Children with disabilities' perceptions of activity participation and

environments: A pilot study

Johanna Harding
Erline Wong-Sing

I
I

Kimberly Harding I Patricia Jamieson

Mary Law I Theresa M. Petrenchik

Maria Mullally

Carolyn Politi

Key words
I

Participation

Children

Enfants

Disability

Photographs

Case study

Mots cls
I

Participation

Handicap

Photos

tude de cas

Abstract
Background. Children with disabilities are particularly vulnerable to participation restrictions resulting from the interactions
between children and their physical and social environments. Purpose. The purpose of this study was to gain a better
understanding of how children with disabilities view their participation in out-of-school-time (OST) activities in a range of
environmental settings. Methods. A case-study design was used to examine six childrens views on their OST activities using the
Childrens Assessment of Participation and Enjoyment (CAPE), photographs of their OST activity settings, and semi-structured
interviews. Findings. CAPE results indicated that the children participated most often in recreational activities. Through the use
of photographs and interviews, four major themes emerged that emphasized a deep interconnection between childhood
activities and settings. Implications. This unique pilot study contributes to developing an understanding for occupational
therapists about how children with disabilities view their participation, their activity environments, and how photographs can
be used to engage children in research.

Rsum
Description. Les interactions entre les enfants et leur environnement physique et social permettent dobserver que ceux et celles
qui sont atteints dun handicap sont particulirement vulnrables aux restrictions de participation. But. Cette tude avait pour
objectif de mieux comprendre la perception des enfants handicaps lgard de leur participation des activits se droulant
divers endroits en dehors des heures de classe. Mthodologie. Une tude de cas a t utilise afin dexaminer la perception de six
enfants diffrents au moyen de la Childrens Assessment of Participation and Enjoyment (CAPE), de photos prises lors des activits
en dehors des heures de classes et dentrevues semi-structures. Rsultats. Les rsultats de la mesure CAPE indiquent que les
enfants participaient le plus souvent des activits de loisirs. Les photos et les entrevues ont permis de faire ressortir quatre
thmes principaux mettant en valeur le lien profond qui existe entre les activits des enfants et les diffrents endroits o elles ont
lieu. Consquences. En plus daider les ergothrapeutes mieux comprendre comment les enfants handicaps conoivent leur
participation et peroivent les endroits o se droulent leurs activits, cette tude pilote dmontre comment la photographie
peut permettre de faire participer des enfants la recherche.

n the International Classification of Functioning,

Disability and Health, the World Health Organization
(WHO) defines participation as involvement in a life
situation (2001). Participation in out-of-school-time (OST)
activities plays an important role in the promotion of
childrens health, well-being, and development. Participation
in such activities is positively associated with childrens
mental and physical health and the development of essential
skills, competencies, and social relationships (Forsyth &
Jarvis, 2002; Larson & Verma, 1999; Mahoney, Larson, &
Eccles, 2005; Simeonsson, Carlson, Huntington, McMillen, &
Brent, 2001). Involvement in the everyday activities of

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childhood has also been identified as an important predictor

of future life satisfaction (Kinney & Coyle, 1992).
Research pertaining to children with disabilities
identifies this population as particularly vulnerable to limited
participation, which results from the interaction between
children and their physical and social environments (Forsyth
& Jarvis, 2002; Law et al., 1999; Law, King, et al., 2006).
Recent studies have shown links between household income,
parent education level, or geographic region and the childs
participation (Law, King, et al., 2006; Sloper, Turner,
Knussen, & Cunningham, 1990). Furthermore, King et al.
(2006) identified the childs functional ability, child activity
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preferences, and family participation in social and
recreational activities as major determinants of the childs
participation. In addition, they found that child and family
preferences were important predictors of childrens participation following adjustment for the childs functional ability.
They also found that factors such as family cohesion and
parental perceptions of environments were relatively
unsupportive, and supportive relationships for the child
indirectly influenced child participation (King et al.).
Research on childrens issues has typically been
conducted by gathering information about the child from
sources such as parents and health care professionals without
seeking the unique perspective of the child (Driessnack,
2005; Kortesluoma, Hentinen, & Nikkonen, 2003).
Researchers have acknowledged the importance of capturing
childrens unique perspectives, which differ from adult
concerns and perceptions (Coles, 1986). Despite this
recognition, interviewing children poses unique challenges
and many of the traditional adult interviewing techniques are
not effective for eliciting childrens perspectives (Bradding &
Horstman, 1999, as cited in Driessnack). Nonetheless,
understanding children with disabilities unique perspectives
is essential to the future development of programs, services,
and opportunities to effectively meet their activity needs.
Two theoretical frameworks were used to guide the
exploration of children with disabilities perspectives of their
OST activities and their environments: The International
Classification of Function and Disability ([ICF]; WHO, 2001)
and the Canadian Model of Occupational Performance
([CMOP]; Canadian Association of Occupational Therapists
[CAOT], 1997). The ICF recognizes that disability is a
universal human experience and shifts the focus from the
cause of a specific disability to the impact it has on the lives
of people in society. The ICF takes into account the social
model of disability, which regards disability as a social issue
and not an individuals attribute (Forsyth, Colver, Alvanides,
Woolley, & Lowe, 2007). The CMOP is an occupational
therapy model that depicts the dynamic interaction that
exists between persons, environment, and occupation
(CAOT). Spirituality lies at the centre of the model,
representing the idea that spirituality resides in persons, is
shaped by the environment, and gives meaning to
occupations (CAOT, p. 33).
In the present study, photographs were used as a
medium to give a voice to children with disabilitiesa
population whose perspective has often been overlooked in
past research. The photographs were used as a tool during the
interview process to elicit information and descriptions of
supports and barriers to childrens OST activity
environments. Please note that typically developing children
were not used as a comparison in this study. The purpose of
this study was to gain a better understanding of how children
with disabilities view their participation in OST activities and
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settings. The knowledge gained in this pilot study may

inform the practice of occupational therapists and other
health care professionals and will contribute to the future
development of a larger research study.

Methods
A case study design was used to gain a better understanding
of the OST activities and activity settings of children and
youth with disabilities. Case studies are useful when
exploring new or complex phenomena in order to obtain a
more holistic view of the phenomenon of interest (Fitzgerald,
1999; Tellis, 1997). In this study, cases consisted of a child or
youth with a disability and a parent, as appropriate. This pilot
study is a collective case study; that is, it examines multiple
cases in order to develop a greater understanding of a
phenomenon and explore new or under-researched areas
(Fitzgerald; Stake, 1995).

Participants
Ethical approval for the study was obtained from McMaster
University and a childrens rehabilitation centre in southern
Ontario. This centre previously completed research with
CanChild Centre for Childhood Disability Research and had
expressed an interest to be involved in any CanChild research
that focused on childrens participation. CanChild works in
partnership with all Ontario childrens rehabilitation centres.
Prior to participation in the study, written consent was
obtained from the parents or the guardians of participants
and assent was obtained from the child participants.
Participants were able to withdraw from the study at any time
without consequence.
Recruitment packages were sent to the childrens rehabilitation centre and then mailed by the administrator to eligible
families. Included in the study were children and youth of
either sex, between the ages of 8 and 13, living with a
disability, and attending the centre where recruitment was
done. Children were excluded if they were unable to
communicate their activities and experiences (as judged by
their parents at time of recruitment), or if participants or
their parent(s)/guardian(s) felt uncomfortable or unable to
respond to interview questions and questionnaires in
English. Children under the age of eight years were excluded
from the study as children of this age have been found to be
less able to reliably recall and articulate their activity participation and activity settings (Zwiers & Morrissette, 1999).
Study participants consisted of six English-speaking
Caucasian children ages 8 to 13 with various physical and
developmental disabilities. Four participants had physical or
motor impairments and two participants had developmental
disabilities. The sample consisted of five males, including one
set of brothers, and one female. Five participants were from a
two-parent family, and one participant was from a singleparent family. Five participants lived in a major urban
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TABLE 1
Participant information.
Participant

Sex Age

Type of disability

Mobility

13

11

13

10

13

Emotional/Behavioural/ Independent
Developmental
Emotional/Behavioural/ Independent
Developmental
Cardiopulmonary
Independent/
Wheelchair
Physical/Motor
Independent
impairment
Wheelchair
Physical/Motor
Independent/
impairment
Wheelchair
Physical/Motor
impairment
Wheelchair

community (population over 100,000), and one participant

lived in a rural community (population less than 3,000). The
majority of the participants lived in a household with an
annual family income of $60,000 or more.

Data collection
Measures
Participants views of their OST activities, their environments,
and their associated meanings were captured using multiple
methods, including a standardized assessment, the Childrens
Assessment of Participation and Enjoyment (CAPE; King et
al., 2004), photographs, and semi-structured interviews.
Quantitative data and photographs were used selectively to
enhance the qualitative interview data. The use and
integration of multiple sources of data help to support case
findings and reduce the likelihood of misinterpretation (Yin,
2003). Specifically in relation to research with children, it has
been noted that the use of multiple methods may produce
richer data and a better representation of childrens
experiences, especially if the methods help to engage the
childrens attention and interest (Darbyshire, MacDougall, &
Schiller, 2005).
The CAPE is a standardized assessment of childrens
activity participation outside of school-mandated activities. It
measures five dimensions of activity participation: the
number of activities a child/youth does, how often, with
whom, where, and their level of enjoyment. The CAPE
includes 50 activities within 5 activity types: recreational,
active physical, social, skill-based, and self-improvement
activities. The psychometric properties of the CAPE have
been reported (King et al., 2004; Law, Baum, & Dunn, 2005).
Test-retest reliability for the five scales on the CAPE range
from poor to good (0.64 to 0.86) based on intra-class
correlation coefficients. Internal consistency ranges from
poor to adequate (0.32 to 0.62) based on Cronbachs alpha.
Content validity was addressed in the tool development, and
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construct validity has been established by comparison with

known predictors of childrens participation and the
Preferences for the Activities of Children (PAC; King et al.,
2007). Despite having some variability in its validity and
reliability, the CAPE was the most appropriate measure as it
is a self-report measure for children/youth ages 6 to 21 years,
and is one of the few existing instruments that directly
measures participation (King et al., 2006). Based on the
CMOP theoretical framework depicting the dynamic
interaction that exists between person, environment, and
occupation (CAOT, 1997), the CAPE allows the child to place
importance on activities that are meaningful to them rather
than on parental and other individuals beliefs of what they
consider is meaningful to the child. Thus, the CAPE was used
in this pilot study as a measure that may be useful for a point
of comparison in future studies.
Phase one of the CAPE is a self-administered questionnaire that measures the first two dimensions: which activities
the child participated in and how often they had participated
within the previous four-month period. How often a child
participated is measured on a scale of 1 (1 time in the past 4
months) to 7 (1 time a day or more). Phase two of the
CAPE measures the last three dimensions: where and with
whom the child took part in activities and the childs level of
enjoyment. Level of activity enjoyment is measured on a scale
of 1 (not at all) to 5 (love it).
Children took photographs with parental/guardian help
as needed, using a disposable camera over a period of at least
seven days. These photographs were used as a tool to
facilitate semi-structured interviews with the participants.
The student researchers conducted semi-structured
interviews in the participants homes to discuss the content of
photographs the child/youth had taken. To address the
uniqueness of interviewing children, special attention was
given to building rapport with participants, using both openand closed-ended questions, minimizing leading, and having
a parent/guardian present or involved as needed (Irwin &
Johnson, 2005). Participants were asked to select their two
favourite places and one least favourite place. Next, an
interview guide with open- and closed-ended questions was
used to gain more information about the activity settings and
participants perspectives of these environments. Questions
asked in the interview guide included, Tell me about this
place and what you do here, and Tell me what you like/dont
like about this place. Why? They were developed from the
researchers reflections on what basic questions would help
encourage a child to describe an activity environment. These
questions allowed the participants to explore the positive as
well as negative aspects surrounding their activity
environments rather than placing a focus on their disability.
Examples of further questions beyond the interview guide
included how the participant felt in a given environment and
what was special about it; these were consistent with the
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CMOP, which places importance on the meaning behind the
activity (CAOT, 1997). The open-ended interview questions
provided the child participants the opportunity to identify
and explore the meaning of their activity environments.
Questions asked were also consistent with the ICF, which
recognizes that disability is a universal human experience
and shifts the focus from the cause of a specific disability to
the impact it has on the lives of people in society (Forsyth et
al., 2007).
All interviews were conducted by pairs of entry-level
masters occupational therapy students. Each pair of students
interviewed at least one participant, and there were six
student researchers in total. The same pair of researchers
carried out both interviews (phase two of the CAPE and the
semi-structured interview) with a given participant in order
to establish and maintain rapport. Researchers did not have
knowledge of participants or the recruitment agency prior to
the study. Before conducting interviews, each member of the
study team used self-reflection to identify potential personal
preconceptions relevant to the study and also identified and
bracketed their assumptions about expected results.

Procedure
Families who expressed interest in participating in the study
were contacted by a member of the study team to arrange an
initial home visit. Prior to the visit, families received a
package in the mail containing a letter of information,
consent form, self-report demographic questionnaire, and
phase one of the CAPE to complete on their own.
In the initial meeting at the participants home, the
researchers facilitated completion of phase two of the CAPE
by the participant with the assistance of a parent, as
appropriate. Participants were then given a disposable camera
and instructed to take photographs of their usual OST activity
settings over a minimum of seven days. The families received
postage-paid envelopes in which to return the cameras to the
study team. Photographs were then developed and returned to
participants during the second meeting. At that time, the
content of the photographs was discussed with the participants in semi-structured, home-based interviews. Interviews
lasted an average of 30 minutes and no longer than one hour.
Interviews were tape-recorded, transcribed, and reviewed by
the interviewers to check for accuracy. The total time
commitment for each participant, including both home visits,
was no more than two hours. Data for this pilot study was
collected over the five-week time period available for the
student research project. Transcription of the interviews was
completed by an outside source and checked by the pairs who
had completed the interviews.

Data analysis
Descriptive statistics (means, medians, and standard
deviations) for CAPE data were calculated and served to
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describe five dimensions of the participants activity participation. Using the CAPE data, participation intensity was also
calculated by dividing the sum of item frequency by the
number of possible activities in each activity-type scale. The
photographs that study participants took were used to
illustrate and enrich interview findings. The content of the
photos was not analyzed per se, but all researchers viewed the
photos during the coding process to be aware of OST activity
environments that participants had photographed.
The six researchers analyzed the Interview transcripts
using an inductive content-analysis approach (Graneheim &
Lundman, 2004). This process involved coding statements
based on their key concepts, clustering these codes into
themes, and then refining the themes. An editing approach to
analysis was also used in that codes emerged from the data
and were not predetermined (Miller & Crabtree, 1999).
Coding was done manually, and negative case analysis was
used to ensure that all data were represented in the final
themes. The entire student research team established a
coding scheme based on the first two transcripts, and one
pair of student researchers coded the remaining four
transcripts once an understanding of the phenomenon had
been established. Maintaining at least two researchers in this
role guaranteed triangulation. To ensure that all researchers
had an understanding of each participants perception of OST
activities, each team member read all six interview
transcripts. Themes were subsequently developed by all
researchers from an inductive analysis of the codes. This
involves grouping related codes and identifying them under a
theme so that each code is captured in one of five themes.
Theoretical saturation cannot be presumed as sampling was
not continued to the point of redundancy in the data because
the time available for data collection was limited.
The quantitative and qualitative data were used to
develop a description of the nature and context of OST
activities for the study participants. A decision trail was
documented by the researchers as a group throughout the
analysis process.

Trustworthiness
Several strategies were implemented during the research
process to ensure the trustworthiness of the results (Letts et
al., 2007). Credibility was ensured by using multiple methods
of gathering data, using a reflective approach on the part of
the research team to increase awareness of personal bias,
triangulation in the use of quantitative and qualitative data,
and having multiple researchers. The time constraints of the
study precluded the use of member-checking to verify data
and interpretation. Dependability was reinforced by the
description of an audit trail. Confirmability was also
supported by having a team of researchers along with expert
input from experienced research supervisors.

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Results
Results from the CAPE were used to gain a general
description of the participants participation over the fourmonth period from December to April prior to the
interviews. The CAPE was used to determine the intensity of
activity (what form of activities children participated in the
most) and the enjoyment of activities. CAPE results group
activities based on type as well as their formal or informal
nature. The five activity types include recreation activities
(e.g., puzzles and watching television), physical activities
(e.g., swimming and track and field), social activities (e.g.,
playing with friends and talking on the phone), skill-based
activities (e.g., music lessons or horseback riding), and selfimprovement activities (e.g., reading and going to the
library). Formal activities have designated leaders and rules
or goals, whereas informal activities involve no planning
prior to the activity.
The results of the mean intensity scores from the CAPE
indicate that subjects participated the most in recreational
activities (mean = 4.07, standard deviation [SD] = 1.02)
followed by social (mean = 3.20, SD = 0.87), selfimprovement (mean = 2.77, SD = 1.40), active physical
(mean = 1.53, SD = 1.35), and skill-based activities (mean =

0.85, SD = 0.67). Intensity scores for each subscale vary by

participant as shown in Figure 1. The mean intensity for
formal and informal activities was also calculated.
Participants in the study participated in more informal
activities (mean = 3.15, SD = 0.72) than formal activities
(mean = 1.19, SD = 0.85). Figure 2 illustrates the intensities
for participants formal and informal activities.
Participants mean enjoyment indicated participants
enjoyed physical activities most (mean = 4.42, SD = 0.49),
followed by social (mean = 4.38, SD = 0.28), recreational
(mean = 4.21, SD = 0.48), self-improvement (mean = 3.05,
SD = 0.73), and skill-based (mean = 2.83, SD = 0.96)
activities. Specific enjoyment scores for each participant for
subscales can be seen in Figure 3. Participants demonstrated
comparable mean enjoyment for both informal and formal
activities. Figure 4 demonstrates individual participant
enjoyment scores for formal and informal activities.
Table 2 presents the activity environments that participants
identified when discussing the photographs of their favourite
and least favourite activity settings, as well as the activities they
do there. Four themes emerged from these discussions:
experience of place, connecting with the natural environment,
negotiating the environment, and supports and barriers.

FIGURE 1
Intensity of participation divided by activity type, from the Childrens Assessment of Participation and Enjoyment.

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FIGURE 2
Intensity of participation divided by formality of activities from the Childrens Assessment of Participation and Enjoyment.

FIGURE 3
Enjoyment of participation divided by activity type, from the Childrens Assement of Participation and Enjoyment.

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FIGURE 4
Intensity of participation divided by formality of activities from the Childrens Assessment of Participation and Enjoyment.

Experience of place
Participants articulated both positive and negative experiences
of place in relation to their level of enjoyment, likes and
dislikes, and feelings about being in that place. Experience of
place was intertwined with, and thus difficult to differentiate
from, the activity done there. Participants enjoyed a variety of
activities that they often found meaningful.
Positive experiences were often described as fun and
matched their interests and abilities while negative

TABLE 2
Participants photographs of activity environments.
Participant
1
2
3
4
5
6

Favourite places
Butterfly
conservatory
Park
Road/Street
Bedroom
Bedroom
Barnyard

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Least favourite place

Respite home

Church

Grocery store
The path
Church
Park
Living room

Library
Park
Garden
Library
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experiences did not match their interests. Participants liked

various aspects of the environment, including the people, the
activity, and nature. They also reported that feeling accepted
and having a choice of activity was important to them in their
experience of place. Participants had positive feelings in
many places; they felt happy, excited, free, relaxed, good,
important, and accepted. Places were described as special and
comfortable.
P4: Its a comfortable place . . . theres special things we
do every Sunday in service. We come in, we . . . theres
the greeting. And then theres a few songs of praise then
youve got announcements and celebrations. Its fun
some of the things that come up. Our minister or one of
our ministers celebrates every time that the Leaf s win a
game.
Conversely, some of the negative feelings related to place
and activity included feelings of anger, fear, or annoyance.
Participants health status also affected their experience.
Participants often reported that there was nothing that
they disliked about their favourite places. When describing
their least favourite place, participants identified aspects of
the activity and environment that they disliked, but also
noted many positive aspects.
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FIGURE 5

FIGURE 6

Experience of place (Participant 5); A photographic

example relating to the experience of place theme.

Connecting with the natural environment (Participant 1);

A picture of a butterfly garden corresponding to the
theme of connecting with the natural environment.

Limitations of public places and accessibility contributed

to negative experiences of place. Participants were able to
identify ways of changing limitations within their
environments, specifically related to their dislikes.
P3: Ah, mostly a playground should be more . . . like a
playground should be more tarmac and it should be
more accessible.
Two participants valued independence in activities while
two other participants valued being alone in their bedrooms.
Figure 5 shows one participants photograph of a favourite
activity setting.
When asked why this was a favourite place, the
participant explained:
P5: Well . . . a lot of its because I really like playing with
my stuffed animals in there and also I just like playing in
there mostly.

Connecting with the natural environment

The theme of connecting with the natural environment
evolved from the way the participants described their
interaction with their natural environment through their five
senses. Participant Fours description of a garden illustrates
this theme:
P4: I like the garden ... there was one plant, there were a
few plants there ... I really liked. There was one
somebody started it looked like it was fake, a plastic
plant. It looked that way but it was completely real. In
that same garden there was a fuzzy plant, a soft one.
Uhm ... there were some special things for people. There
were gardens for you to look at, smell, touch ... I liked
some of the grass there. Driving by in my chair it would
brush on me; thats so nice. I like it. It ... in the end I ... we
began calling it tickle grass.
Connections with animals and nature were very
apparent. Participants noted colourful butterflies, tickle
grass, fuzzy plants, puff ball spores, nuzzling a horse, looking
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at and smelling gardens, and watching wildlife and nature.

Figure 6 portrays a butterfly garden, an environment in
which Participant One was able to come into physical contact
with the creatures.
The participant explained the experience of being in a
butterfly garden, stating:
P1: Not a glass window; you actually get to ... touch them ...

Negotiating the environment

Negotiating the environment is a theme that emerged from
participants discussing moving around in, getting to, and
ensuring safety in different environments. Participants were
thus required to negotiate environments in order to
successfully participate within them. For example, Participant
Two described negotiating the grocery store as follows:
P2: I just go zoom and right out.
Participants revealed an awareness of their individual
needs, adaptability, problem-solving skills, and positive
attitudes while in different environments. They reported
using different assistive devices depending on the activity as
well as occasionally having assistance from others to get
around. Various means of transportation were used to access
the activity environments, for example, walking, taking
public buses, riding bikes, and using wheelchairs; participants also relied on adults for transportation. The type of
transportation used also depended on time considerations
and proximity of the place, especially for one participant who
lived in a rural location. As participants and their parents
were keenly aware of their needs, safety was ensured by
various means depending on the nature of the environment
and the activity. For example, cell phone technology and
community support were described. Participant Six discusses
negotiating the environment as seen in Figure 7.
P6: Once I went at the theatre to get, I think it was a
drink, and one of the staff . . . people he helped me back
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FIGURE 7

FIGURE 8

Negotiating the environment (Participant 6); One

participant described the navigation of this environment
associated with the theme negotiating the environment.

Supports and barriers (Participant 3); This photograph

correlates to a barrier for one study participant and falls
within the theme of supports and barriers.

into the theatre, which was really good because theres

[a] heavy door on the theatre which I cant really push
open by myself and then theres the ramp to get up to like
all the seating which some . . . if I have like my electric
chair I can handle it, but if I have like my manual one I .
. . I cant get it open on my own.

their participation. In Figure 8, Participant Three describes

an environment where a barrier limits participation.
P3: I liked it but its just I dont find it as accessible as the
other places, so like my friends were here and I go, then I cant
really play with them, so theres actually a little bench sitting
area in the park and on the slide area where that house is, so
Im just sitting there and sometimes my friends come up . . .

Supports and barriers

Participants consistently identified aspects of their
environments and activities that acted as supports or barriers
to their participation. These supports and barriers were part
of both the physical and social environment, and participants
spoke predominantly of supports rather than barriers.
Features that made an environment accessible as well as those
that made a place physically comfortable were noted as
supports. Social supports came in the form of friends, nice
helpers, pets, and neighbours. Participants health issues were
a barrier to their participation in some settings.
For some participants, weather was not an issue, whereas
for others, different aspects of the weather, such as snow and
muddy terrain, restricted their participation in certain
environments, especially if it made the use of wheelchairs
difficult, as illustrated by Participant Fives comment:
P5: Yeah, its annoying when I get stuck because I dont
really mind using my wheelchair that much.
Participants also said that their parents sometimes
imposed different kinds of restrictions on them, such as
making guidelines in relation to their safety or not allowing
them to watch certain movies. Only a few social barriers were
noted, such as having different interests than others or not
being able to control certain aspects of the social
environment that affected their participation, which may
have upset them. Finally, participants noted that not all
environments were accessible and identified changes they
would like to see made to make a place more conducive to
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Discussion
The six children in this study participated in and enjoyed a
wide variety of activities in various settings, as captured by
the CAPE data and the qualitative interviews and as
illustrated in their diverse photos. There was no significant
evidence of participation restriction, though it has been
noted that children with disabilities may be vulnerable to this
(Forsyth & Jarvis, 2002; Law et al., 1999; Law, King, et al.,
2006). These findings could be a testament to participants
and their families making participation in activities a priority,
although results may indicate a bias in that parents who are
actively involved with their childrens participation may have
been eager to be a part of the study.
The CAPE data show that participants had the highest
mean intensity of participation in recreational activities, and
higher intensity of informal activities overall when compared
to formal activities. Participants also enjoyed physical
activities best as shown by the mean enjoyment data and had
similar enjoyment of formal and informal activities. It was
noted that participants did not necessarily have the highest
intensity participation in the activities in which they also had
the highest enjoyment. A previous study using the CAPE
with a large sample also showed higher participation in
informal versus formal activities (Law, King, et al., 2006).
This study also noted different patterns of participation
between genders. The sample of the current study had only
one girl and five boys, and therefore no trends can be seen.
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Though the participants photographs were not analyzed
in a systematic way, they proved to be an effective method in
this study for several reasons. For example, they allowed
researchers to access participants unique views in that a
given place might be named by one participant as favourite
and by another as least favourite. This was seen with the
park and church activity environments. Having the participants then elaborate on their photos allowed the researchers
to understand their experiences in greater depth. Using
photographs in a qualitative interview also allowed
researchers to engage children in research, and it was a
communication tool to elicit their experiences and ideas.
Both participants and their parents were receptive to taking
photographs. For some participants, the use of cameras was
an important factor in their decision to participate in the
study. Furthermore, some children actually took up
photography as a new hobby after using the cameras. In this
way, the current pilot study expands on previous studies in
which children took photographs but did not have the
opportunity to discuss them (Darbyshire et al., 2005).
Overall, in discussing OST activities and activity
settings, participants experiences highlighted that the setting
and the activity were closely interconnected. For example,
when asked about their likes and dislikes, participants often
cited that they liked a setting because of the activity they did
there. In essence. this finding illustrates one of the theoretical
frameworks used to guide the study, the CMOP (CAOT,
1997), as it speaks to the dynamic interaction between the
participants, the activities, and activity settings. Participants
many activities clearly brought meaning to their lives. This
finding is similar to that found in the literature that describes
participation as an experience of engaging in meaningful
occupations and maintains that participation is important to
health (CAOT; Law, Petrenchik, Ziviani, & King, 2006). In
general, participants focussed on the positive and were more
easily able to articulate what they liked about both favourite
and least favourite places as opposed to what they disliked.
This may have been because they were asked to take pictures
of places they go to, and they may rarely frequent places that
they dislike, for personal reasons or simply because their
families do not go there. Also, the findings are weighted
towards favourite places since two of these photographs were
discussed, compared with only one least favourite place.
Participants ability to connect to an environment was an
important aspect of their experience. It is significant that all
participants described positive experiences with nature or
animals, including pets. These connections provided
opportunities for discovery and learning. Furthermore, the
social support necessary for participation stood out, an
observation that, in fact, previous authors (Heah, Case,
McGuire, & Law, 2007; King et al., 2006) have noted. Children
viewed people in the environment as helpful and rarely
described the social environment as a barrier to participation.
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This is in contrast with a previous finding that social barriers,

including attitudes, were in fact a significant environmental
barrier (Law et al., 1999). Interestingly, the young participants
did not explicitly name their parents as supports; however,
this may simply reflect their perception of their parents role.
Participating in some environments or activities may not
always have been straightforward, but these young participants negotiated their environment and were able to have
fun despite any setbacks. Nonetheless, children did identify
some barriers to participation; for example, accessibility was
raised as a common challenge. In contrast, they did not name
specific aspects of their own disabilities as barriers, disability
came across as a part of their lived experience and they
named factors in the environment around them as barriers.
This also relates to previous findings that participation was
better predicted by combined positive factors related to the
subjects and the environment rather than by type of disability
or diagnosis (Almqvist & Granlund, 2005; Law et al., 2004).
This observation is also consistent with the ICF (WHO,
2001), which incorporates the social model of disability and
emphasizes the role of society, including its environments, in
creating disability.
Participants had positive attitudes when discussing their
experiences, and these positive attitudes would presumably
enhance their participation. In some cases, they shared ideas
they had for changes that would minimize barriers in the
future. In other cases, they described actions they had already
taken to advocate for change. Thus, as seen in a previous
study (Law et al., 1999), a discussion of peoples views of an
environment naturally leads to ideas of how to change and
improve it. This may also indicate childrens developing
ability to advocate for themselves. By asking about childrens
life experiences and using photographs as a tool to see
through their eyes, this study provided children with an
opportunity to share their ideas for change.
The findings of this pilot study are limited for several
reasons. Since the themes did not reach saturation, the
findings may not fully describe the experiences of all children
with physical or developmental disabilities (Morse, 1997).
The time constraints of the study also precluded the use of
member-checking, which is a useful way of increasing
trustworthiness. Finally, interviewing children has been
described as challenging for various reasons (Irwin &
Johnson, 2005), and this may have had an impact on both the
data collected and the analysis. For example, though steps
were taken to interview the participants in a child-friendly
way, children may be more easily led by words an interviewer
uses (Irwin & Johnson), and this may have influenced the
content of the transcripts. Also, children may say few words
at a time or speak in a tangential way, and therefore
researchers need to be cautious not to miss the value of a
small or seemingly unrelated comment (Irwin & Johnson) in
the interview and when analyzing the data.
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HARDING ET AL.
This study has relevance to clinical practice with
children with disabilities and to policies that influence the
built environment. For example, the results may encourage
health care practitioners such as occupational therapists to
focus on what a child can do and a childs participation rather
than on participation restriction. Also, this study shows that
children with disabilities, along with their social supports, are
able to negotiate the environment to participate and have fun.
Occupational therapists may be in roles in which they can
partner with children and families to facilitate this process. It
was also noted that participants volunteered ideas to change
and improve the activity environments around them. This is
certainly a reminder of the importance of involving people
with disabilities when developing policies that will influence
them as they are the end-users and have an expertise based
on their life experiences.
This pilot study demonstrates that many opportunities
remain for developing further research that explores the
relationship between childrens participation in OST activities
and the activity settings. Future studies could use larger
samples to allow for a better comparison with previous CAPE
studies with large samples or to make it possible to have two
groups within a study to allow for comparison. For example, a
group of children with disabilities could be compared with a
group of typically developing children to look at similarities
and differences in participation in OST activities and views on
activity settings. This study included children with varied
disabilities; therefore, future research could focus on a larger,
more homogenous sample in order draw stronger conclusions
related to the perspective of one group. Other areas for further
investigation include advocacy by children with disabilities
and the roles that families and communities play in facilitating
or limiting a childs participation.

Conclusion
This study demonstrates the wide variety of activities and the
respective settings experienced by six children with various
disabilities. Participants often enjoyed activities when they
felt connected to the environment and if the activity setting
provided physical or social supports to enable their participation. Despite experiencing environmental barriers, the
children did not focus on how their disabilities limited their
participation, but rather they adapted to and overcame these
obstacles. Ultimately, they were able to fulfill a major goal of
activity participation for all children: having fun. By
interviewing the young participants, this study provided a
platform that gave these children an opportunity to share
their ideas and to speak about their activities and
environments using their own voices. The results of this
study should encourage other researchers to employ the
voices of children in future research endeavours. The
application of this client-centred research is important not
only in the exchange of critical information between
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researchers and health care service providers, but it is also

beneficial in ensuring that this unique client-centred
perspective is included in government policy and ultimately
reflected in all facets of health care, social programming, and
service provision for all children.

Key messages
This pilot study explored OST activity participation
from childrens perspectives. Using photographs in a
qualitative interview was an effective method to engage
children in research and elicit their experiences.
Participants experiences highlighted that the setting
and the activity were closely interconnected.
Participants described actions they had taken to elicit
change in order to enhance their participation. This
research project provided them a platform from which
they could share their ideas for change. The voices of
children can be valuable to future research, especially
to maintain a client-centred focus.

Acknowledgements
The authors would like to thank the child development centre
and their staff as well as the CanChild Centre for Childhood
Disability Research, Hamilton, Ontario, for their support
with this research. Special thanks to the children and families
who participated in this project and shared their unique
voices with us.

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Authors
Johanna Harding, MSc OT, OT Reg. (Ont.) is Occupational
Therapist, CBI Physiotherapy and Rehabilitation Centre, 305
Milner Ave., Suite 214, Scarborough, ON, Canada, M1B 3V4.
Telephone: 1-416-289-3930. E-mail: jharding@cbi.ca.
Kimberly Harding, MSc OT, OT Reg. (NS.), is Occupational
Therapist, St. Marthas Regional Hospital, 25 Bay St.,
Antigonish, NS, Canada, B2G 2G5.
Patricia Jamieson, MSc OT, OT Reg. (Ont.), is Occupational
Therapist, Hpital Rgional de Sudbury Regional Hospital, 41
Ramsey Lake Road, Sudbury, ON, Canada, P3E 5J1.
Maria Mullally, MSc OT, OT Reg. (Ont.), is Occupational
Therapist, The Ottawa Hospital, Civic Campus, 1053 Carling
Ave., Ottawa, ON, K2P 0X7.
Carolyn Politi, MSc OT, OT Reg. (Ont.), is Occupational
Therapist, Functional Rehabilitation, Inc., 115 King St. W., Suite
200, Dundas, ON, Canada, L9H 1V1.
Erline Wong-Sing, MSc OT, is Occupational Therapist, Providence
Health Care, 1081 Burrard Street, Vancouver, BC, Canada, V6Z
1Y6.
Mary Law, PhD, FACOT, FCAHS, Professor and Associate Dean,
School of Rehabilitation Science, McMaster University, 1400
Main St W, Hamilton, ON, Canada, L8S 1C7
Theresa M. Petrenchik, PhD, OT Reg. (Ont.), CanChild Centre for
Childhood Disability Research, McMaster University, 1400
Main St W, Hamilton, ON, Canada, L8S 1C7.

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