49–50 (2016) 268–276
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Research in Developmental Disabilities
Comparing participation in physical recreation activities between children with disability and children with typical development: A secondary analysis of matched data Carmen Woodmansee a, Andrew Hahne a, Christine Imms c,d,e, Nora Shields a,b,* a
Department of Rehabilitation, Sport and Nutrition, School of Allied Health, La Trobe University, Melbourne 3086, VIC, Australia Northern Health, 185 Cooper St., Epping, Melbourne 3076, VIC, Australia School of Allied Health, Australian Catholic University, Fitzroy 3065, VIC, Australia d Murdoch Childrens Research Institute, Royal Children’s Hospital, 50 Flemington Road, Parkville, Melbourne 3052, VIC, Australia e CanChild Centre for Childhood Disability Research, Institute for Applied Health Sciences, McMaster University, 1400 Main Street West, Hamilton, ON, Canada L8S 1C7 b c
A R T I C L E I N F O
A B S T R A C T
Article history: Received 9 July 2015 Received in revised form 11 November 2015 Accepted 3 December 2015 Available online 29 December 2015
Background: Facilitating participation in physical recreation among children with disability is an increasingly important aim of paediatric rehabilitation. Aim: To compare the extent (diversity and frequency), context (where and companionship), experience (enjoyment) and preference for participation in physical recreation activities outside-of-school between children with disability and children with typical development. Methods and procedures: One hundred and sixty-three children with physical, intellectual, sensory or multiple disabilities (67 girls; mean age 10.8 yr) were matched with 163 children with typical development for age, sex, geographical location and socioeconomic status. Participation in 16 physical recreation activities (including walking, cycling, team sports) was compared between these two groups using non-parametric statistics and relative risk ratios. Outcomes and results: There were significant differences between the groups in 14 activities. A lower percentage of children with disability reported participating in 5 physical recreation activities. A higher percentage of children with disability reported not participating in their preferred activities. Children with disability were less likely to participate on their own in some day-to-day physical recreation activities such as walking and cycling. Conclusions and implications: Differences between the groups related to the context (companionship) and preference for participation. Understanding and addressing these differences may enhance participation among children with disability. ß 2015 Elsevier Ltd. All rights reserved.
Keywords: Physical activity Youth Leisure Childhood disability Sport
* Corresponding author at: Department of Rehabilitation, Sport and Nutrition, School of Allied Health, La Trobe University, Bundoora, Melbourne 3086, VIC, Australia. Tel.: +61 3 9479 5852. E-mail addresses: [email protected] (C. Woodmansee), [email protected] (A. Hahne), [email protected] (C. Imms), [email protected] (N. Shields). http://dx.doi.org/10.1016/j.ridd.2015.12.004 0891-4222/ß 2015 Elsevier Ltd. All rights reserved.
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What this paper adds Previous research on the participation of children with disability in physical recreation activities, and how they compare to their peers with typical development, has focused on broad domains of activity such as formal or informal activities. This study builds on this literature by investigating the participation (extent, context and experience) and the preferences (a known predictor of participation) of children with disability (physical, intellectual, sensory or multiple disabilities) in 16 specific physical recreation activities participated in outside-of-school including swimming, dancing and gymnastics, and how their patterns of participation in these activities compare to typically developing children. Our research found differences between children with disability and children with typically development relating to the extent (diversity), context (companionship) and preference for participation in physical recreation activities. A lower percentage of children with disability reported participating in 5 physical recreation activities and a higher percentage reported not participating in their preferred physical activities (team sports, non-team sports, individual physical activities and athletics). Also, children with disability were less likely to participate on their own in some day-to-day physical recreation activities such as walking and cycling.
1. Background Participation in physical activity is a vital part of a healthy lifestyle for all children, including those with physical, intellectual, sensory and multiple disabilities. Physical activity is any bodily movement produced by skeletal muscles that results in energy expenditure (Caspersen, Powell, & Christenson, 1985). Physical recreation is a type of physical activity and is defined as: An activity or experience that involves varying levels of physical exertion, prowess and/or skill which may not be the main focus of the activity and is voluntarily engaged in by an individual in leisure time for the purpose of mental or physical satisfaction. (Australian Bureau of Statistics, 2008, p. 8). Physical recreation includes organised formal activities structured by rules (for example, team sport), and spontaneous informal activities requiring little preparation and training (for example, play). It encompasses a range of physical intensities but excludes sedentary activity. Participation in physical recreation can positively influence a child’s physical and psychological health and can help to develop healthy lifestyle behaviours (Telama et al., 2005). An inability to participate in physical recreation has been shown to negatively impact the quality of life of children with disability (Dahan-Oliel, ShikakoThomas, & Majnemer, 2012). Research suggests that compared to their typically developing peers, children with disability spend more leisure time in sedentary activities (Maher, Williams, Olds, & Lane, 2007). In particular, they have been shown to participate less in formal physical recreation (Arim, Findlay, & Kohen, 2012; Imms, 2008; Westendorp, Houwen, Hartman, & Visscher, 2011). However, most previous studies have analysed participation in physical activity including physical recreation by measuring the amount of physical activity performed; for example, using activity monitors (Carlon, Taylor, Dodd, & Shields, 2013) or the level of engagement in categories of activity; for example, formal or informal activities (Arim et al., 2012; Bedell et al., 2013). These approaches provide broad information about participation in physical recreation only (i.e. overall amount of movement per day). Categorising activities is problematic as activities included with the same domains can have vastly different characteristics. For example 8-ball (or snooker) and bicycling are both considered informal recreational physical activities, but occur in different environments and require different physical skills and levels of exertion. There is a lack of information about the extent (diversity and frequency), context (where and companionship), experiences of (enjoyment), and preferences for participation in specific physical recreation activities outside-of-school among children with disability and how they compare to their typically developing peers. Four published studies have investigated participation among children with disability in one or more specific physical recreation activities outside-of-school compared to children with typical development (Imms, Reilly, Carlin, & Dodd, 2008; King, Law, Hurley, Petrenchik, & Schwellnus, 2010; Westendorp et al., 2011; Zwier et al., 2010). However, each of these studies measured rates of participation (diversity) only and none compared the groups statistically or included samples of children with disability matched to those with typical development. Therefore, it is unclear if the extent, context and experiences of children with disability in physical recreational activities are different to those of their typically developing peers. Facilitating participation in physical recreation outside-of-school among children with disability is increasingly recognised as an important aim of rehabilitation (Dahan-Oliel et al., 2012). Health professionals need to understand the pattern of participation in specific physical recreation activities among children with disability to help realise this aim (Imms et al., 2008). This information can also assist with identifying areas where therapy, sport and recreation services could provide better access to programs for children with disabilities. The aim of this study was to compare the extent (diversity and frequency), context (where and companionship), experiences of (enjoyment) and preferences for participation in specific physical recreation activities between children with disabilities and children with typical development.
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2. Material and methods 2.1. Research design A secondary analysis of matched data was completed. Data were extracted from two pre-existing databases created during 2009 and 2010; the first comprised data from 286 children with disability (Shields, Synnot, & Kearns, 2015) and the second comprised data from 403 children with typical development. Data from these databases were matched on four variables: age, gender, geographical region and socioeconomic status; the total possible number of matches therefore was 286. Data for children with disability were not included if no corresponding match could be found from the children with typical development database. Therefore the data analysed in this paper are a subset of the original data. Ethical approval for this study was granted by the La Trobe University Human Ethics Committee and registered with the Australian Catholic University Ethics Committee. 2.2. Participants and procedure Participants lived in Victoria, Australia and were aged between 6 and 17 years at the time of data collection. Children with disability were included if they had a physical (for example cerebral palsy, muscular dystrophy, spina bifida), intellectual (for example Down syndrome) or sensory disability (hearing or vision impairment) and were able to contribute to answering questions about their participation preferences and enjoyment. Children with typical development were included if they understood English and attended a school in Victoria, Australia. They were excluded if they required an integration aid at school, as this may indicate the presence of a disability, or if they were diagnosed with an acute or chronic medical condition that might interfere with their participation. Children from either group were excluded if they experienced a significant life event in the previous four months (for example, surgery) that might have impacted their participation in physical recreation (see flow diagram in Appendix A). Children with disability were recruited via two methods (King, Shields, Imms, Black, & Ardern, 2013). The first method involved distributing flyers through community disability groups, specialist schools and tertiary hospitals. Families who were interested in taking part contacted the researchers and if deemed eligible to participate, were sent a questionnaire pack. Reminder letters were sent 4 weeks and 8 weeks after the questionnaire pack was sent. The second method involved organisations identifying children who met the inclusion criteria and sending them a questionnaire pack on the researchers’ behalf. In all cases children completed the questionnaires (with assistance from a parent if required) and returned them by post. Children with typical development were recruited from 24 schools (14 primary, 9 secondary and 1 preparatory to grade 12) in Victoria using stratified random sampling (n = 19) and convenience sampling (n = 5). The schools included government schools (n = 21), Catholic schools (n = 2) and an independent school (n = 1). Eleven schools were located in regional areas. This reflected the distribution of schools in Victoria. Government schools were sampled according to the level of funding received to ensure children from a diverse range of socioeconomic backgrounds were recruited. Of 9257 children invited to participate, 480 agreed (5% consent rate), and of these 403 questionnaires were returned (84% response rate). Schools were also given the option for children to complete their questionnaires during a school based session assisted by a researcher. Missing data were followed up by phone call or letter where possible. 2.3. Outcome measures Data were collected on 16 activities (Table 1) that fit the Australian Bureau of Statistics (2008) definition of physical recreation. The activities were chosen from the Children’s Assessment of Participation and Enjoyment (CAPE) self-reported questionnaire designed to measure how children aged 6–21 years, with and without disability, participate in outsideof-school activities (King et al., 2004). Although the CAPE questionnaire includes an active-physical scale, that scale includes non-physical recreation activities (e.g. a paid job) and additional items that are physical recreation activities are included in other scales (e.g. walking in the recreation scale; swimming and gymnastics in the skill-based scale). As the focus of this study was on participation in physical recreation activities, we selected the 16 items from the CAPE that fit the definition of physical recreation. Six dimensions of participation in these 16 activities (King et al., 2004) were assessed: diversity (whether the activity was participated in or not), frequency (how often the activity was performed), location (where the activity was performed), companionship (who the activity was done with), enjoyment (to what extent the activity was enjoyed) and preference (given the choice would the child choose to participate in the activity). A demographic questionnaire, collecting information about the child’s age, gender, date of birth, address, schooling, and if the child had experienced any significant events in the past 4 months, was completed by the participants’ parents. For children with disability, a question about the severity of the child’s disability (rated mild, moderate or severe based on parent perception) and any secondary medical conditions was included. 2.4. Data extraction Children with disability were matched to children with typical development on four variables: age, gender, geographical region (metropolitan or regional area) and socioeconomic status (Socioeconomic Index for Area [SEIFA] scores 50 units).
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Table 1 Physical recreation activities from the children’s assessment of participation and enjoyment. Domains
Activity type Recreational
Formal
Informal
Going for a walk/hike Playing on equipment
Active-physical
Skill-based
Martial arts Athletics Team sports
Swimming Gymnastics Horse riding Learning to dance Dancing
Bicycling Water sports Snow sports Playing games Individual physical activities Non-team sports
Note: Activities from the children’s assessment of participation and enjoyment questionnaire were included if they fit the Australian Bureau of Statistics (2008) definition of physical recreation.
Location was determined using the Australian Bureau of Statistics 2006 Census Data for remoteness area and the participant’s home address (Australian Bureau of Statistics, 2006). SEIFA scores measure the relative socioeconomic advantage/disadvantage of a geographical area compared to other areas in Australia. The mean SEIFA score is 1000 (SD 100) with lower scores indicating fewer socioeconomic resources. 2.5. Data analysis A power calculation based on published data (King et al., 2010) determined 139 matched pairs were required to find a clinically important difference of 10% between the groups in the diversity of participation for a specific activity (assuming power of 0.80 and a p value of 0.05). A Bonferroni adjustment was not completed as all comparisons were planned prior to data extraction (Smeets, Maher, Nicholas, Refshauge, & Herbert, 2009). Data were analysed at the item level using IBM SPSS Statistics, version 22 (IBM Corp, 2012). Diversity of participation was scored as a dichotomous variable (0 = did not participate in, 1 = participated in). Frequency of participation was scored as 0 = never completed the activity, 1 = once in 4 months, 2 = twice in 4 months, 3 = once a month, 4 = 2–3 times per month, 5 = once a week, 6 = 2–3 times per week, 7 = once a day). Enjoyment was scored as 0 = never completed that activity, 1 = not at all, 2 = somewhat, 3 = pretty much, 4 = very much, 5 = loved it (King et al., 2004). For location, companionship and preferences, we did not use the original scoring formulae provided by the CAPE authors, as the raw scores provide categorical data that are difficult to interpret when summarised. Therefore, similar to Shimoni, Engel-Yeger, and Tirosh (2010) we chose to use dichotomised choices for these variables (at home or not at home; alone or not alone; not at all or would like to do) which provided statistically appropriate outcomes that are more easily interpreted. ‘Not at home’ included at a relative’s home, in the child’s neighbourhood, at school but not during class, in the child’s community or beyond the child’s community, ‘not alone’ included with family, relatives, friends and others, and ‘would like to do’ included would sort of like to do or would really like to do. A subgroup analysis combined diversity and preference scores to determine if children were participating in their preferred activities. We also completed an exploratory analysis to compare the diversity of participation of children with typical development (n = 163) to the subgroups of children with disability stratified for disability type (i.e. physical, intellectual, multiple or other disability). Results were analysed using descriptive statistics and non-parametric (Mann–Whitney U and Chi-square test) tests. For dichotomous data, relative risks (RR) with 95% confidence intervals (CI) were calculated. A relative risk of 1 indicates no difference in risk, while results greater than one indicates higher scores for children with disability. 3. Results 3.1. Participants One-hundred and sixty-three children with disability (67 girls; mean age 10 y 9 mo, SD 3 y 1 mo) were matched with 163 children with typical development (Table 2). Their SEIFA scores were within one standard deviation of the average SEIFA score. 3.2. Diversity On average, children with disability participated in 6.7 (SD 2.2) of the 16 physical recreation activities, compared to children with typical development, who participated in 7.6 (SD 2.6) activities (mean difference 0.9 activities, 95% CI 1.2 to 0.6). Diversity of participation differed between the groups for 5 activities (Table 3); children with disability were less likely
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Table 2 Participant’s demographic data.
SEIFA score SD (range) Remoteness Metropolitan Inner-regional Outer-regional Schoola n (%) Primary Secondary Specialist Other Type of disability n (%) Physical Intellectual Multiple Other Assistance to complete questionnaireb n (%) No assistance Assistance required
Children with disability n (%)
Children with TD n (%)
1033 75 (866–1184)
1047 74 (866–1184)
139 (85) 23 (14) 1 (1)
139 (85) 23 (14) 1 (1)
75 20 53 15
(46) (12) (33) (9)
108 53 0 0
47 41 48 27
(29) (25) (29) (17)
– – – –
17 (10) 146 (90)
(66) (33) (0) (0)
93 (57) 64 (39)
Note: Type of disability-other incorporates: vision impairment (4%), hearing impairment (5%), speech impairment (1%) and autism spectrum disorder/Asperger’s (7%). TD: typical development. a Missing data: n = 2 (1%) for children with typical development. b Missing data: n = 6 (4%) for children with typical development.
to participate in athletics (RR 0.6, 95% CI 0.4 to 0.8), team sports (RR 0.6, 95% CI 0.5 to 0.7), snow sports (RR 0.3, 95% CI 0.2 to 0.7), playing games (RR 0.9, 95% CI 0.8 to 1.0) and non-team sports (RR 0.7, 95% CI 0.6 to 0.9). The exploratory analysis (Table 4) found the diversity of participation in team sports of children with typical development (n = 163) was significantly higher than for all subgroups of children with disability (i.e. physical, intellectual, multiple or other disability). Children with multiple disabilities had the highest number of differences in participation diversity relative to children with typical development; they were less likely to participate in six activities (athletics, cycling, individual physical activities, non-team sports, playing games, team sports) and more likely to participate in three activities (dancing, horse riding and playing on equipment) than children with typical development. Other differences between the subgroups were noted; for example, the children with intellectual disability were more likely than children with typical development to be learning to dance (Table 4). These results should be interpreted with caution as the numbers involved are small. 3.3. Frequency Frequency of participation was similar between the groups for 13 of the 16 activities (Table 3; Appendix B). Children with disability participated more frequently in swimming (U = 6056.5, p = 0.05) and less frequently in team sports (U = 3623.5, p < 0.01) and playing games (U = 7136.0, p < 0.01).
Table 3 Summary of the participation patterns of children with disabilities compared to children with typical development. Activity
Diversity
Frequency
Alone
Outside the home
Enjoyment
Preference for
Going for a walk/hike Playing on equipment Martial arts Athletics Team sports Bicycling Water sports Snow sports Playing games Individual physical activities Non-team sports Swimming Gymnastics Horse riding Learning to dance Dancing
– – – # # – – # # – # – – – – –
– – – – # – – – # – – " – – – –
# – – – – # – – – # – – – # – –
– – – – – – – – # – – – – – – –
– – – – – – – – – # – " – – – –
– " – – # – # # – – – – – – " "
Note: – = % similar for children with and without disability, " = % higher for children with disability, # = % lower for children with disability. Raw data are presented in Appendices A–E.
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Table 4 Subgroup analysis showing number and percentage of children with disability stratified by disability type who took part in physical recreational activities in the previous four months (diversity). Activity
Athletics Bicycling Dancing Going for a walk Gymnastics Horse riding Individual physical activities Learning to dance Martial arts Non-team sports Playing games Playing on equipment Snow sports Swimming Team sports Water sports
Typical development
Physical
Intellectual
Multiple
Other
n
%
n
%
n
%
n
%
n
%
54 125 81 120 30 19 94 32 27 87 145 101 24 112 128 55
33.1* 76.7 49.7 73.6 18.4 11.7 57.7 19.6 16.6 53.4* 89.0* 62.0 14.7* 68.7 78.5* 33.7
11 29 24 33 6 8 25 5 5 18 32 27 2 36 19 8
23.4 61.7* 51.1 70.2 12.8 17.0 53.2 10.6 10.6 38.3 68.1* 57.4 4.3 76.6 40.4* 17.0*
7 32 26 30 6 7 19 14 5 18 35 31 2 32 24 10
17.1* 78.0 63.4 73.2 14.6 17.1 46.3 34.1* 12.2 43.9 85.4 75.6 4.9 78.0 58.5* 24.4
8 29 32 37 5 12 15 12 5 15 33 41 2 39 16 16
16.7* 60.4* 66.7* 77.1 10.4 25* 31.3* 25.0 10.4 31.3* 68.8* 85.4* 4.2 81.3 33.3* 33.3
5 20 7 17 3 4 17 2 5 13 25 18 2 19 16 10
18.5 74.1 25.9* 63.0 11.1 14.8 63.0 7.4 18.5 48.1 92.6 66.7 7.4 70.4 59.3* 37.0
Note: N = total number of participants in each group were 163 children with typical development, 47 children with physical disability, 41 children with intellectual disability, 48 children with multiple disability and 27 children with other disability n = number who took part in the activity. * Significance at p < 0.05, all comparisons are against children with typical development.
3.4. Companionship Differences in companionship were found between the groups for 4 of the 16 activities (see Table 3 and Appendix C). Children with disability were more likely to participate with others in bicycling (RR 1.1, 95% CI 1.0 to 1.3), individual physical activities (RR 1.8, 95% CI 1.5 to 2.1), horse riding (RR 1.9, 95% CI 1.4 to 1.8) and walking (RR 1.2, 95% CI 1.1 to 1.3). 3.5. Location A higher percentage of children with disability reported ‘playing games’ at home than children with typical development (RR 1.9, 95% CI 1.4 to 2.7; see Table 3, Appendix D). This was the only activity where a difference between the groups was found for location of participation. 3.6. Enjoyment Both groups reported moderate to high levels of enjoyment in the 16 physical recreation activities. Children with disability reported a higher level of enjoyment participating in swimming (U = 6007.00, p = 0.04), and a lower level of enjoyment participating in individual physical activities (U = 2735.50, p = 0.01) than their typically developing peers (Table 3; Appendix E). 3.7. Preferences Differences between the groups were found in their preferences for 6 of the 16 activities (Table 3). Compared to their typically developing peers, children with disability were less likely to prefer team sports (RR 0.89, 95% CI 0.82 to 0.96), water sports (RR 0.86, 95% CI 0.79 to 0.94) and snow sports (RR 0.80, 95% CI 0.72 to 0.90) and more likely to prefer learning to dance (RR 1.28, 95% CI 1.04 to 1.56), dancing (RR 1.24, 95% CI 1.06 to 1.47) and playing on equipment (RR 1.13, 95% CI 1.01 to 1.27). Sub-group analysis found the percentage of children with disability not participating in their preferred activities was different to children with typical development for four activities (Table 5). Even though they would prefer to participate, children with disability were less likely to participate in athletics (RR 1.7, 95% CI 1.4 to 2.1), team sports (RR 2.9, 95% CI 1.8 to 4.7), individual physical activities (RR 1.9, 95% CI 2.4 to 2.6) and non-team sports (RR 1.9, 95% CI 1.4 to 2.5). 4. Discussion Our main findings were that compared to children with typical development, a lower percentage of children with disability reported participating in 5 of the 16 physical recreation activities (Table 3) and a higher percentage of children with disability reported not participating in their preferred activities (Table 5). In this study, we only included activities from the CAPE that met the Australian Bureau of Statistics (2008) definition of physical recreation. These activities come from the active-physical, skill-based and recreation scales of the CAPE. Our
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Table 5 Percentage of children who took part in physical recreational activities in the previous four months (diversity), percentages of children who would prefer to participate in these activities (preferences) and the percentages of children not participating in their preferred activities. Activity type
n Per group
Martial arts Swimming Gymnastics Horse riding Athletics Team sports Learning to dance Dancing Walking/hiking Bicycling Water sports Snow sports Play on equipment Playing games Individual activities Non-team sports
161 162 161 162 162 161 162 162 162 162 161 162 162 162 161 161
Diversity
Preferences
Not participating in preferred activities
Disability
TD
Disability
TD
Disability
TD
12.3 77.3 12.3 19.0 19.0* 46.0* 20.2 54.6 71.8 67.5 27.0 4.9* 71.8 76.7* 46.6 39.3*
16.6 68.7 18.4 11.7 33.1* 78.5* 19.6 49.7 73.6 76.7 33.7 14.7* 62.0 89.0* 57.7 53.4*
50.9 90.1 54.0 68.5 67.3 82.6* 61.1* 72.8* 77.8 82.7 80.1* 70.8* 84.0* 92.6 79.5 78.3
55.2 89.6 65.0 67.5 74.1 93.3* 47.9* 58.3* 86.5 86.5 93.3* 88.3* 74.2* 97.5 82.8 81.6
63.0 14.6 71.1 63.2 67.7* 31.7* 51.7 17.6 15.6 18.7 64.6 90.2 15.4 16.0 46.3* 53.5*
60.0 14.3 54.0 74.1 40.0* 11.0* 41.7 12.0 14.7 11.8 60.4 78.4 13.8 8.3 24.6* 28.9*
Note: TD = typical development; n = number of participants. * Significance at p < 0.05.
findings concur with previously published studies which reported reduced participation in active-physical activities by children with disability (Imms et al., 2008; King et al., 2010; Poulsen, Ziviani, Cuskelly, & Smith, 2007) and of an increased frequency and enjoyment for swimming and increased preference for learning to dance and dancing (Imms et al., 2008). Our data suggests that similar percentages of children with disability and children with typical development participate in physical recreation activities taken from the skill-based activities scale of the CAPE (i.e. swimming, gymnastics, horse riding, learning to dance, and dancing). This is different from previous studies which suggest fewer children with disability participate in skillbased activities (King et al., 2010; King et al., 2013). This difference may be because the CAPE skills-based activities scale used by previous studies includes cultural activities such as art and music as well as physical recreation activities. Understanding children’s patterns of participation can help health professionals and service providers meet the increasingly important aim of rehabilitation programs to facilitate the participation of children with disability in physical recreation. Health professionals can facilitate positive experiences in physical recreation activities by considering therapy that incorporates skill development for an activity of interest to the child, for example equipment handling or multi-tasking. This has been shown to be a facilitator of participation in physical activities (Shields, Synnot, & Barr, 2012). Furthermore, it is also important that recreation service providers work in concert with health professionals to develop and promote suitable opportunities for children with disability. Poorly designed programs and/or an inability to access appropriate services are known barriers to participation for children with disability (Shields et al., 2012). A difference in companionship during participation for children with disability compared to their typically developing peers was one of the main differences in this study. Three of the four activities where children with disability were less likely to participate on their own were day-to-day physical recreation activities (walking, bicycling and individual physical activities). Children with disability may not participate in these physical recreation activities alone for many reasons, including a need for support because they are unable to engage in an activity independently, for safety reasons, because they prefer to have company while participating, or they lack the confidence to participate alone. This raises the question of what happens when support or companionship cannot be provided for participation. Transition periods, particularly from adolescence to adulthood, are associated with a decline in services and supports (King, Baldwin, Currie, & Evans, 2006). This decline may result in an inability to continue participating in these physical recreation activities into adulthood, increasing the risk of sedentary behaviour. To help prevent a decline in participation in such activities, health professionals can support young people with disability by promoting independence, safety and confidence, and increasing available support, for example, through establishing links with community-based disability support groups. In collaboration with their clients, health professionals can identify skills to be developed or equipment that might facilitate greater independence and safety, with the ultimate aim of establishing positive physical recreation habits that can be continued into adulthood (Telama et al., 2005). Service providers may also consider proving individualised support programs for people with disabilities, for example through the use of paid support workers, volunteers or friends with or without disabilities themselves. Peer mentoring can assist young people with disability to maintain or enhance their participation in physical recreation (Shields et al., 2013). There are a number of limitations to this study. We explored participation in physical recreation activities outsideof-school among children with disability compared to children with typical development, thus excluding an examination of participation in physical recreation activities during school. There is a growing literature that proposes providing physical activity options for children with typical development at school (Beets et al., 2015; Kesaniemi, Riddoch, Reeder, Blair, & Sorensen, 2010; Kriemler et al., 2011) and this might also be relevant for children with disability. Another limitation is the
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potential for recall bias as children were asked to document their participation over the previous 4 months, influencing the accuracy of responses. In addition, only children who were able to contribute to answering the questionnaires were included, therefore the results may not be applicable to those with more severe cognitive disabilities. Lastly, multiple comparisons increase the risk of type I error, meaning there is an increased risk of incorrectly rejecting the null hypothesis. However, an adjustment to the p value was not made as this would increase the risk of Type II error, meaning real differences may be missed (Portney & Watkins, 2009). Future studies using qualitative designs might explore in more depth the differences in participation found in this study between children with disability (including subgroups of disability) and children with typical development. For example, an important question is to determine if the differences found here are a true reflection of the physical recreation preferences of children with disability and the extent to which their preferences are a product of past experiences. Participation in childhood may affect participation in adulthood; therefore further work needs to explore how participation through life is best facilitated. 5. Conclusion This study found differences between children with disability and children with typically development that related to the extent, context (companionship) and preference for participation in physical recreation activities. A lower percentage of children with disability reported participating in 5 of 16 physical recreation activities and a higher percentage reported not participating in their preferred activities. Also, children with disability were less likely to participate on their own in some day-to-day physical recreation activities such as walking and cycling. Addressing these differences within rehabilitation and service provision settings may enhance participation among children with disability and potentially improve physical and psychosocial development in children with disability. Acknowledgements The authors would like to thank the children, their families and schools participating in this study. We would like to thank Anneliese Synnot, Matthew King, Monique Corbett, Rachel Chin, Sarah McMillan and Clare Ardern for their work on data collection. We acknowledge VicHealth for funding to support the collection of data from children with disability and the Faculty of Health Sciences, La Trobe University for funding to support the data collection from children with typical development. The authors have stated that they had no interests which might be perceived as posing a conflict or bias. References Arim, R. G., Findlay, L. C., & Kohen, D. E. (2012). Participation in physical activity for children with neurodevelopmental disorders. 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Making policy practice in afterschool programs: A randomized controlled trial on physical activity changes. American Journal of Preventative Medicine, 48(6), 694–706. http://dx.doi.org/10.1016/ j.amepre.2015.01.012 Carlon, S. L., Taylor, N. F., Dodd, K. J., & Shields, N. (2013). Differences in habitual physical activity levels of young people with cerebral palsy and their typically developing peers: A systematic review. Disability and Rehabilitation, 35(8), 647–655. http://dx.doi.org/10.3109/09638288.2012.715721 Caspersen, C., Powell, K., & Christenson, G. (1985). Physical activity, exercise, and physical fitness: Definitions and distinctions for health-related research. Public Health Reports, 100(2), 126–131. Dahan-Oliel, N., Shikako-Thomas, K., & Majnemer, A. (2012). Quality of life and leisure participation in children with neurodevelopmental disabilities: A thematic analysis of the literature. Quality of Life Research, 21(3), 427–439. http://dx.doi.org/10.1007/s11136-011-0063-9 IBM Corp (2012). IBM SPSS statistics for Windows (Version 22.0) [Computer software]. Armonk, NY: IBM Corp. Imms, C. (2008). Review of the children’s assessment of participation and enjoyment and the preferences for activity of children. Physical & Occupational Therapy in Pediatrics, 28(4), 389–404. http://dx.doi.org/10.1080/01942630802307135 Imms, C., Reilly, S., Carlin, J., & Dodd, K. (2008). Diversity of participation in children with cerebral palsy. Developmental Medicine and Child Neurology, 50, 363–369. Kesaniemi, A., Riddoch, C., Reeder, B., Blair, S., & Sorensen, T. (2010). Advancing the future of physical activity guidelines in Canada: An independent expert panel interpretation of the evidence. International Journal of Behavioural Nutrition and Physical Activity, 7(1), 41. King, G., Baldwin, P. J., Currie, M., & Evans, J. (2006). The effectiveness of transition strategies for youth with disabilities. Children’s Health Care, 35(2), 155– 178. http://dx.doi.org/10.1207/s15326888chc3502_4 King, G., Law, M., Hurley, P., Hanna, S., Kertoy, M., Rosenbaum, P., et al. (2004). Children’s assessment of participation and enjoyment and preferences for activities of children. San Antonio, TX: PsychCorp. King, G., Law, M., Hurley, P., Petrenchik, T., & Schwellnus, H. (2010). A developmental comparison of the out-of-school recreation and leisure activity participation of boys and girls with and without physical disabilities. International Journal of Disability, Development and Education, 57(1), 77–107. http://dx.doi.org/10.1080/10349120903537988 King, M., Shields, N., Imms, C., Black, M., & Ardern, C. (2013). Participation of children with intellectual disability compared with typically developing children. Research in Developmental Disabilities, 34(5), 1854–1862. http://dx.doi.org/10.1016/j.ridd.2013.02.029 Kriemler, S., Meyer, U., Martin, E., van Sluijs, E., Andersen, L., & Martin, B. (2011). Effect of school-based interventions on physical activity and fitness in children and adolescents: A review of reviews and systematic update. British Journal of Sports Medicine, 45(11), 923–930.
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Maher, C. A., Williams, M. T., Olds, T., & Lane, A. E. (2007). Physical and sedentary activity in adolescents with cerebral palsy. Developmental Medicine & Child Neurology, 49(6), 450–457. http://dx.doi.org/10.1111/j.1469-8749.2007.00450 Portney, L., & Watkins, M. (2009). Foundations of clinical research applications to practice (3rd ed.). Upper Saddle River, NJ: Pearson Education Inc. Poulsen, A. A., Ziviani, J. M., Cuskelly, M., & Smith, R. (2007). Boys with developmental coordination disorder: Loneliness and team sports participation. American Journal of Occupational Therapy, 61(4), 451–462. http://dx.doi.org/10.5014/ajot.61.4.451 Shields, N., Synnot, A. J., & Barr, M. (2012). Perceived barriers and facilitators to physical activity for children with disability: A systematic review. British Journal of Sports Medicine, 46(14), 989–997. http://dx.doi.org/10.1136/bjsports-2011-090236 Shields, N., Taylor, N. F., Wee, E., Wollersheim, D., O’Shea, S. D., & Fernhall, B. (2013). A community-based strength training programme increases muscle strength and physical activity in young people with down syndrome: A randomised controlled trial. Research in Developmental Disabilities, 34(12), 4385–4394. http://dx.doi.org/10.1016/j.ridd.2013.09.022 Shields, N., Synnot, A., & Kearns, C. (2015). The extent, context and experience of participation in out-of-school activities among children with disability. Research in Developmental Disabilities, 47, 165–174. http://dx.doi.org/10.1016/j.ridd.2015.09.007 Shimoni, M., Engel-Yeger, B., & Tirosh, E. (2010). Participation in leisure activities among boys with attention deficit hyperactivity disorder. Research in Developmental Disabilities, 31(6), 1234–1239. http://dx.doi.org/10.1016/j.ridd.2010.07.022 Smeets, R. J., Maher, C. G., Nicholas, M. K., Refshauge, K. M., & Herbert, R. D. (2009). Do psychological characteristics predict response to exercise and advice for subacute low back pain? Arthritis Care & Research, 61(9), 1202–1209. http://dx.doi.org/10.1002/art.24731 Telama, R., Yang, X., Viikari, J., Va¨lima¨ki, I., Wanne, O., & Raitakari, O. (2005). Physical activity from childhood to adulthood: A 21-year tracking study. American Journal of Preventive Medicine, 28(3), 267–273. http://dx.doi.org/10.1016/j.amepre.2004.12.003 Westendorp, M., Houwen, S., Hartman, E., & Visscher, C. (2011). Are gross motor skills and sports participation related in children with intellectual disabilities? Research in Developmental Disabilities, 32(3), 1147–1153. http://dx.doi.org/10.1016/j.ridd.2011.01.009 Zwier, J. N., van Schie, P. E., Becher, J. G., Smits, D.-W., Gorter, J. W., & Dallmeijer, A. J. (2010). Physical activity in young children with cerebral palsy. Disability & Rehabilitation, 32(18), 1501–1508. http://dx.doi.org/10.3109/09638288.2010.497017
Contents lists available at ScienceDirect
Research in Developmental Disabilities
Comparing participation in physical recreation activities between children with disability and children with typical development: A secondary analysis of matched data Carmen Woodmansee a, Andrew Hahne a, Christine Imms c,d,e, Nora Shields a,b,* a
Department of Rehabilitation, Sport and Nutrition, School of Allied Health, La Trobe University, Melbourne 3086, VIC, Australia Northern Health, 185 Cooper St., Epping, Melbourne 3076, VIC, Australia School of Allied Health, Australian Catholic University, Fitzroy 3065, VIC, Australia d Murdoch Childrens Research Institute, Royal Children’s Hospital, 50 Flemington Road, Parkville, Melbourne 3052, VIC, Australia e CanChild Centre for Childhood Disability Research, Institute for Applied Health Sciences, McMaster University, 1400 Main Street West, Hamilton, ON, Canada L8S 1C7 b c
A R T I C L E I N F O
A B S T R A C T
Article history: Received 9 July 2015 Received in revised form 11 November 2015 Accepted 3 December 2015 Available online 29 December 2015
Background: Facilitating participation in physical recreation among children with disability is an increasingly important aim of paediatric rehabilitation. Aim: To compare the extent (diversity and frequency), context (where and companionship), experience (enjoyment) and preference for participation in physical recreation activities outside-of-school between children with disability and children with typical development. Methods and procedures: One hundred and sixty-three children with physical, intellectual, sensory or multiple disabilities (67 girls; mean age 10.8 yr) were matched with 163 children with typical development for age, sex, geographical location and socioeconomic status. Participation in 16 physical recreation activities (including walking, cycling, team sports) was compared between these two groups using non-parametric statistics and relative risk ratios. Outcomes and results: There were significant differences between the groups in 14 activities. A lower percentage of children with disability reported participating in 5 physical recreation activities. A higher percentage of children with disability reported not participating in their preferred activities. Children with disability were less likely to participate on their own in some day-to-day physical recreation activities such as walking and cycling. Conclusions and implications: Differences between the groups related to the context (companionship) and preference for participation. Understanding and addressing these differences may enhance participation among children with disability. ß 2015 Elsevier Ltd. All rights reserved.
Keywords: Physical activity Youth Leisure Childhood disability Sport
* Corresponding author at: Department of Rehabilitation, Sport and Nutrition, School of Allied Health, La Trobe University, Bundoora, Melbourne 3086, VIC, Australia. Tel.: +61 3 9479 5852. E-mail addresses: [email protected] (C. Woodmansee), [email protected] (A. Hahne), [email protected] (C. Imms), [email protected] (N. Shields). http://dx.doi.org/10.1016/j.ridd.2015.12.004 0891-4222/ß 2015 Elsevier Ltd. All rights reserved.
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What this paper adds Previous research on the participation of children with disability in physical recreation activities, and how they compare to their peers with typical development, has focused on broad domains of activity such as formal or informal activities. This study builds on this literature by investigating the participation (extent, context and experience) and the preferences (a known predictor of participation) of children with disability (physical, intellectual, sensory or multiple disabilities) in 16 specific physical recreation activities participated in outside-of-school including swimming, dancing and gymnastics, and how their patterns of participation in these activities compare to typically developing children. Our research found differences between children with disability and children with typically development relating to the extent (diversity), context (companionship) and preference for participation in physical recreation activities. A lower percentage of children with disability reported participating in 5 physical recreation activities and a higher percentage reported not participating in their preferred physical activities (team sports, non-team sports, individual physical activities and athletics). Also, children with disability were less likely to participate on their own in some day-to-day physical recreation activities such as walking and cycling.
1. Background Participation in physical activity is a vital part of a healthy lifestyle for all children, including those with physical, intellectual, sensory and multiple disabilities. Physical activity is any bodily movement produced by skeletal muscles that results in energy expenditure (Caspersen, Powell, & Christenson, 1985). Physical recreation is a type of physical activity and is defined as: An activity or experience that involves varying levels of physical exertion, prowess and/or skill which may not be the main focus of the activity and is voluntarily engaged in by an individual in leisure time for the purpose of mental or physical satisfaction. (Australian Bureau of Statistics, 2008, p. 8). Physical recreation includes organised formal activities structured by rules (for example, team sport), and spontaneous informal activities requiring little preparation and training (for example, play). It encompasses a range of physical intensities but excludes sedentary activity. Participation in physical recreation can positively influence a child’s physical and psychological health and can help to develop healthy lifestyle behaviours (Telama et al., 2005). An inability to participate in physical recreation has been shown to negatively impact the quality of life of children with disability (Dahan-Oliel, ShikakoThomas, & Majnemer, 2012). Research suggests that compared to their typically developing peers, children with disability spend more leisure time in sedentary activities (Maher, Williams, Olds, & Lane, 2007). In particular, they have been shown to participate less in formal physical recreation (Arim, Findlay, & Kohen, 2012; Imms, 2008; Westendorp, Houwen, Hartman, & Visscher, 2011). However, most previous studies have analysed participation in physical activity including physical recreation by measuring the amount of physical activity performed; for example, using activity monitors (Carlon, Taylor, Dodd, & Shields, 2013) or the level of engagement in categories of activity; for example, formal or informal activities (Arim et al., 2012; Bedell et al., 2013). These approaches provide broad information about participation in physical recreation only (i.e. overall amount of movement per day). Categorising activities is problematic as activities included with the same domains can have vastly different characteristics. For example 8-ball (or snooker) and bicycling are both considered informal recreational physical activities, but occur in different environments and require different physical skills and levels of exertion. There is a lack of information about the extent (diversity and frequency), context (where and companionship), experiences of (enjoyment), and preferences for participation in specific physical recreation activities outside-of-school among children with disability and how they compare to their typically developing peers. Four published studies have investigated participation among children with disability in one or more specific physical recreation activities outside-of-school compared to children with typical development (Imms, Reilly, Carlin, & Dodd, 2008; King, Law, Hurley, Petrenchik, & Schwellnus, 2010; Westendorp et al., 2011; Zwier et al., 2010). However, each of these studies measured rates of participation (diversity) only and none compared the groups statistically or included samples of children with disability matched to those with typical development. Therefore, it is unclear if the extent, context and experiences of children with disability in physical recreational activities are different to those of their typically developing peers. Facilitating participation in physical recreation outside-of-school among children with disability is increasingly recognised as an important aim of rehabilitation (Dahan-Oliel et al., 2012). Health professionals need to understand the pattern of participation in specific physical recreation activities among children with disability to help realise this aim (Imms et al., 2008). This information can also assist with identifying areas where therapy, sport and recreation services could provide better access to programs for children with disabilities. The aim of this study was to compare the extent (diversity and frequency), context (where and companionship), experiences of (enjoyment) and preferences for participation in specific physical recreation activities between children with disabilities and children with typical development.
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2. Material and methods 2.1. Research design A secondary analysis of matched data was completed. Data were extracted from two pre-existing databases created during 2009 and 2010; the first comprised data from 286 children with disability (Shields, Synnot, & Kearns, 2015) and the second comprised data from 403 children with typical development. Data from these databases were matched on four variables: age, gender, geographical region and socioeconomic status; the total possible number of matches therefore was 286. Data for children with disability were not included if no corresponding match could be found from the children with typical development database. Therefore the data analysed in this paper are a subset of the original data. Ethical approval for this study was granted by the La Trobe University Human Ethics Committee and registered with the Australian Catholic University Ethics Committee. 2.2. Participants and procedure Participants lived in Victoria, Australia and were aged between 6 and 17 years at the time of data collection. Children with disability were included if they had a physical (for example cerebral palsy, muscular dystrophy, spina bifida), intellectual (for example Down syndrome) or sensory disability (hearing or vision impairment) and were able to contribute to answering questions about their participation preferences and enjoyment. Children with typical development were included if they understood English and attended a school in Victoria, Australia. They were excluded if they required an integration aid at school, as this may indicate the presence of a disability, or if they were diagnosed with an acute or chronic medical condition that might interfere with their participation. Children from either group were excluded if they experienced a significant life event in the previous four months (for example, surgery) that might have impacted their participation in physical recreation (see flow diagram in Appendix A). Children with disability were recruited via two methods (King, Shields, Imms, Black, & Ardern, 2013). The first method involved distributing flyers through community disability groups, specialist schools and tertiary hospitals. Families who were interested in taking part contacted the researchers and if deemed eligible to participate, were sent a questionnaire pack. Reminder letters were sent 4 weeks and 8 weeks after the questionnaire pack was sent. The second method involved organisations identifying children who met the inclusion criteria and sending them a questionnaire pack on the researchers’ behalf. In all cases children completed the questionnaires (with assistance from a parent if required) and returned them by post. Children with typical development were recruited from 24 schools (14 primary, 9 secondary and 1 preparatory to grade 12) in Victoria using stratified random sampling (n = 19) and convenience sampling (n = 5). The schools included government schools (n = 21), Catholic schools (n = 2) and an independent school (n = 1). Eleven schools were located in regional areas. This reflected the distribution of schools in Victoria. Government schools were sampled according to the level of funding received to ensure children from a diverse range of socioeconomic backgrounds were recruited. Of 9257 children invited to participate, 480 agreed (5% consent rate), and of these 403 questionnaires were returned (84% response rate). Schools were also given the option for children to complete their questionnaires during a school based session assisted by a researcher. Missing data were followed up by phone call or letter where possible. 2.3. Outcome measures Data were collected on 16 activities (Table 1) that fit the Australian Bureau of Statistics (2008) definition of physical recreation. The activities were chosen from the Children’s Assessment of Participation and Enjoyment (CAPE) self-reported questionnaire designed to measure how children aged 6–21 years, with and without disability, participate in outsideof-school activities (King et al., 2004). Although the CAPE questionnaire includes an active-physical scale, that scale includes non-physical recreation activities (e.g. a paid job) and additional items that are physical recreation activities are included in other scales (e.g. walking in the recreation scale; swimming and gymnastics in the skill-based scale). As the focus of this study was on participation in physical recreation activities, we selected the 16 items from the CAPE that fit the definition of physical recreation. Six dimensions of participation in these 16 activities (King et al., 2004) were assessed: diversity (whether the activity was participated in or not), frequency (how often the activity was performed), location (where the activity was performed), companionship (who the activity was done with), enjoyment (to what extent the activity was enjoyed) and preference (given the choice would the child choose to participate in the activity). A demographic questionnaire, collecting information about the child’s age, gender, date of birth, address, schooling, and if the child had experienced any significant events in the past 4 months, was completed by the participants’ parents. For children with disability, a question about the severity of the child’s disability (rated mild, moderate or severe based on parent perception) and any secondary medical conditions was included. 2.4. Data extraction Children with disability were matched to children with typical development on four variables: age, gender, geographical region (metropolitan or regional area) and socioeconomic status (Socioeconomic Index for Area [SEIFA] scores 50 units).
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Table 1 Physical recreation activities from the children’s assessment of participation and enjoyment. Domains
Activity type Recreational
Formal
Informal
Going for a walk/hike Playing on equipment
Active-physical
Skill-based
Martial arts Athletics Team sports
Swimming Gymnastics Horse riding Learning to dance Dancing
Bicycling Water sports Snow sports Playing games Individual physical activities Non-team sports
Note: Activities from the children’s assessment of participation and enjoyment questionnaire were included if they fit the Australian Bureau of Statistics (2008) definition of physical recreation.
Location was determined using the Australian Bureau of Statistics 2006 Census Data for remoteness area and the participant’s home address (Australian Bureau of Statistics, 2006). SEIFA scores measure the relative socioeconomic advantage/disadvantage of a geographical area compared to other areas in Australia. The mean SEIFA score is 1000 (SD 100) with lower scores indicating fewer socioeconomic resources. 2.5. Data analysis A power calculation based on published data (King et al., 2010) determined 139 matched pairs were required to find a clinically important difference of 10% between the groups in the diversity of participation for a specific activity (assuming power of 0.80 and a p value of 0.05). A Bonferroni adjustment was not completed as all comparisons were planned prior to data extraction (Smeets, Maher, Nicholas, Refshauge, & Herbert, 2009). Data were analysed at the item level using IBM SPSS Statistics, version 22 (IBM Corp, 2012). Diversity of participation was scored as a dichotomous variable (0 = did not participate in, 1 = participated in). Frequency of participation was scored as 0 = never completed the activity, 1 = once in 4 months, 2 = twice in 4 months, 3 = once a month, 4 = 2–3 times per month, 5 = once a week, 6 = 2–3 times per week, 7 = once a day). Enjoyment was scored as 0 = never completed that activity, 1 = not at all, 2 = somewhat, 3 = pretty much, 4 = very much, 5 = loved it (King et al., 2004). For location, companionship and preferences, we did not use the original scoring formulae provided by the CAPE authors, as the raw scores provide categorical data that are difficult to interpret when summarised. Therefore, similar to Shimoni, Engel-Yeger, and Tirosh (2010) we chose to use dichotomised choices for these variables (at home or not at home; alone or not alone; not at all or would like to do) which provided statistically appropriate outcomes that are more easily interpreted. ‘Not at home’ included at a relative’s home, in the child’s neighbourhood, at school but not during class, in the child’s community or beyond the child’s community, ‘not alone’ included with family, relatives, friends and others, and ‘would like to do’ included would sort of like to do or would really like to do. A subgroup analysis combined diversity and preference scores to determine if children were participating in their preferred activities. We also completed an exploratory analysis to compare the diversity of participation of children with typical development (n = 163) to the subgroups of children with disability stratified for disability type (i.e. physical, intellectual, multiple or other disability). Results were analysed using descriptive statistics and non-parametric (Mann–Whitney U and Chi-square test) tests. For dichotomous data, relative risks (RR) with 95% confidence intervals (CI) were calculated. A relative risk of 1 indicates no difference in risk, while results greater than one indicates higher scores for children with disability. 3. Results 3.1. Participants One-hundred and sixty-three children with disability (67 girls; mean age 10 y 9 mo, SD 3 y 1 mo) were matched with 163 children with typical development (Table 2). Their SEIFA scores were within one standard deviation of the average SEIFA score. 3.2. Diversity On average, children with disability participated in 6.7 (SD 2.2) of the 16 physical recreation activities, compared to children with typical development, who participated in 7.6 (SD 2.6) activities (mean difference 0.9 activities, 95% CI 1.2 to 0.6). Diversity of participation differed between the groups for 5 activities (Table 3); children with disability were less likely
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Table 2 Participant’s demographic data.
SEIFA score SD (range) Remoteness Metropolitan Inner-regional Outer-regional Schoola n (%) Primary Secondary Specialist Other Type of disability n (%) Physical Intellectual Multiple Other Assistance to complete questionnaireb n (%) No assistance Assistance required
Children with disability n (%)
Children with TD n (%)
1033 75 (866–1184)
1047 74 (866–1184)
139 (85) 23 (14) 1 (1)
139 (85) 23 (14) 1 (1)
75 20 53 15
(46) (12) (33) (9)
108 53 0 0
47 41 48 27
(29) (25) (29) (17)
– – – –
17 (10) 146 (90)
(66) (33) (0) (0)
93 (57) 64 (39)
Note: Type of disability-other incorporates: vision impairment (4%), hearing impairment (5%), speech impairment (1%) and autism spectrum disorder/Asperger’s (7%). TD: typical development. a Missing data: n = 2 (1%) for children with typical development. b Missing data: n = 6 (4%) for children with typical development.
to participate in athletics (RR 0.6, 95% CI 0.4 to 0.8), team sports (RR 0.6, 95% CI 0.5 to 0.7), snow sports (RR 0.3, 95% CI 0.2 to 0.7), playing games (RR 0.9, 95% CI 0.8 to 1.0) and non-team sports (RR 0.7, 95% CI 0.6 to 0.9). The exploratory analysis (Table 4) found the diversity of participation in team sports of children with typical development (n = 163) was significantly higher than for all subgroups of children with disability (i.e. physical, intellectual, multiple or other disability). Children with multiple disabilities had the highest number of differences in participation diversity relative to children with typical development; they were less likely to participate in six activities (athletics, cycling, individual physical activities, non-team sports, playing games, team sports) and more likely to participate in three activities (dancing, horse riding and playing on equipment) than children with typical development. Other differences between the subgroups were noted; for example, the children with intellectual disability were more likely than children with typical development to be learning to dance (Table 4). These results should be interpreted with caution as the numbers involved are small. 3.3. Frequency Frequency of participation was similar between the groups for 13 of the 16 activities (Table 3; Appendix B). Children with disability participated more frequently in swimming (U = 6056.5, p = 0.05) and less frequently in team sports (U = 3623.5, p < 0.01) and playing games (U = 7136.0, p < 0.01).
Table 3 Summary of the participation patterns of children with disabilities compared to children with typical development. Activity
Diversity
Frequency
Alone
Outside the home
Enjoyment
Preference for
Going for a walk/hike Playing on equipment Martial arts Athletics Team sports Bicycling Water sports Snow sports Playing games Individual physical activities Non-team sports Swimming Gymnastics Horse riding Learning to dance Dancing
– – – # # – – # # – # – – – – –
– – – – # – – – # – – " – – – –
# – – – – # – – – # – – – # – –
– – – – – – – – # – – – – – – –
– – – – – – – – – # – " – – – –
– " – – # – # # – – – – – – " "
Note: – = % similar for children with and without disability, " = % higher for children with disability, # = % lower for children with disability. Raw data are presented in Appendices A–E.
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Table 4 Subgroup analysis showing number and percentage of children with disability stratified by disability type who took part in physical recreational activities in the previous four months (diversity). Activity
Athletics Bicycling Dancing Going for a walk Gymnastics Horse riding Individual physical activities Learning to dance Martial arts Non-team sports Playing games Playing on equipment Snow sports Swimming Team sports Water sports
Typical development
Physical
Intellectual
Multiple
Other
n
%
n
%
n
%
n
%
n
%
54 125 81 120 30 19 94 32 27 87 145 101 24 112 128 55
33.1* 76.7 49.7 73.6 18.4 11.7 57.7 19.6 16.6 53.4* 89.0* 62.0 14.7* 68.7 78.5* 33.7
11 29 24 33 6 8 25 5 5 18 32 27 2 36 19 8
23.4 61.7* 51.1 70.2 12.8 17.0 53.2 10.6 10.6 38.3 68.1* 57.4 4.3 76.6 40.4* 17.0*
7 32 26 30 6 7 19 14 5 18 35 31 2 32 24 10
17.1* 78.0 63.4 73.2 14.6 17.1 46.3 34.1* 12.2 43.9 85.4 75.6 4.9 78.0 58.5* 24.4
8 29 32 37 5 12 15 12 5 15 33 41 2 39 16 16
16.7* 60.4* 66.7* 77.1 10.4 25* 31.3* 25.0 10.4 31.3* 68.8* 85.4* 4.2 81.3 33.3* 33.3
5 20 7 17 3 4 17 2 5 13 25 18 2 19 16 10
18.5 74.1 25.9* 63.0 11.1 14.8 63.0 7.4 18.5 48.1 92.6 66.7 7.4 70.4 59.3* 37.0
Note: N = total number of participants in each group were 163 children with typical development, 47 children with physical disability, 41 children with intellectual disability, 48 children with multiple disability and 27 children with other disability n = number who took part in the activity. * Significance at p < 0.05, all comparisons are against children with typical development.
3.4. Companionship Differences in companionship were found between the groups for 4 of the 16 activities (see Table 3 and Appendix C). Children with disability were more likely to participate with others in bicycling (RR 1.1, 95% CI 1.0 to 1.3), individual physical activities (RR 1.8, 95% CI 1.5 to 2.1), horse riding (RR 1.9, 95% CI 1.4 to 1.8) and walking (RR 1.2, 95% CI 1.1 to 1.3). 3.5. Location A higher percentage of children with disability reported ‘playing games’ at home than children with typical development (RR 1.9, 95% CI 1.4 to 2.7; see Table 3, Appendix D). This was the only activity where a difference between the groups was found for location of participation. 3.6. Enjoyment Both groups reported moderate to high levels of enjoyment in the 16 physical recreation activities. Children with disability reported a higher level of enjoyment participating in swimming (U = 6007.00, p = 0.04), and a lower level of enjoyment participating in individual physical activities (U = 2735.50, p = 0.01) than their typically developing peers (Table 3; Appendix E). 3.7. Preferences Differences between the groups were found in their preferences for 6 of the 16 activities (Table 3). Compared to their typically developing peers, children with disability were less likely to prefer team sports (RR 0.89, 95% CI 0.82 to 0.96), water sports (RR 0.86, 95% CI 0.79 to 0.94) and snow sports (RR 0.80, 95% CI 0.72 to 0.90) and more likely to prefer learning to dance (RR 1.28, 95% CI 1.04 to 1.56), dancing (RR 1.24, 95% CI 1.06 to 1.47) and playing on equipment (RR 1.13, 95% CI 1.01 to 1.27). Sub-group analysis found the percentage of children with disability not participating in their preferred activities was different to children with typical development for four activities (Table 5). Even though they would prefer to participate, children with disability were less likely to participate in athletics (RR 1.7, 95% CI 1.4 to 2.1), team sports (RR 2.9, 95% CI 1.8 to 4.7), individual physical activities (RR 1.9, 95% CI 2.4 to 2.6) and non-team sports (RR 1.9, 95% CI 1.4 to 2.5). 4. Discussion Our main findings were that compared to children with typical development, a lower percentage of children with disability reported participating in 5 of the 16 physical recreation activities (Table 3) and a higher percentage of children with disability reported not participating in their preferred activities (Table 5). In this study, we only included activities from the CAPE that met the Australian Bureau of Statistics (2008) definition of physical recreation. These activities come from the active-physical, skill-based and recreation scales of the CAPE. Our
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Table 5 Percentage of children who took part in physical recreational activities in the previous four months (diversity), percentages of children who would prefer to participate in these activities (preferences) and the percentages of children not participating in their preferred activities. Activity type
n Per group
Martial arts Swimming Gymnastics Horse riding Athletics Team sports Learning to dance Dancing Walking/hiking Bicycling Water sports Snow sports Play on equipment Playing games Individual activities Non-team sports
161 162 161 162 162 161 162 162 162 162 161 162 162 162 161 161
Diversity
Preferences
Not participating in preferred activities
Disability
TD
Disability
TD
Disability
TD
12.3 77.3 12.3 19.0 19.0* 46.0* 20.2 54.6 71.8 67.5 27.0 4.9* 71.8 76.7* 46.6 39.3*
16.6 68.7 18.4 11.7 33.1* 78.5* 19.6 49.7 73.6 76.7 33.7 14.7* 62.0 89.0* 57.7 53.4*
50.9 90.1 54.0 68.5 67.3 82.6* 61.1* 72.8* 77.8 82.7 80.1* 70.8* 84.0* 92.6 79.5 78.3
55.2 89.6 65.0 67.5 74.1 93.3* 47.9* 58.3* 86.5 86.5 93.3* 88.3* 74.2* 97.5 82.8 81.6
63.0 14.6 71.1 63.2 67.7* 31.7* 51.7 17.6 15.6 18.7 64.6 90.2 15.4 16.0 46.3* 53.5*
60.0 14.3 54.0 74.1 40.0* 11.0* 41.7 12.0 14.7 11.8 60.4 78.4 13.8 8.3 24.6* 28.9*
Note: TD = typical development; n = number of participants. * Significance at p < 0.05.
findings concur with previously published studies which reported reduced participation in active-physical activities by children with disability (Imms et al., 2008; King et al., 2010; Poulsen, Ziviani, Cuskelly, & Smith, 2007) and of an increased frequency and enjoyment for swimming and increased preference for learning to dance and dancing (Imms et al., 2008). Our data suggests that similar percentages of children with disability and children with typical development participate in physical recreation activities taken from the skill-based activities scale of the CAPE (i.e. swimming, gymnastics, horse riding, learning to dance, and dancing). This is different from previous studies which suggest fewer children with disability participate in skillbased activities (King et al., 2010; King et al., 2013). This difference may be because the CAPE skills-based activities scale used by previous studies includes cultural activities such as art and music as well as physical recreation activities. Understanding children’s patterns of participation can help health professionals and service providers meet the increasingly important aim of rehabilitation programs to facilitate the participation of children with disability in physical recreation. Health professionals can facilitate positive experiences in physical recreation activities by considering therapy that incorporates skill development for an activity of interest to the child, for example equipment handling or multi-tasking. This has been shown to be a facilitator of participation in physical activities (Shields, Synnot, & Barr, 2012). Furthermore, it is also important that recreation service providers work in concert with health professionals to develop and promote suitable opportunities for children with disability. Poorly designed programs and/or an inability to access appropriate services are known barriers to participation for children with disability (Shields et al., 2012). A difference in companionship during participation for children with disability compared to their typically developing peers was one of the main differences in this study. Three of the four activities where children with disability were less likely to participate on their own were day-to-day physical recreation activities (walking, bicycling and individual physical activities). Children with disability may not participate in these physical recreation activities alone for many reasons, including a need for support because they are unable to engage in an activity independently, for safety reasons, because they prefer to have company while participating, or they lack the confidence to participate alone. This raises the question of what happens when support or companionship cannot be provided for participation. Transition periods, particularly from adolescence to adulthood, are associated with a decline in services and supports (King, Baldwin, Currie, & Evans, 2006). This decline may result in an inability to continue participating in these physical recreation activities into adulthood, increasing the risk of sedentary behaviour. To help prevent a decline in participation in such activities, health professionals can support young people with disability by promoting independence, safety and confidence, and increasing available support, for example, through establishing links with community-based disability support groups. In collaboration with their clients, health professionals can identify skills to be developed or equipment that might facilitate greater independence and safety, with the ultimate aim of establishing positive physical recreation habits that can be continued into adulthood (Telama et al., 2005). Service providers may also consider proving individualised support programs for people with disabilities, for example through the use of paid support workers, volunteers or friends with or without disabilities themselves. Peer mentoring can assist young people with disability to maintain or enhance their participation in physical recreation (Shields et al., 2013). There are a number of limitations to this study. We explored participation in physical recreation activities outsideof-school among children with disability compared to children with typical development, thus excluding an examination of participation in physical recreation activities during school. There is a growing literature that proposes providing physical activity options for children with typical development at school (Beets et al., 2015; Kesaniemi, Riddoch, Reeder, Blair, & Sorensen, 2010; Kriemler et al., 2011) and this might also be relevant for children with disability. Another limitation is the
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potential for recall bias as children were asked to document their participation over the previous 4 months, influencing the accuracy of responses. In addition, only children who were able to contribute to answering the questionnaires were included, therefore the results may not be applicable to those with more severe cognitive disabilities. Lastly, multiple comparisons increase the risk of type I error, meaning there is an increased risk of incorrectly rejecting the null hypothesis. However, an adjustment to the p value was not made as this would increase the risk of Type II error, meaning real differences may be missed (Portney & Watkins, 2009). Future studies using qualitative designs might explore in more depth the differences in participation found in this study between children with disability (including subgroups of disability) and children with typical development. For example, an important question is to determine if the differences found here are a true reflection of the physical recreation preferences of children with disability and the extent to which their preferences are a product of past experiences. Participation in childhood may affect participation in adulthood; therefore further work needs to explore how participation through life is best facilitated. 5. Conclusion This study found differences between children with disability and children with typically development that related to the extent, context (companionship) and preference for participation in physical recreation activities. A lower percentage of children with disability reported participating in 5 of 16 physical recreation activities and a higher percentage reported not participating in their preferred activities. Also, children with disability were less likely to participate on their own in some day-to-day physical recreation activities such as walking and cycling. 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