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Physical & Occupational Therapy in Pediatrics, 33(4):384–404, 2013


C 2013 by Informa Healthcare USA, Inc.
Available online at http://informahealthcare.com/potp
DOI: 10.3109/01942638.2013.791915

Psychosocial Determinants of Out of School


Activity Participation for Children with and
without Physical Disabilities

Gillian King, PhD1 , Mary Law, PhD2 , Theresa Petrenchik, PhD2 , &
Patricia Hurley, MA2
1
Bloorview Research Institute, Toronto, Ontario, Canada, 2 McMaster University,
Rehabilitation Science, Hamilton, Ontario, Canada

ABSTRACT. Psychosocial determinants of children’s out of school participation were


examined, using secondary analyses of data from 427 children with physical disabili-
ties (from 12 service locations in Ontario Canada) and 354 children without disabilities,
ages 6 to 14. For both groups of children, hierarchical regression analyses indicated that
psychosocial variables added significant incremental variance (6% to 14%) to the pre-
diction of active physical intensity and social activity enjoyment, beyond that accounted
for by family income, child age and sex, and physical functioning. As well, there were
significant psychosocial determinants, with medium to large effect sizes. Athletic com-
petence and hyperactivity had specific effects on active physical activities and social
activities, respectively, for both groups of children. Disability-specific determinants in-
cluded social acceptance, emotional functioning, and peer difficulties (only significant
for children with disabilities). It was concluded that psychosocial variables play an im-
portant role in children’s enjoyment and intensity of participation in leisure activities.

KEYWORDS. CAPE, childhood disability, leisure, participation, psychosocial,


recreation

Compared to peers without disabilities, children with physical disabilities are at in-
creased risk for poorer psychosocial functioning (Lavigne & Faier-Routman, 1992;
McDougall et al., 2004; Wallander, Thompson, & Alriksson-Schmidt, 2003). Al-
though it is generally assumed that emotional well-being and life satisfaction are
positively associated with recreation and leisure participation (Austin, 1998), few
studies have directly examined relationships between psychosocial factors and the
activity participation of children with disabilities (Desha & Ziviani, 2007). A recent
systematic review by Dahan-Oliel, Shikako-Thomas, and Majnemer (2011) indi-
cated only a few studies showing participation in leisure activities to be associated
with emotional well-being, social well-being, and self-perception.

Address correspondence to: Dr. Gillian King, PhD, Bloorview Research Institute, 150 Kilgour Road, Toronto,
Ontario, Canada M4G 1R8 (E-mail: gking27@uwo.ca).
(Received 7 August 2012; accepted 21 March 2013)

384
Psychosocial Determinants of Participation 385

Studies of the psychosocial well-being of children with physical disabilities gen-


erally address broader aspects of psychosocial functioning, such as internalizing
or externalizing behaviors or overall maladjustment (Hunt, 2009). It is important,
however, to address specific types of psychosocial strengths and difficulties, since
there are likely different determinants of, for example, enjoyment of active physi-
cal activities such as sports compared to enjoyment of quiet recreational activities
such as reading.
In this article, we define “psychosocial variables” as those that are social and psy-
chological in nature, including self-concept, self-esteem, and mental health func-
tioning (i.e., emotional, behavioral, and social functioning), all of which may be
expected to be associated with the participation of children with and without dis-
abilities in out of school recreation and leisure activities. The variables of commu-
nicative functioning and social support were also of interest, due to their associa-
tions with psychosocial well-being. The ability to communicate is considered to be a
socio-cognitive skill that “provides the basis by which we experience thought, inten-
tions, and information and thus determines the quality of our social relationships”
(Beauchamp & Anderson, 2010, p. 49). Social support is a meso-level psychoso-
cial concept (Martikainen, Bartley, & Lahelma, 2002) that is associated with better
psychological well-being (Turner, 1981).
We propose that there are generic, activity-specific, and disability-specific deter-
minants of participation patterns. These reflect a gradient ranging from factors with
the broadest influence (generic) to those with the most specific type of influence on
participation outcomes (disability-specific). Generic determinants are those that
cut across activities and are relevant for all children. Activity-specific determinants
are those with localized effects for particular types of activities (for both children
with and without disabilities). For example, self-perceptions of athletic competence
may be relevant only for activities with an active physical component. Disability-
specific determinants are those that affect participation in a specific activity only for
one group of children. For example, difficulties with peers might have a significant
effect only on the social participation of children with disabilities.
Understanding associations between psychosocial factors and participation has
implications for consideration of these factors in clinical practice. If the most impor-
tant psychosocial factors apply to children with and without disabilities, this implies
the utility of universal programs that aim to foster the participation of all children
(Offord, Kraemer, Kazdin, Jensen, & Harrington, 1998). Knowledge of activity-
specific determinants can be used to encourage the likelihood of particular kinds
of activities. Finally, disability-specific determinants are those that should be the
target of clinical interventions.
Ascertaining generic, activity-specific, and disability-specific determinants re-
quires examining the magnitude of their influence in studies comparing children
with and without disabilities. We examined whether there were different directions
and magnitudes of associations for children with and without physical disabilities.
Based on the view that the major participation-enhancing processes include the
presence of opportunities, supports, and skill development through experiential
participation (King et al., 2005), we posited that social comparison, social support,
and social stigmatization processes might have appreciably different effects with
respect to the determinants of participation enjoyment and intensity for children
386 King et al.

with and without disabilities. Children with chronic health conditions are suscepti-
ble to negative self-comparison with peers, lower levels of social support, and social
stigma (Hunt, 2009), and social support from parents, teachers, and close friends
has been found to be a significant indirect predictor of the participation intensity of
children with physical disabilities (King, Law, Hanna et al., 2006). Consequently, for
children with disabilities, inferences about competencies generated by social com-
parison, lower levels of social support, and internalized stigma (i.e., negative ideas
and feelings that one has about oneself) may all contribute to lower enjoyment and
intensity of participation. These processes may particularly influence participation
in social activities, as well as active physical and skill-based activities, which usually
take place with others. Studies have indicated that several variables are important
predictors of participation outcomes for children with physical disabilities, includ-
ing their age and sex, family income, and their physical functioning levels (King,
Law, Hanna et al., 2006; Law et al., 2006; Majnemer et al., 2008), and so these vari-
ables were included in the present study.
The study involved secondary analyses of two datasets using the Children’s As-
sessment of Participation and Enjoyment (CAPE) (King et al., 2004), one examin-
ing the participation of children with disabilities and the other children without dis-
abilities. We have published two previous comparative studies (King, Law, Hurley,
Petrenchik, & Schwellnus, 2010; King, Petrenchik, Law, & Hurley, 2009), neither
of which used the psychosocial variables reported here. For children with disabil-
ities only, we have previously reported associations of psychosocial variables with
the intensity of participation in formal versus informal activities (King, Law, King
et al., 2006) and with activity participation profiles (King, Petrenchik et al., 2010),
and have examined the role of mental health variables as predictors of change over
time (King, McDougall et al., 2009). The present study makes a unique contribution
to the literature by comparing the degree to which self-concept, self-esteem, and
mental health functioning are associated with participatory experiences for chil-
dren with and without disabilities.

Objectives and Predictions


Our first aim was to examine the unique contribution of psychosocial variables (i.e.,
self-concept, self-esteem, and mental health functioning) to participation enjoy-
ment and intensity, controlling for demographic variables known to be associated
with children’s participation and, for children with disabilities only, level of physical
functioning. We were also interested in the roles of communicative functioning and
social support (children with disabilities only).
Our second aim was to examine the generic, activity-specific, and disability-
specific determinants of participation enjoyment and intensity. First, we predicted
that age and sex would be generic determinants for most activities, for both chil-
dren with and without physical disabilities. Second, we made the following activity-
specific predictions for all children: (a) perceived athletic competence would be re-
lated to the enjoyment and intensity of participation in active physical activities, and
(b) perceived social competence would be related to the enjoyment and intensity
of participation in social and skill-based activities (since skill-based activities often
occur in group settings involving others). Third, with respect to disability-specific
Psychosocial Determinants of Participation 387

determinants, we predicted that disability status would particularly affect the en-
joyment and intensity of participation in active physical, social, and skill-based ac-
tivities. Due to social comparison and stigmatization processes, we predicted that
social acceptance, emotional functioning, and peer difficulties would be important
predictors for children with disabilities only.
We also made two predictions concerning the variables measured only for chil-
dren with disabilities. First, we predicted that social support would be a general de-
terminant of participation across different types of activities. Second, we predicted
that greater communicative functioning would be associated with greater partici-
pation in social activities.

METHODS

Participants and Recruitment


The study involved two samples of children: 427 children (229 boys and 198 girls)
with physical functional limitations in three age cohorts (6–8 years, 9–11 years, and
12–14 years) and 354 children (147 boys and 207 girls) without disabilities in corre-
sponding age cohorts. Ethics approval for the studies was obtained from McMaster
University, participating children’s service organizations, and a local school board.

Children with Disabilities


This sample constituted the first wave of data from a 3-year longitudinal study of
the participation of children with physical disabilities, in which three age cohorts
of children were followed forward in time, with data collected at 9-month intervals.
Recruitment took place through 11 publicly funded regional children’s rehabilita-
tion centers and one children’s hospital in the province of Ontario, Canada. Details
are given in King, Law et al. (2010). The sample included rehabilitation centers
from both rural and urban areas of the province; the majority of children with phys-
ical disabilities have the opportunity to be served by these centers. Children with
the following primary diagnoses or conditions were included: amputation; cerebral
palsy; cerebral vascular accident/stroke; congenital anomalies; hydrocephalus; ju-
venile arthritis; nonprogressive muscular disorders; neuropathy; orthopedic condi-
tions; spinal cord injury; spina bifida; and traumatic brain injury.

Children without Disabilities


These children were recruited through a regional school board in southwestern On-
tario, Canada, serving an urban/rural district, to take part in a cross-sectional study
of the participation of children without physical disabilities, conducted for compar-
ison purposes. Schools with grades Kindergarten through Grade 8 were stratified by
income distribution within the district, and 16 schools were randomly selected from
within these income bands. Packages containing questionnaires and study informa-
tion were sent to the schools to be distributed to every second, third, or fourth child
on the alphabetical class list (depending on the size of the class), and taken home.
School staff members were asked to exclude children who had a physical disability,
were in a self-contained or segregated class, or could not read English sufficiently
well to answer the questions. There were 354 children in the final sample.
388 King et al.

TABLE 1. Characteristics of Samples of Children with and without Physical Disabilities

Sample 1: Sample 2:
Children Children
with disabilities without disabilities
(n = 427) (n = 354)
Variable Categories n % N %

Age 6–8 years 125 29.3 143 40.4


9–11 years 176 41.2 147 41.2
12–14 years 126 29.5 64 18.1
Sex Boy 229 53.6 147 41.5
Girl 198 46.4 207 58.5
Family type Two-parent 355 83.1 303 85.6
Single-parent 71 16.6 50 14.1
Missing 1 0.2 1 0.3
Family income <$30,000 68 16.0 34 9.6
$30,000–$59,999 153 35.8 95 26.9
$60,000–$89,999 114 26.7 116 32.7
≥ $90,000 87 20.4 109 30.8
Missing 5 1.2 n/a n/a
Number of 1 child 83 19.4 57 16.1
children 2 children 184 43.1 185 52.3
living 3 children 114 26.7 86 24.3
at home 4 children 31 7.3 17 4.8
5 or more children 14 3.3 5 1.4
Missing 1 0.2 4 1.1
Ethnicity Arab/West Asian 7 1.6 6 1.7
background Black 25 5.9
of respondent Caucasian 345 80.8 309 87.3
(Parent or Chinese 5 1.2 7 2.0
Guardian) Filipino 4 0.9
Japanese 2 0.5 1 0.3
Korean 1 0.3
Latin-American 8 1.9 3 0.8
Multi-ethnica 10 2.3
North American Indian 4 0.9
South Asian 13 3.0 3 0.8
South East Asian 2 0.5
Missing 1 0.5 24 6.8
a
Two or more options were checked for ethnic background.

Characteristics of the samples of participating children and their families are pre-
sented in Table 1. Compared to children with disabilities, the sample of children
without disabilities contained a smaller percentage of children ages 12–14 years
(29.5% and 18.1%, respectively) and a smaller proportion of boys (53.6% and
41.5%, respectively). The majority of families of children with disabilities had an
annual family income in the $30,000–$59,999 range (35.8%), whereas the major-
ity of families of children without disabilities had an annual family income in the
$60,000–$89,999 range (32.7%). The two samples were similar with respect to the
percentage of two-parent families (83.1% and 85.6%, respectively). The majority of
families in both samples had two children living at home (43.1% and 52.3%, respec-
tively). Participants in both samples were predominantly of Caucasian background
(80.8% and 87.3%, respectively), although the sample of children with disabilities
was more ethnically diverse.
Psychosocial Determinants of Participation 389

Control Variables
Due to sample differences, family income and ethnicity were evaluated as possible
control variables. Income and ethnicity (Caucasian vs. non-Caucasian) were signif-
icantly different in the two samples [t(774) = 5.3, p < .001 and t(764) = 28.2, p <
.001, respectively] and significantly correlated with one another, r(761) = .18, p <
.001. According to Norman and Streiner (2000), multiple covariates should be used
only when unrelated to each other. For theoretical reasons, it made most sense to
control for income, which is a proxy for the relative availability of tangible resources
(disposable income, transportation) that studies have shown are predictive of activ-
ity participation. We also controlled for child age, sex, and physical functioning by
entering these variables into the regression models first. This allowed us to exam-
ine the effects of psychosocial variables above and beyond these variables (Table 3
portrays the analysis procedure).

Data Collection Procedures


Children with Disabilities
Self-administered questionnaires were mailed to the family. The parent-completed
questionnaires included measures of demographic characteristics and environmen-
tal, family, and child factors, including the Strengths and Difficulties Questionnaire
(SDQ) (Goodman, 1997). Parents also completed the Communication Domain of
the Vineland Adaptive Behavior Scales (VABS) (Sparrow, Balla, & Cicchetti, 1984)
via a phone interview. The child-completed measures included the 49-item version
of the CAPE (King et al., 2004) and the Activities Scale for Kids (ASK) (Young,
Williams, Yoshida, & Wright, 2000). Children also completed the Self-Perception
Profile for Children (Harter, 1985a) or the Self-Perception Profile for Adolescents
(Harter, 1988), depending on their age, and the Social Support Scale for Children
(Harter, 1985b).

Children without Disabilities


The packages included a demographic questionnaire and the SDQ, completed by
the parent, and the self-administered version of the CAPE and the self-perception
measure, completed by the child. Families were asked to return the completed ques-
tionnaires by mail in a provided stamped and addressed envelope. The VABS, ASK,
and social support measures were not administered for these children.

Description of Measures
Measures of study independent variables are presented in Table 2, along with psy-
chometric information. Other study measures are discussed below.

Demographic Questionnaire
This questionnaire, completed by the parent, provided measures of child’s sex and
age (in years), parent/caregiver’s ethnicity, and annual household income (mea-
sured in five categories).
390 King et al.

TABLE 2. Study Constructs and Measures of Independent Variables

Overall construct and


measure Psychometric information Specific variables

Physical functioning The ASK is a 30-item child report Physical functioning


Measured using the ASKa measure that provides a total score of (Total score)
(Young et al., 2000) physical disability in children 5 to
15 years of age. The ASK measures a
child’s ability to perform daily tasks
such as personal care, dressing, eating
and drinking, and play. Questions are
scored based on whether a child can
do an activity independently none of
the time (0), once in a while (1),
sometimes (2), most of the time (3), or
all of the time (4). Scores range from 0
to 100; 0 indicates extreme disability.
The ASK has excellent reliability
(internal consistency, test–retest,
inter-rater, and intra-rater reliabilities of
0.94 or greater) and good construct and
criterion validity (Young et al., 2000).
Self-concept and The Self-Perception Profile for Children Social acceptance
self-esteem (for children in grades 3 to 8) taps (Social acceptance
Measured using the domain-specific judgments of scale)
Self-Perception Profile for competence in five domains, as well as Scholastic competence
Children or Adolescents global self-worth, with adequate (Scholastic competence
(Harter, 1985a, 1988) internal consistency reliabilities, ranging scale)
from 0.71 to 0.86. The Self-Perception Athletic competence
Profile for Adolescents (for youth in (Athletic competence
grades 9 to 12) also has adequate scale)
internal consistency reliabilities, ranging Self-esteem
from 0.58 to 0.91. We calculated (Global self-worth
Z-scores for the two samples to scale)
standardize scores for the two
measures. Lower scores represent
lower self-concept or self-esteem.
Mental health functioning The SDQ consists of 25 questions Emotional functioning
Measured using the providing measures on five scales. The (Emotional symptom
Strengths and Difficulties SDQ has satisfactory internal scale)
Questionnaire (SDQ) consistency (mean Cronbach’s alpha of Behavioral functioning
(Goodman, 1997) 0.73) and satisfactory test–retest (Conduct problems
reliability (mean correlation of 0.62 over scale)
4 to 6 months) (Goodman, 2001). Hyperactivity
Higher scores indicate worse (Hyperactivity scale)
functioning, with the exception of the Peer difficulties
Prosocial Scale, where higher scores (Peer problems scale)
indicate better functioning. Social functioning
(Prosocial scale)
Communicative functioning The VABS has excellent reliability and Communicative functioning
Measured using the content, construct, and criterion (Overall communications
Vineland Adaptive validity. It provides a measure of the standard score)
Behavior Scales (VABS)a child’s adaptive function in the areas of
(Sparrow et al., 1984) communication, daily living skills,
socialization, and motor skills. Higher
scores indicate higher functioning.
Perceived social support The SS is a 20-item questionnaire Friend social support
Measured using Social measuring parent support, classmate (Close friend support)
Psychosocial Determinants of Participation 391

TABLE 2. Study Constructs and Measures of Independent Variables (Continued)

Overall construct and measure Psychometric information Specific variables

Support Scale for Children support, teacher support, and close Classmate social support
(SS)a (Harter, 1985b) friend support (Harter, 1985b). The (Classmate support)
measure uses a four-point Likert scale,
with higher scores indicating greater
levels of support. The measure has
adequate reliability and validity
(Appleton et al., 1994; Harter, 1985b).
a
The ASK, VABS, and SS were not administered for children without disabilities.

Children’s Assessment of Participation and Enjoyment (CAPE)


Leisure participation was measured using the CAPE, a widely used self-report mea-
sure of participation for children/youth ages 6–21 that measures enjoyment and in-
tensity of participation in recreational, active physical, social, skill-based, and self-
improvement activities (King et al., 2004; King, Law, King et al., 2006). Frequency
response options range from 1 = “1 time in the past 4 months” to 7 = “1 time a day
or more”; enjoyment response options range from 1 = “not at all” to 5 = “love it.”
Participation intensity is calculated by dividing the sum of item frequency by the
number of possible activities in each activity type scale. Intensity scores are useful
for comparing participation across activity types (Imms, 2008). CAPE test–retest
reliabilities for the activity intensity scores range from 0.72 to 0.81, indicating suffi-
cient test–retest reliability; construct validity has been shown by correlations with
environmental, family, and child variables (King, Law, King et al., 2006). Details
of CAPE administration are reported in King et al. (2010). The CAPE is the only
existing psychometrically sound, self-report measure of participation in recreation
and leisure activities (Morris, Kurinczuk, & Fitzpatrick, 2005; Sakzewski, Boyd, &
Ziviani, 2007).

Overview of Analyses
Separate hierarchical multiple regression analyses were performed for children
with and without physical disabilities, since we wanted to control for the physical

TABLE 3. Blocks of Variables Entered into the Hierarchical Multiple Regression Analyses

Block 1 Block 2 Block 3 Block 4

Family income Social acceptance Communicative Friend support


Child age Scholastic competence functioning Classmate support
Child sex Athletic competence
Physical functioning Self-esteem
Emotional functioning
Behavioural functioning
Hyperactivity
Peer difficulties
Social functioning
392 King et al.

functioning of children with disabilities, which is a known predictor of the intensity


of their participation (King, Law, Hanna et al., 2006), and also to examine the role
of communication functioning and social support (measured only for children with
disabilities). Based on the rule of thumb that N = 50 + 8(k), where k is the number
of independent variables (Tabachnick & Fidell, 2001), the required sample sizes
for these analyses are 154 and 178 participants (where k = 13 and 16, for children
without and with disabilities, respectively). Our sample sizes (n = 354 and 422, re-
spectively) provided ample power. Variables were entered in blocks. The order of
entry reflected our interest in examining the unique contribution of psychosocial
variables over and above more static sociodemographic variables and, for children
with disabilities, physical functioning.
As shown in Table 3, the covariates (income, age, sex, and physical functioning
when appropriate) were entered in block 1, and the psychosocial variables were
entered in block 2. For children with disabilities, communicative functioning was
entered in block 3, followed by social support variables in block 4. The regression
models were identical with respect to the variables entered in block 2. The effects of
variables in each successive block controlled for the effects of variables in previous
blocks, allowing us to determine the influence of psychosocial variables, commu-
nicative functioning, and social support over and above the known roles of physi-
cal functioning, sex, age, and family income. We examined the incremental variance
added by successive blocks of variables, and then compared the relative importance
of the individual psychosocial variables by comparing beta weights in the final re-
gression models.

RESULTS
The most comprehensive predictive models (i.e., those with all blocks of variables
entered) accounted for the largest amount of variance in enjoyment and partic-
ipation. Tolerance statistics were typically over 0.90, indicating no collinearity
problems. Table 4 shows the significance of R square change due the introduction of
each successive block for the participation outcome variables. Due to the number
of analyses performed (n = 10 for both enjoyment and intensity), alpha was set at
p < .005. The block of covariates accounted for significant variance in the outcome
variables for 17 of the predictive equations (only three exceptions). The block of
psychosocial variables added significant incremental variance for active physical
intensity for both groups (9.8% and 11.7% respectively), and active physical enjoy-
ment for children without disabilities (13.7%). As well, the psychosocial variables
added significant variance for social enjoyment for both groups (12% and 5.8%,
respectively), and social activity intensity for children with disabilities (11.7%).
Communicative functioning added significant incremental variance to the model
for self-improvement activity intensity for children with disabilities (5%). As well,
social support added significant variance to the models for social and skill-based
activity enjoyment for children with disabilities (3.3% and 5.7%, respectively).
The relative predictive power of the individual variables in the final regression
equations are presented in Tables 5 and 6. In the sections below, we focus on generic,
activity-specific, and disability-specific effects.
Psychosocial Determinants of Participation 393

TABLE 4. R Squared Change with the Entry of Successive Blocks of Variables for
Enjoyment and Intensity of Participation in CAPE Activity Types

Children with physical disabilities Children without physical disabilities


(n = 427) (n = 354)

R R
Blocks of R square square Blocks of R square square
CAPE predictor change change predictor change change
activity type variables enjoyment intensity variables enjoyment intensity

Recreational Covariates 0.081c 0.174c Covariates 0.170c 0.281c


Psychosocial 0.036 0.025 Psychosocial 0.039 0.019
variables variables
Communicative 0.004 0.007
functioning
Social support 0.014 0.002
Active physical Covariates 0.023 0.198c Covariates 0.033a 0.120c
Psychosocial 0.073 0.098c Psychosocial 0.137c 0.117c
variables variables
Communicative 0.013 0.000
functioning
Social support 0.014 0.006
Social Covariates 0.042 0.121c Covariates 0.056c 0.130c
Psychosocial 0.120c 0.117c Psychosocial 0.058a 0.052
variables variables
Communicative 0.005 0.001
functioning
Social support 0.033a 0.004
Skill-based Covariates 0.070a 0.085c Covariates 0.068c 0.164c
Psychosocial 0.025 0.027 Psychosocial 0.030 0.024
variables variables
Communicative 0.012 0.002
functioning
Social support 0.057b 0.001
Self-improvement covariates 0.061a 0.041 Covariates 0.139c 0.095c
Psychosocial 0.047 0.039 Psychosocial 0.039 0.042
variables variables
Communicative 0.018 0.050c
functioning
Social support 0.003 0.009
a
p < .005.
b
p < .001.
c
p < .0001 for F change.

Predictors of Participation Enjoyment


As shown in Table 5, the final regression models for enjoyment of the different
leisure activity types were all significant, accounting for 10% to 21% of the variance
(large effect sizes). The multiple correlation (R2 ) is the percent of variance in the
dependent variable explained collectively by all of the independent variables.
Table 5 provides the standardized regression coefficients (parameter estimates)
for each predictor in the final equations. Significant predictor variables are pre-
sented according to the magnitude of their parameter estimates, which ranged from
+/−0.07 to +/−0.40 and were typically in the 0.20 range. The magnitude of a vari-
able’s beta weight reflects its relative predictive power, controlling for all other in-
dependent variables in the equation for a given model. These partial correlations
394
TABLE 5. Predictive Models for Enjoyment of Participation in CAPE Activity Types

Children with physical disabilities (n = 427) Children without physical disabilities (n = 354)

CAPE activity p r2 (% Parameter p p r2 (% Parameter


type Predictor variables (model) variance) estimate (variable) Predictor variables (model) variance) estimate p (variable)

Recreational Age <.005 13 −0.238 <.0001 Age <.0001 21 −0.403 <.0001


Physical functioning −0.123 <.07 Sex 0.109 <.05
Friend support 0.138 <.06 Social functioning 0.116 <.05
Active physical Emotional functioning <.02 12 −0.196 <.01 Athletic competence <.0001 17 0.273 <.0001
Age −0.149 <.05 Age −0.147 <.005
Athletic competence 0.158 <.05 Social functioning 0.175 <.005
Friend support 0.137 <.07
Social Friend support <.0001 20 0.216 <.005 Sex <.0001 11 0.259 <.0001
Social acceptance 0.219 <.01 Hyperactivity 0.210 <.002
Sex 0.167 <.01
Hyperactivity 0.192 <.05
Emotional functioning −0.167 <.05
Physical functioning −0.070 <.05
Skill-based Classmate support <.002 16 −0.265 <.005 Sex <.0001 10 0.279 <.0001
Friend support 0.232 <.005 Hyperactivity 0.173 <.01
Age −0.189 <.01
Sex 0.184 <.01
Social acceptance 0.178 <.06
Self- Sex <.006 13 0.228 <.001 Sex <.0001 18 0.323 <.0001
improvement Age −0.162 <.05 Age −0.189 <.0001
Peer 0.160 <.05 Social 0.175 <.005
difficulties functioning
Communicative −0.157 <.05
functioning

Note. This table shows the overall variance accounted for by the final models and the standardized beta weights (parameter estimates), which show the relative importance of the independent
variables in each model.

395
396
TABLE 6. Predictive Models for Intensity of Participation in CAPE Activity Types

Children with physical disabilities (n = 427) Children without disabilities (n = 354)

r2 (% Parameter p r2 (% Parameter
CAPE activity type Predictor variables p (model) variance) estimate p (variable) Predictor variables (model) variance) estimate p (variable)

Recreational Age <.0001 21 −0.403 <.0001 Age <.0001 30 −0.522 <.0001


Physical functioning 0.176 <.005 Social functioning 0.101 <.06
Active physical Athletic competence <.0001 26 0.305 <.0001 Athletic competence <.0001 24 0.245 <.0001
Physical functioning 0.356 <.0001 Sex −0.172 <.001
Age −0.133 <.05 Family income 0.145 <.005
Family income 0.127 <.05 Age 0.139 <.005
Scholastic competence 0.135 <.05
Social Physical functioning <.0001 19 0.293 <.0001 Age <.0001 18 0.341 <.0001
Peer difficulties −0.223 <.005 Hyperactivity 0.123 <.06
Age 0.139 <.05
Hyperactivity −0.155 <.05
Skill-based Sex <.02 11 0.239 <.0001 Sex <.0001 19 0.414 <.0001
Athletic competence 0.118 <.09 Athletic competence 0.109 <.06
Self-improvement Communicative <.002 14 0.269 <.0001 Sex <.0001 14 0.240 <.0001
functioning 0.124 <.05 Age 0.144 <.01
Family income Social functioning 0.163 <.01
Social acceptance −0.168 <.02

Note. This table shows the overall variance accounted for by the final models and the standardized beta weights (parameter estimates), which show the relative importance of the
independent variables in each model.
Psychosocial Determinants of Participation 397

show the unique contributions of variables when all other variables are held con-
stant. Joint contributions contribute to R2 but are not attributed to any particular
independent variable.
More variance in the enjoyment of recreational, active physical, and self-
improvement activities was accounted for in the sample of children without dis-
abilities (21, 17, and 18%, respectively) than for children with disabilities (13, 12,
and 13%, respectively). More variance in the enjoyment of social and skill-based
activities was accounted for in the sample of children with disabilities (20 and 16%,
respectively) compared to children without disabilities (11 and 10%, respectively).
Generic determinants. Age was a significant predictor of enjoyment of recre-
ational, active physical, and self-improvement activities in both samples. Sex was a
significant predictor of enjoyment of social, skill-based, and self-improvement ac-
tivities in both samples. In all cases, greater enjoyment was reported by younger
children and by girls. For children with disabilities, friend support was a signifi-
cant or marginally significant predictor of enjoyment of all activities except self-
improvement activities. Greater enjoyment was reported by children with disabili-
ties who reported higher friend support.
Activity-specific determinants. These refer to variables that affect participation in
specific activities (for both children with and without disabilities). Activity-specific
predictor variables were (a) athletic competence, with higher levels of perceived
athletic competence predicting greater enjoyment of active physical activities in
both samples, and (b) hyperactivity, with higher levels of hyperactivity predicting
greater enjoyment of social activities in both samples.
Disability-specific determinants. These refer to variables whose effects are associ-
ated with disability status. Social acceptance was a significant (or marginally signifi-
cant) predictor of the enjoyment of social and skill-based activities for children with
disabilities, but not for children without disabilities. Lower emotional functioning
was associated with lower enjoyment of active physical and social activities only
for children with disabilities. Higher social functioning was associated with greater
enjoyment of recreational, active physical, and self-improvement activities only for
children without disabilities.

Predictors of Participation Intensity


As shown in Table 6, the final (most complete) regression models for participation
intensity were all significant, accounting for between 11% and 30% of the variance.
As for enjoyment, more variance in recreational activities was accounted for in
the sample of children without disabilities (30%) than for children with disabilities
(21%), despite fewer entered predictors. The parameter estimates were similar to
those for enjoyment, ranging from +/−0.10 to +/−0.52.
Generic determinants. Age was a significant generic predictor of recreational,
active physical, and social activity intensity. In both samples, greater recreational
activity intensity was reported by younger children, and higher age was associated
with greater social activity intensity. Children with disabilities reported lower active
physical intensity with higher age, whereas children without disabilities displayed
the opposite trend.
Activity-specific determinants. Family income, sex, athletic competence, and hy-
peractivity had effects for only two or fewer activity types, indicating localized
398 King et al.

effects on intensity. In both samples, higher family income was associated with
greater intensity in active physical activities, girls reported greater intensity in skill-
based activities, and greater athletic competence was associated with greater in-
tensity of participation in active physical activities. The two samples differed in the
direction of effects for hyperactivity difficulties on social activities: for children with
physical disabilities, greater hyperactivity was associated with lower social activity
intensity, whereas children without disabilities displayed the opposite relationship.
Disability-specific determinants. For children with disabilities, more peer difficul-
ties were related to lower social activity intensity. For children without disabilities,
higher social functioning was related to greater intensity of participation in recre-
ational and self-improvement activities, and lower social acceptance was related to
greater intensity of participation in self-improvement activities.

DISCUSSION
This study examined the psychosocial variables associated with the enjoyment and
intensity of participation for 427 children with physical disabilities and 354 children
without disabilities, aged 6–14, in five types of leisure activities. For both groups
of children, psychosocial variables added significant incremental variance (6% to
14%) to the prediction of active physical intensity and social activity enjoyment,
beyond that accounted for by family income, child age and sex, and physical func-
tioning. There were also activity-specific and disability-specific psychosocial deter-
minants of participation with medium to large effect sizes (in addition to significant
generic determinants of a sociodemographic nature). It was concluded that psy-
chosocial variables play an important role in children’s enjoyment and intensity of
participation in leisure activities.
The psychological needs and inner lives of children with disabilities tend to be
over-shadowed by attention to physical impairments and functional limitations, and
little research attention has been paid to the relationship between mental health
and activity participation (Desha & Ziviani, 2007). There are therefore few stud-
ies with which to compare our findings. Existing studies have focused on relation-
ships between children’s participation (assessed using the CAPE) and specific psy-
chosocial variables, such as cognitive and behavioral difficulties (Majnemer et al.,
2008), coping strategies (Lindwall et al., 2012), and adaptive behavior (Palisano
et al., 2011). These studies have indicated that higher social support, lower self-
criticism, more effective adaptive behavior, and lower hyperactivity are associated
with higher levels of participation (Lindwall et al., 2012; Majnemer et al., 2008;
Palisano et al., 2011).
Our study indicated that age and sex were generic determinants of participa-
tion, with significant effects for recreational, social, and active physical activities
for both groups of children. Age and sex have shown general predictive power in
previous studies of children’s participation, as measured by the CAPE (e.g., Law
et al., 2006), perhaps because these variables have wide-spread effects on prefer-
ences and normative behaviors. Interestingly, but not surprisingly, the age effect
differed for active physical activities, with children with disabilities reporting lower
intensity with higher age, and children without disabilities displaying the opposite
trend. This may be due to a combination of factors, including lack of social support,
Psychosocial Determinants of Participation 399

lack of opportunities for physical activities adapted for children with disabilities,
and physical functioning difficulties.
Self-perceived athletic competence and hyperactivity were significant activity-
specific predictors of enjoyment and intensity. Greater athletic competence was as-
sociated with greater enjoyment and intensity of active physical activities for both
groups of children. Greater hyperactivity was associated with greater enjoyment
of social activities in both samples but had different associations with the intensity
of their social participation: greater hyperactivity was associated with lower social
activity intensity for children with disabilities, whereas children without disabilities
displayed the opposite relationship. The combination of hyperactivity and physical
disabilities may lead parents or children themselves to curtail social activity due to
perceived social stigma, or peers may be more reluctant to engage in social activi-
ties when children with physical disabilities display hyperactive behaviors such as
restlessness, fidgeting, and lack of concentration—behaviors that likely impact on
the quality of social interactions.
This is the first study to indicate associations for both groups of children between
self-concept and the intensity and enjoyment of participation in matching or corre-
sponding types of activities. Unlike self-concept, self-esteem was not a significant
determinant of participation for either group of children. Children with disabili-
ties do not differ from their peers in self-esteem but they do differ in self-concept
(King, Shultz, Steel, Gilpin, & Cathers, 1993; Shields, Murdoch, Loy, Dodd, &
Taylor, 2006).
Disability-specific determinants included social acceptance, emotional function-
ing, and peer difficulties (only for children with disabilities) and social function-
ing (only for children without disabilities). For children with disabilities, greater
social acceptance was associated with greater enjoyment of social and skill-based
activities; greater emotional functioning difficulties (such as worries, fears, and ner-
vousness in new situations) were associated with lower enjoyment of active phys-
ical and social activities; and more peer difficulties (e.g., plays alone, not liked,
picked on or bullied) were related to lower social activity intensity. It is notewor-
thy that the combined impact of disability status and social, emotional, and be-
havioral functioning occurred with respect to activities that typically have a social
component. Children with disabilities experience higher than average rates of men-
tal health conditions and adjustment problems (Lavigne & Faier-Routman, 1992;
Simeonsson, McMillen, & Huntington, 2002); it is not surprising that social and
emotional issues can affect their enjoyment of particular types of activities.
For children without disabilities, higher social functioning (i.e., considerate
of other people’s feelings, shares readily, often volunteers to help others) was
associated with greater enjoyment of recreational, active physical, and self-
improvement activities, and greater intensity of participation in recreational and
self-improvement activities. As well, for children without disabilities, less social ac-
ceptance was related to greater intensity of participation in self-improvement activ-
ities, suggesting that children without disabilities choose self-improvement activi-
ties as a route to meaningful participation when they are either not socially accepted
or are not particularly oriented toward prosocial behavior.
The roles of communicative functioning and social support were only examined
for children with disabilities. Higher communicative functioning was associated
400 King et al.

with greater intensity but lower enjoyment of self-improvement activities, but the
predicted association with social activities was not found. We speculate that higher
communicative functioning may lead parents to encourage children to take part in
self-improvement activities, which these children do not particularly enjoy. Social
support from friends was a significant predictor of children with disabilities’ enjoy-
ment of all but one type of activity, but was not a significant predictor of intensity.
This finding makes sense; the presence and support of friends appears to increase
enjoyment but not the intensity of participation in a given type of activity.
Although similar predictors were found for children with and without disabilities,
there were several noteworthy exceptions. Most importantly, emotional function-
ing difficulties played a unique role for children with physical disabilities, indicating
the influence of worries and fears on their enjoyment of social activities and active
physical activities. We speculate that social comparison, social stigma, and social
support processes operate here. Indeed, higher perceived social acceptance was as-
sociated with greater enjoyment of social and skill-based activities.
In conclusion, psychosocial variables were found to have important influences
on leisure participation, over and above physical functioning limitations, and while
controlling for leisure opportunities known to be associated with age, sex, and fam-
ily income. The findings help us begin to disentangle associations between physi-
cal and psychosocial well-being as predictors of children’s participation. The find-
ings indicated that different psychosocial competencies influence the enjoyment
and intensity of participation in different kinds of activities—reflecting the notion
of specificity or “fit” between the child’s self-concept and activity engagement.
This suggests a needs-based explanation for the role of psychosocial variables, with
higher engagement occurring when activities meet needs.

Study Strengths and Weaknesses


Strengths include the large sizes of the samples of children with and without dis-
abilities. The samples were similar in most regards; sample differences in income
were controlled for in the regression analyses. In addition to parent-report mea-
sures of psychosocial variables, the study used child-report measures that are reli-
able and valid measures for both groups of children. Study weaknesses include the
use of datasets or samples that were not matched or population-based, the lack of
measurement of all variables in both samples, and the potential for social desirabil-
ity bias, due to the use of parent- and child-report measures. The cross-sectional
nature of the study did not allow for determination of causality among variables.
Since fewer variables were measured in the sample of children without disabilities,
we were not able to conduct a single analysis with disability status as a dummy
variable; however, similar patterns of determinants were found for the two sam-
ples, which suggests that type of activity trumps disability status as a determinant
of participation (and also provides an internal replication of the findings).

Research Implications
First, future work should explore the predictive specificity of environmental, child,
and family variables on dimensions of activity participation such as preference
(what children would like to do, given a choice) and in-the-moment experiences
(such as a sense of control, fun, or social belonging). For example, it would be
Psychosocial Determinants of Participation 401

important to examine the “fit” between the child’s self-concept and the types of ac-
tivities he or she prefers, enjoys, and engages in. Second, more work is required to
understand unique psychosocial determinants and processes for children with phys-
ical disabilities, particularly emotional functioning difficulties and social stigma.
Third, we believe it is necessary to take a more theoretically driven and fine-grained
approach to understanding the predictors, processes, and outcomes of activity par-
ticipation, as “participation” is clearly not a global construct or a single variable.
Relatedly, there is a need to examine the subjective experiences of children, since
enjoyment is predicted by different psychosocial variables than is intensity.

Clinical and Service Implications


It is important for service providers to be aware of the influence of psychosocial
factors on participation, particularly with respect to children’s participation in ac-
tive physical and social activities. When assessing supports and barriers to desired
participation outcomes, it is important to consider the child’s own view of his/her
competencies and his/her fears and worries in activity settings with a social or
performance component. Since parents play an important role in channeling chil-
dren’s activities, service providers can encourage optimal participatory experiences
by ascertaining parents’ awareness of their child’s self-concept and mental health
functioning, discussing how parents’ inferences or expectations of success may be
linked to these understandings, and encouraging parents to help their children de-
velop strategies for coping with situations that make them fearful or nervous. In
some situations, it may be worthwhile to administer measures of psychosocial vari-
ables within the clinical setting, when psychosocial issues (fears, worries) are pre-
venting the child from trying new activities. Secondary conditions are preventable
and thus are an important priority for clinical interventions (Simeonsson et al.,
2002).
In summary, there are important psychosocial influences on children’s recreation
and leisure participation. Since what children do during their outside-of-school time
has important implications for their life satisfaction, personal development, and life
choices, it is important to address psychosocial influences in health promotion and
intervention for children with physical disabilities.

ACKNOWLEDGEMENTS
We acknowledge the contributions of all those who participated in the research
studies providing data for this article. Appreciation is extended to the many inter-
viewers, organizations, and families who contributed their time and commitment
to this research project. We thank Madhu Pinto for her help with the analyses and
Dayle McCauley and Lisa Avery for their support.

Declaration of Interest: The authors report no declarations of interest. The au-


thors alone are responsible for the content and writing of this article. These studies
were supported by a research grant from the National Institutes of Health (Grant
HD38108-02).
402 King et al.

ABOUT THE AUTHORS


Dr. Gillian King, PhD, is affiliated with Bloorview Research Institute, Toronto, On-
tario, Canada. Dr. Mary Law, PhD, is affiliated with McMaster University, Hamil-
ton, Ontario, Canada. Dr. Theresa Petrenchik, PhD, was affiliated with McMaster
University, Hamilton, Ontario, Canada. Patricia Hurley, MA, was affiliated with
McMaster University, Hamilton, Ontario, Canada.

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