Promoting Participation in Leisure Activities: Expanding Role for Pediatric Therapists

Recent issues of Physical & Occupational Therapy in Pediatrics as well as articles in other pediatric journals in the field are increasingly focusing on “topics” (measures, outcomes, models, interventions) related to participation and enjoyment. Indeed, in this issue of the journal, there is an important paper by Dwyer and colleagues encouraging therapists to broaden their perspective by more actively promoting participation in physical activity. Participation may be defined as taking part or being involved in everyday-life activities and roles. It is a concept in rehabilitation that has been brought to the forefront by the World Health Organization's classification framework of health and functioning (i.e., International Classification of Functioning, Disability and Health: ICF; [World Health Organization, 2001]). Examples of life roles that children participate in include social relationships with family and friends, domestic chores, learning at school, and leisure and recreational activities at home and in the community. Level of participation may be modified by a chronic health condition, activity limitations, personal attributes, and environmental factors. Each may impose barriers, thus compromising the level of participation. Leisure activities are those in which we freely choose to participate during our spare time, when not involved in self-care or work (school), because they are enjoyable. Participation in leisure activities brings about happiness, better health, and social supports, thereby providing mechanisms for coping with life stress. For children and youth, participation in leisure activities is driven by an intrinsic need to enhance competence, practice social skills, develop personal identity, and explore new peer, family, and community roles ([King et al., 2006]). Gaining autonomy in one's personal environment is achieved in part through leisure experiences. Leisure activities are particularly important for school-aged children and adolescents, which are developmental stages in which parents are less likely to orchestrate these activities and children are increasingly gaining autonomy and control of their participation in leisure activities they want to be involved in.

There is a paucity of literature on participation in leisure activities in children and youth with disabilities. Nonetheless, preliminary evidence suggests that these individuals experience lower levels of participation in extracurricular activities when compared to peers ([King et al., 2006]; [Shikako-Thomas, Majnemer, Law, & Lach, 2008]). Their leisure activities lack variety and tend to be more passive, home-based activities. In particular, there is less participation in social engagements, active recreation, household chores, and community-based programs. Recent studies on children with physical disabilities showed that the children favored participating in informal activities (e.g., watching TV, using computer, listening to music) ([Imms, Reilly, Carlin, & Dodd, 2008]; [Law et al., 2006]; [Majnemer et al., 2008]). Although most participated in at least one formal, organized activity (e.g., art lessons, horseback riding, youth groups, organized sports), frequency of participation was lower for these more structured activities. Interestingly, children with physical disabilities experience a high level of enjoyment when participating in leisure activities, at a level comparable to typically developing peers ([Majnemer et al., 2008]). A recent systematic review in our journal on determinants of participation in leisure activities in children with physical disabilities highlighted the lack of evidence in this area ([Shikako-Thomas et al., 2008]). To date, studies have begun to identify a number of factors that may influence level of involvement in leisure activities. These include child factors such as age, gender and activity limitations, as well as environmental factors, such as family preferences and resources, physical barriers, and social supports and policies.

As we learn more about leisure participation and their determinants in children and youth with disabilities, how can we more effectively use this evidence to inform clinical practice? Traditionally, rehabilitation interventions focus on minimizing impairments (e.g., muscle weakness, poor eye–hand coordination, sensory loss, limited attention span) and maximizing function across activity domains (e.g., going up stairs, sitting independently, eating with utensils, writing legibly), with the expectation that this will ultimately enhance participation and quality of life. Indeed, studies demonstrate that there is a modest association at best between changes at the body function level (minimizing impairments) after interventions, with concomitant improvements in activity and participation ([Wright, Rosenbaum, Goldsmith, Law, & Fehlings, 2008]). Therefore, how can we ensure that we are facilitating positive changes at the level of participation in leisure activities? In my view, this begins with the evaluation process, whereby identification of the child's own desires and choices for leisure activities are specifically ascertained and intrinsic and extrinsic factors limiting participation in these activities are determined. Client-centered practice is a core value of rehabilitation and individualized goals should be informed by the child's personal needs and aspirations ([Hammel et al., 2008]). Therefore, goals addressing leisure participation should be a priority. For example, this may include facilitating involvement in fitness and sports activities, art or swimming lessons, or joining community clubs and programs with peers.

Children with disabilities may have the capability of and the interest in participating in a range of leisure activities, yet there are important obstacles in their real-life experiences that limit participation. Rehabilitation efforts cannot only focus on the capacity (‘can do’) to do particular tasks and activities in the rehabilitation setting, but must also address the child's ability to perform (‘does do’) these activities in their natural environment ([Hammel et al., 2008]). Therapists, together with the child and family, would need to identify the barriers to participation in order to overcome these obstacles. One approach may be that the activity or the environment may need to be modified in some way to enable the child to be actively involved. There may be the need to apply particular aids and adaptations to ensure successful participation. For example, creative application and use of computerized technologies may facilitate opportunities to play musical instruments or paint pictures. Virtual reality technologies such as the Wii are increasingly available commercially, and can enable children to participate in a range of recreational and active physical activities together with peers.

Another important obstacle to participation in leisure activities is diminished self-confidence and self-efficacy. Personal barriers such as fear of failure may limit a child's motivation to try and master particular leisure activities (e.g., social or skill-based activities), even if he or she would like to participate in them. The therapist may want to explore why the child has low expectations for success, and whether the conditions of the activity can be modified through peer support, practice opportunities and adjustments to the task. Task-training and ongoing skill development remains appropriate strategies for therapeutic intervention, thus enabling them to be more skilled in the natural environment.

Often, a number of adapted programs (e.g., adapted winter or water sports, horseback riding, fitness programs) exist in the local communities; however, families are unaware of these specialized activities. Therapists should therefore be kept abreast of opportunities in their regions, so as to inform and guide families.

Finally, rehabilitation specialists need to be more effective, proactive advocates for policy changes that will facilitate participation. For example, advocating for policy change to guarantee that environments are accessible and adapted transportation are more available will ensure that children and youth are able to gain greater access to activities in the community setting.

Clearly, further research evidence is needed to develop better measures of participation and to identify key attributes of the person and his or her environment that can potentially be modified to promote participation and community engagement. Greater knowledge of the factors that positively or negatively influence participation will guide our therapeutic intervention strategies and health promotion initiatives. Nonetheless, occupational therapists and physical therapists are positioned to more actively promote participation in leisure activities than we already do, first by identifying the leisure activities in which individual children or adolescents would like to engage, and determining the intrinsic and extrinsic factors that are limiting their participation. A gradual shift in health care practice from a medical model focusing on ‘ill-being’ and fixing deficits to a biopsychosocial model focusing on ‘well-being’ and health promotion further supports this need for expansion of our roles as rehabilitation specialists. The potential benefits of promoting participation in leisure activities are abundant. We can actively help the children and youth we service to engage in meaningful activities of their own choosing, which is essential for promoting their health and fitness, skill competencies and productivity, personal autonomy, community inclusion and life satisfaction.