R E S E A R C H R E P O R T

I Want to Play: Children With Cerebral Palsy Talk About Their Experiences on Barriers
and Facilitators to Participation in Leisure Activities
Egmar Longo, PhD; Isabelly Cristina Rodrigues Regalado, MSc; Elida Rayane Viana Pinheiro Galvão, MSc;
Haryelle Nárima Confessor Ferreira, MSc; Marta Badia, PhD; Begonã Orgaz Baz, PhD
Department of Health of Children (Dr Longo), Graduate Program in Rehabilitation Sciences (Ms Galvão), and Graduate Program in Public Health
(Ms Ferreira), Federal University of Rio Grande do Norte, Santa Cruz, Brazil; Graduate Program of Physiotherapy (Ms Regalado), Federal University of Rio
Grande do Norte, Natal, Brazil; Institute on Community Integration (INICO), Faculty of Psychology (Dr Badia), University of Salamanca, Salamanca, Spain;
Faculty of Psychology (Dr Baz), University of Salamanca, Salamanca, Spain.
Downloaded from https://journals.lww.com/pedpt by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1AWnYQp/IlQrHD3ne1tVsBOHA4A4uJ9Bgdq+wVmLfPf+fRzPXBoYOBw1Qk= on 07/24/2020

Purpose: To explore how children with cerebral palsy (CP) experience participation in leisure activities and to describe the
environmental barriers and facilitators.
Methods: Sixteen children with cerebral palsy aged 7 to 17 years participated in 3 focus groups. Data were analyzed
thematically by 3 researchers on the basis of the International Classification of Functioning, Disability and Health.
Results: A total of 38 International Classification of Functioning, Disability and Health categories were identified (4 linked
to Body functions; 2 linked to Body structures; 8 linked to Activities & Participation, and 24 to Environmental factors: 10
facilitators and 14 barriers). The most mentioned categories were Voluntary movement control functions, Functions related
to gait pattern, Structure of upper arm, Recreation and leisure, Nuclear family and finally, and Individual attitudes of
acquaintances.
Conclusions: The main barriers identified by children with cerebral palsy highlight aspects of the physical, social, and
attitudinal environment that could be modified to enhance participation in leisure activities. (Pediatr Phys Ther
2020;32:190–200)
Key words: cerebral palsy, children, environmental factors, focus group, ICF, leisure activities, participation

INTRODUCTION
Cerebral palsy (CP) is the most common cause of dis-
ability in children, and it is estimated that there were 400 000
people living with CP in the European Union before its recent
enlargement, with 10 000 new cases occurring each year.1
Because of their motor problems, children and adolescents with
CP experience participation restrictions and physical activity
limitations.2,3 Participation constitutes a core concept related to
health and disease, ability, and disability within the framework
of the World Health Organization’s International Classification
of Functioning, Disability and Health (ICF).4
The concept of participation reflects the extent of engage-
ment in the full range of activities that accomplish a larger
0898-5669/110/3203-0190
Pediatric Physical Therapy
Copyright © 2020 Academy of Pediatric Physical Therapy of the American
Physical Therapy Association
Correspondence: Egmar Longo, PhD, Department of Health of Children,
Federal University of Rio Grande do Norte—UFRN/FACISA, Rua Vila
Trairi, S/N, Santa Cruz, RN, 59200-000, Brazil (egmarlongo@yahoo.es).
The authors declare no conflicts of interest.
DOI: 10.1097/PEP.0000000000000719
goal.5 The factors that influence participation include the child’s
aspects such as age and complexity of his or her health con-
dition; family factors such as income and family function; and
environmental factors such as resources and supports.6 When
these factors have a positive influence on an individual’s partici-
pation, they are facilitators, and when they have a negative influ-
ence, they are barriers. In the ICF model, participation restric-
tions are viewed as the results of dynamic interactions between
a person and his or her environment, rather than solely as the
result of his or her health condition or impaired body function
and structure.7
Participation in leisure activities provides children with
opportunities for enjoyment, relaxation, recreation, self-
enrichment, and goal achievement. Moreover, leisure is of
central importance for building children’s competence, self-
determination, and identity, as well as for social and personality
development.8-11 Participation in meaningful leisure activi-
ties correlates with children’s well-being12 and quality of life
(QoL).10 Studies conducted in the United States, Europe, and
Canada have demonstrated that environmental factors impact
the participation of children who have disabilities.13-15 The
environment can serve as an affective target of intervention
extending beyond physical accessibility or the built environ-
ment and includes other modifiable aspects such as attitudinal,
social, and institutional factors.16 The current perspective

190 Longo et al Pediatric Physical Therapy

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of intervention for people with CP focuses on promoting
participation in leisure activities, because this variable has
become a strong indicator of good levels, because high levels of
participation indicate high QoL and health.17,18
Spanish children who have CP have low diversity and inten-
sity of participation in leisure activities, although they enjoy very
much or love the activities they participate in.3,19,20 According
to the parents, the main barriers to participation in the Spanish
context are products and technology (eg, adapted toilet, com-
munication aids, smooth pavements in town services), systems
and policies (eg, parent support groups in area, special staff help
child in school), support and relationships (eg, emotional sup-
port from family members), and attitudes (eg, child encouraged
to reach potential from classmates).17,21,22 Parents’ perceptions
reinforce the importance of considering environmental factors
that negatively interfere in the QoL and social inclusion of chil-
dren with disabilities.21-23
Including children with disabilities in participatory research
is a growing trend in countries in Europe and North
America,24-26 in following Article 12 of the UN Convention on
the Rights of the Child, which states that children’s views must
be taken into account in all matters concerning them, and Article
7 of the 2006 UN Convention on the Rights of Persons with Dis-
abilities, which emphasizes the right of children with disabilities
to express their views. Parents of children with chronic diseases
rated their children as worse in QoL than their own.27,28 There-
fore, relying only on parents’ perceptions may not be sufficient,
reinforcing the importance of listening to the voices of children
and adolescents with CP regarding their own perception of par-
ticipation in leisure activities.
Qualitative research facilitates information capture and is
sensitive to context variations, enabling the child to express
information as well as his or her individual and actual needs.
This model enables the researcher to know the reality of each
child and to define viable goals to improve his or her participa-
tion levels and QoL.25,29
This is the first article that considers the opinions of
Spanish children with CP regarding their participation in
leisure activities. The study explores how children and ado-
lescents with CP experience participation in leisure activities
and to identify facilitators as well as issues or barriers affecting
participation.
METHODS
30
This was a descriptive study using qualitative methods.
Focus groups explored the level of participation in leisure activ-
ities among children with CP. The goal was to draw out their spe-
cific experiences of what helped and what hindered their partici-
pation in leisure activities for children with CP in order to inform
practice and future research. The focus group method takes
advantage of group interaction to encourage discussion between
the participants to compare and contrast their experiences.31 It
provided a free and relaxed format for the children to express
their views.
Ethical approval for the study was obtained from the
Bioethical Committee of the University of Salamanca. Written
informed consent was obtained from parents and from children
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Copyright © 2020 Academy of Pediatric Physical Therapy of the American Physical Therapy Association.
Unauthorized reproduction of this article is prohibited.
aged 12 years and older. Children and parents were assured that
all necessary privacy measures would be taken during the use
and storage of their data.
This research is part of the Children’s Assessment of Partic-
ipation and Enjoyment (CAPE) study, which evaluated the psy-
chometric properties of the Spanish version of the CAPE ques-
tionnaire and described the participation levels of children and
adolescents with CP in Spain. Full details are published.22,32
The CAPE study included 199 children and adolescents with
CP and 199 without CP, between 8 and 18 years of age, from
7 regions in Spain. The Spanish version of the CAPE question-
naire discriminated children and adolescents with CP from those
without any disability in the results of participation.32
Participants
Children and adolescents between 7 and 17 years of age
with CP were approached to participate. The selection was made
from a convenience sample of children and adolescents with CP
from the CAPE validation study in Spain. A purposeful sampling
strategy was used where cases met the following inclusion cri-
teria: (1) children and adolescents diagnosed with CP; (2) aged 7
to 18 years; (3) currently attending a regular or integrated class-
room; and (4) could communicate verbally or use an alternative
communication system.
All Spanish Confederation of Organizations and Associa-
tions for the Care for people with Cerebral Palsy and Related
Disabilities (ASPACE) centers in the 7 autonomous commu-
nities involved in the previous study were contacted, and 3
focus groups were then formed using the criteria. Each focus
group included 5 to 6 participants of both genders who were
grouped by age to facilitate discussion (1 with 6 and 2 with 5
participants).
Setting
The ASPACE is a nongovernmental organization that pro-
vides support services for children with CP and their fami-
lies. It is the most representative organization in all regions of
Spain where children receive educational and rehabilitation sup-
port in a nonclinical/hospital context. Two groups were held in
ASPACE Cordoba (Andalucia), and 1 in ASPACE Avila (Castilla
and Leon).
Sample Size
The sample size was determined by data saturation. The
concept of “saturation” refers to the point during data collection
when the linkages among the qualitative data of 3 consecutive
focus groups have no more than 5% additional new second-
level ICF categories compared with previous focus groups.
Recent research has used this definition of saturation when ana-
lyzing functioning in children with CP using qualitative research
methods.33
Procedure
The focus groups took place in a comfortable room in each
ASPACE center, lasting between 45 and 60 minutes, plus a
I Want to Play 191
15-minute break. An experienced and previously trained
external moderator conducted the focus groups with assistance
from one of the researchers. A member of the staff (the psychol-
ogist or the social worker) was present in each group to engage
the participants, to support the moderator, and to satisfy health
and safety requirements.
The interviewer used open-ended questions such as: “In
which leisure activities have you participated in the last month/4
weeks, apart from the ones that you have done with ASPACE,
with whom and where did you do it, and did you enjoy them?”;
“What other leisure activities would you like to do?”; “Which
things are an obstacle for you and what things make your partic-
ipation easier in leisure activities?”; and “If it were possible, what
would you change to improve your participation?” The moder-
ator also made notes following each group.
The intellectual ability information was obtained from the
psychological records of the ASPACE center where the chil-
dren or adolescents received services. A psychologist reported
on each child considering the following criteria for intellectual
impairment: none or mild (IQ: >70), moderate (IQ: 50-70), and
severe (IQ: <50).
Data Analysis
The ICF was used as a reference for data analysis through the
linking process of qualitative data based on the rules proposed
by Cieza et al.34 This methodology has been updated twice35,36
and is widely disseminated in the literature.37-40
Five components of functioning are included in the
ICF classification: (1) Body Functions; (2) Body Structures;
(3) Activities and Participation; (4) Environmental Factors; and
(5) Personal Factors. These components consist of chapters
with hierarchical ICF categories as the classification units. An
alphanumeric code is assigned to each ICF category: this is a
letter representing the classification component (b: Body Func-
tions; s: Body Structures; d: Activities and Participation; and e:
Environmental Factors), followed by a number that represents
the chapter (i.e., d4), and followed by the second-level specifi-
cation (ie, d410).
All focus groups were audiotaped and transcribed verbatim.
All transcriptions were carried out by an external research assis-
tant and checked for quality by 2 members of the research team.
Four ICF-trained physical therapists read the transcriptions sev-
eral times and the texts were collated to enable qualitative anal-
ysis. The content analysis approach was used.41 This analysis
ensured identifying narratives referring to the categories estab-
lished in the ICF. These findings were organized by ICF com-
ponents and linked to the ICF categories according to estab-
lished linking rules.35 The 4 coders conducted this process
independently.
If a concept was not contained in the ICF classification,
this concept was assigned as “not covered.” Some concepts were
called “personal factors” according to the definition of the ICF,
which is also a component of contextual factors. One example
that could be linked to personal factors was the concept “moti-
vation.” A concept related to health condition such as “cerebral
palsy or seizures” was linked to “health condition.” Consensus
between the 4 links was used to decide which specific ICF
192 Longo et al
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Unauthorized reproduction of this article is prohibited.
category should be linked to each concept. Disagreement
between the 4 links was resolved by unanimous decision after
discussion.
Data Quality
Credibility of the data was enhanced by having 4 researchers
independently code and interpret the data, providing a basis for
reflective discussions that helped validate the linking process.29
RESULTS
Sixteen children and adolescents aged 7 to 17 years who
have CP distributed at all Gross Motor Function Classifica-
tion System (GMFCS) levels and who resided in 2 regions in
Spain participated in the study. Most of them did not show
intellectual impairment and all children attended regular school
(Table 1).
A total of 38 ICF categories were identified in the focus
groups [4 linked to Body functions; 2 linked to Body structures;
8 linked to Activities and Participation; and 24 linked to Envi-
ronmental factors/facilitators (10) and barriers (14)]. Table 2
shows the second-level categories identified for the ICF domains
as well as the citation frequencies and percentages of these cat-
egories identified in the children’s speeches.
The most cited categories in the functions and structure of
the body domains were b760 (Control of voluntary movement
functions), b770 (Gait pattern functions), and s730 (Structure
of upper extremity). Regarding Activities and Participation, the
most mentioned category was the d920 (Recreation and leisure),
and e410 in the Environmental Factors category, while indi-
vidual attitude of immediate family members was the most men-
tioned facilitator, whereas category e425 (individual attitudes
of acquaintances, peers, colleagues, neighbors, and community
members) was the most cited barrier for children.
Themes are outlined later with illustrative citations included
from the children’s and adolescents’ responses. They have been
grouped into ICF categories approaching experiences and per-
spectives of participation in leisure activities in children and
adolescents with CP.
Function and Body Structure
When asked what they would like to change in order to
improve participation in leisure activities, the children men-
tioned the structure of their hands and legs, tremor, movement
control, muscle tone, and balance. Such desires, expressed in the
following children’s statements, highlight the search for change
in their physical aspect: “I wanted to change my foot, my hand,
and all the left part of my body … I would definitely change
those …” (child 2, female, 9 years, GMFCS I). “I would change
my ‘twisted’ foot for a ‘straight’ one. … Some people make fun of
me because of the way I walk … I wish that wouldn’t happen …”
(child 13, 14 years, female, GMFCS I). Other children men-
tioned “I don’t know … I would change my leg so that I could
go everywhere … and I wouldn’t hear from people that I can’t
play with them during recess, anymore …?” (Child 3, male,
9 years, GMFCS II.)
Pediatric Physical Therapy
 TABLE 1
Characteristics of the Sample of Children and Adolescents With CPa

Child Gender Age, y CP Type GMFCS Intellectual Disability

1 F 7 Spastic unilateral GMFCS I None

2 F 9 Spastic unilateral GMFCS I None
3 M 9 Spastic bilateral GMFCS II None
4 M 9 Spastic bilateral GMFCS IV Mild
5 F 9 Spastic unilateral GMFCS I Mild
6 F 10 Spastic bilateral GMFCS III Mild
7 M 10 Spastic unilateral GMFCS I Mild
8 F 10 Spastic unilateral GMFCS I None
9 F 11 Dyskinectic GMFCS IV None
10 F 12 Spastic unilateral GMFCS I Mild
11 M 13 Spastic bilateral GMFCS II None
12 M 14 Spastic bilateral GMFCS V Mild
13 F 14 Spastic unilateral GMFCS I None
14 M 14 Spastic bilateral GMFCS IV None
15 F 16 Spastic bilateral GMFCS IV None
16 M 17 Spastic bilateral GMFCS III None

Abbreviations: CP, cerebral palsy; F, female; GMFCS, Gross Motor Function Classification System; M, male.
a All of the students were in regular school.

Another child showed interest in modifying one of his hands
to better participate in leisure activities: “I would change one of
my hands to make things better, for example, while practicing
archery, as I need to hold the bow and the string to shoot the
arrow … and that takes a lot of effort from me, well … so I would
change my hand …” (child 12, male, 14 years, GMFCS V).
Likewise, the following child wanted a structural change to facil-
itate participation in sports activities: “I would change my legs,
so that I could run, I could play, could play basketball, and could
practice all the sports that my brother does …” (child 11, male,
13 years, GMFCS II).
The following child expressed her wish to change the struc-
ture of her legs, so she wouldn’t need a wheelchair for locomo-
tion: “I would change my legs, because I think it’s better to walk
by yourself than to go places using a wheelchair … I could do
so many more things…. And with these new legs I wouldn’t
be so dependent on people …” (child 15, female, 16 years,
GMFCS IV).
Activities and Participation
The activities and participation mentioned by the children
pointed out their desires to perform simple tasks of daily life
as being autonomous to make decisions, to buy, to walk, and
so forth. The following child wanted to be able to buy some-
thing independently: “I’d like to buy gifts for my family when
it’s someone’s birthday or do something without them knowing
about it, as I always have to go places with them …” (child 1,
female, 7 years, GMFCS I). Similarly, another child demon-
strated the simple desire to be more autonomous and to be able
to take a walk in her neighborhood independently: “going for a
walk by myself, but I can’t” (child 5, male, 9 years, GMFCS I).
Regarding leisure activities, the children were involved in a
wide range of activities such as skiing: “I spent a week in Andorra
skiing with my father, my mother, my brother and some friends.
I had a great time, because I was able to stand on the skis and I
could ski a little bit. It was the first time that I skied. I had been
there a few times before, but my father always had to hold me.
But this time the instructor was by my side with a ski stick, and
I was skiing by myself, so I was very happy” (child 11, male,
13 years, GMFCS II).
Practicing sports, games, socialization, and activities related
to art and culture was also reported as a leisure option that pro-
vided joy: “I practiced rhythmic gymnastics on Mondays at the
Arangule and on Wednesdays at San Antonio. I loved it” (child 2,
female, 9 years, GMFCS I). Another child reported participating
in weekend trips and going to the movies with friends: “I went
with the people from here to the village …. They were the village
Fiesta Days, and I had a very good time. I went to the movies
with my cousin and with Carlos, I had a good time” (child 15,
female, 16 years, GMFCS IV).
Most children reported that they enjoyed playing computer
games and books, which were the most sited leisure activities in
this study. The following child’s speech demonstrates this reality,
also observed in other children in the study: “and nothing else,
and also, in my spare time, besides playing PSP and going by
taxi, I like watching movies and reading books and comics.
Because I’ve read many Tintin comics, for example, I enjoy
reading them very much” (child 12, 14 years, male, GMFCS V).
Environmental Factors
The environmental factors expressed in terms of barriers
and facilitators were the most cited by the children in the study,
as expressed by the following child: “For me, I think that to im-
prove my participation in activities, for example, I play basket-
ball, so, I wanted the basket to be in a lower place” (child 12,
male, 14 years, GMFCS V). Another child stressed the impor-
tance of electric mobility to help during soccer practice: “For me
the electric wheelchair helped me a lot to go around by myself,
to play soccer, because I can play soccer sometimes catching the
ball with the chair, yeah” (child 12, male, 14 years, GMFCS V).
At the same time, products and technologies can be seen
as important barriers, as expressed by the following child

Pediatric Physical Therapy I Want to Play 193

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Examples of Quotes and Categories Identified for the International Classification of Functioning, Disability and Health (ICF) Domains and
Domains ICF Categories
Body Functions b735 Muscle tone functions
(b)
b760 Control of voluntary
movement functions
b765 Involuntary movement
functions
b770 Gait pattern functions
Total number mentioned
Body Structures s730 Structure of upper extremity
(s)
s750 Structure of lower extremity
Total number mentioned
Activities and d220 Undertaking multiple tasks
Participation (d)
d440 fine hand use
d450 Walking
d460 Moving around in different
locations
d620 Acquisition of good and
services
d820 School education
d920 Recreation and leisure
d940 Human rights
Total number mentioned
Environmental Facilitators
Factors (e)
e120+ Products and technology
for personal indoor and
outdoor mobility and
transportation
e140+ Products and technology
for culture, recreation, and
sports
Barriers
e110− Products or substances
for personal consumption
e115− Products and technology
for personal use in daily living
e120− Products and technology
for personal indoor and
outdoor mobility and
transportation
194 Longo et al
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TABLE 2
Citation Frequencies
Number
Mentioning the
Respective ICF
Quotes Category %
“I would change my “twisted” foot for a “straight” one 1 12.5
….”
“I would change my hands, because I can’t catch, can’t 3 37.5
hold things properly ….”
“I wish I could have more balance … to have 1 12.5
somewhere to lean on, I lean on the wall to play or I
kneel, because I don’t have much balance ….”
“I would like to be able to walk by myself ….” 3 37.5
8 100
“I would change one of my hands, to make things 7 53.8
better, for example, while practicing archery, as I need
to hold the bow and the string to shot the arrow ….”
“I would change my legs, so that I could walk better 6 46.2
and would no longer need the wheelchair ….”
13 100
“I attended to a Farewell Party at my school, I’ve had 2 2.9
such a great time that I miss that day...There was
some music, we danced, it was fantastic.”
“I’ve also played with the play station, alone at home, 2 2.9
I love it”
“I’d like to be walking already, so I wouldn’t need the 2 2.9
wheelchair.”
“Going for a walk with my relatives here in Ávila, 1 1.5
I enjoyed it a lot.”
“I’d like to buy gifts for my family when it’s someone’s 3 4.4
birthday or doing something without them knowing
it, as I always have to go with them ….”
“I’ve played … I’ve gone with the school, with my 1 1.5
teacher ….”
“I’ve been to the swimming pool with my father, there 55 80.9
were more people there, some colleagues. I liked it
very much.”
“Man to you in school was not that they didn’t let you 2 2.9
play because they said you were running slow and
that and that they fell because they tripped over the
Walker.”
68 100
“It makes it easy for me to go up the elevator.” 1 3.6
“For example, I play soccer, it makes it easy for me to 3 10.7
play it as I can use the walker.”
“I would change the medical treatment itself, so that 1 1.6
they’d stop giving me injections, with this toxin
thing … that I have to ‘stay at home … it’s so boring
....”
“I’ve been to Natura with my fellows and as there were 1 1.6
very bad ramps, I had to climb them by using the
control and holding myself from the back, then there
was this curb that had no ramp.”
“I wanted that the cars were a bit lower so that it 6 9.7
wouldn’t be so difficult for the people with
disabilities to go inside them.”
(continues)
Pediatric Physical Therapy

Examples of Quotes and Categories Identified for the International Classification of Functioning, Disability and Health (ICF) Domains and
Citation Frequencies (Continued)
Domains ICF Categories
e140− Products and technology
for culture, recreation, and
sport
e150− Design, construction and
building products and
technology of buildings for
public use
Facilitators
e310+ Immediate family
e315+ Extended family
e320+ Friends
e360+ Other professionals
Barriers
e325− Acquaintances, peers,
colleagues, neighbors, and
community members
e330− People in positions of
authority
e340− Personal care providers
and personal assistants
Facilitators
e410 + individual attitudes of
immediate family members
e425+ Individual attitudes of
acquaintances, peers,
colleagues, neighbors, and
community members
e430+ Individual attitudes of
people in positions of authority
Barriers
e420− Individual attitudes of
friends
e425− Individual attitudes of
acquaintances, peers,
colleagues, neighbors, and
community members
e430− Individual attitudes of
people in positions of authority
e445− Individual attitudes of
strangers
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TABLE 2
Number
Mentioning the
Respective ICF
Quotes Category %
“When I go to the playground, I have to climb the stairs 2 3.2
...as there’s no elevator there ….”
“I don’t know … at my school there’s no escalator … 8 12.9
and I get myself tired when I have to go to my
classroom, as it is on the 2nd floor …. So, it would
make it easier for me if there was an escalator….”
“My parents do my exercises.” 2 7.1
“I play with my aunts and with my uncle.” 2 7.1
“Well, as to me, my new schoolmates, well they said 2 7.1
that I could not play soccer because they didn’t
know me yet, and they thought that I was going to
play with bad intentions.”
“I played … and I went with the school … with my 2 7.1
teacher….”
“Once, at school I tried to talk to some classmates and 2 3.2
they said things that got me upset ….”
“I tried to talk to the coordinator about that but then, 3 4.8
the bell rang, so that’s why I couldn’t do it …. That
affects me, I feel very sad about that ….”
“At school, during the physical education class, our 1 1.6
teacher—I don’t know about yours—but our teacher
she only cares about what the other kids can do, it
seems that she doesn’t see my condition, then she
says: “You, sit down here!”
“Going for a walk with my relatives here in Ávila, I 9 32.1
enjoyed it a lot.”
“I sometimes play with my friends. I have some people 2 7.1
who live near me, they go to my house and from
there we go to the park.”
“On the other hand, on Arts, I have a very good 1 3.6
teacher, and I yes, I can trust her, because when I
had to do the exam, I couldn’t draw very well because
of my hands, so she prepared me an oral exam ….”
“They make fun of me, I don’t know why, they say I am 1 1.6
like a frog and they make fun of the way I speak they
say that I have like “duck’s foot”, I feel terrible ….”
“My schoolmates they didn’t let me play with them.” 27 43.5
“At school, during the physical education class, our 4 6.5
teacher—I don’t know about yours—but our teacher
she only cares about what the other kids can do, it
seems that she doesn’t see my condition, then she
says: “You, sit down here! … because you can not do
that!”
“As they (children) also make fun of me, well, I would 3 4.8
tell them not to do it, because that hurts…”
(continues)
I Want to Play 195

Examples of Quotes and Categories Identified for the International Classification of Functioning, Disability and Health (ICF) Domains and
Citation Frequencies (Continued)
Domains ICF Categories
Facilitators
e580+ Health services, systems
and policies
Barriers
e580− Health services, systems
and policies
e585− Education and training
services, systems, and policies
Total number mentioned:
Facilitators
Total number mentioned: Barriers
Abbreviation: ICF, International Classification of Functioning, Disability and Health.
who wished she did not need a wheelchair and was able
to walk freely: “I’d like to be walking already, so I wouldn’t
need a wheelchair. The wheelchair makes playing soccer dif-
ficult for me” (this child was in the postoperative period of
hamstring lengthening surgery). (Child 6, female, 10 years,
GMFCS III.)
Many children showed dissatisfaction with the presence
of environmental barriers related to the architecture, construc-
tion, and accessibility of buildings, as can be seen in the fol-
lowing child’s quote: “When I go to the movie theater here
in Córdoba, there’s an elevator to go upstairs and downstairs
with the wheelchair, but it works too slowly … it takes a lot of
time. And also, when I hang out with my friends in some pubs
there are steps and that makes things difficult. Once I almost
fell down …” (child 15, female, 16 years, GMFCS IV). Another
child reported a negative experience that made her participation
difficult due to the presence of architectural barriers in a tourist
location: “Once I went to a village palace, and they had to carry
me up in their arms because there was no elevator there …”
(child 6, female, 10 years, GMFCS III).
The school was also the scene of negative experiences that
limited participation due to teachers’ attitudes, as expressed by
the following child: “Once I went to this school trip with our
teacher but one of the monitors couldn’t go with us, so she was
the one responsible for me…. Then, for the next school trip she
was with me again, and she said that I probably wouldn’t enjoy
the trip because the place we were going to was not adapted and
that if that monitor was not going with us again, they couldn’t
move my wheelchair around the place and so on …” (child 15,
female, 16 years, GMFCS IV).
We have also observed the lack of preparation of some pro-
fessionals to embrace and/or integrate diversities, as well as to
include children in nonsegregated physical activities as reported
196 Longo et al
Copyright © 2020 Academy of Pediatric Physical Therapy of the American Physical Therapy Association.
Unauthorized reproduction of this article is prohibited.
TABLE 2
Number
Mentioning the
Respective ICF
Quotes Category %
“I got operated in Murcia, the Russian doctors, it 4 14.3
helped me to get more balance with my feet. It helps
me when I am alone with my brother, to kick the
ball.”
“Me, since I was a child I’ve had to be going to see the 2 3.2
doctors, to be undergoing thru medical treatments,
it’s always the same … I’m sick of this … the same
room ....”
“I don’t know … at my school there’s no escalator … 1 1.6
and I get myself tired when I have to go to my
classroom, as it is on the 2nd floor …. So, it would
make it easier for me if there was an escalator ….”
28 100
62 100
by this child: “During physical education class at school, our
teacher—I don’t know about yours—but our teacher, she only
cares about what the other kids can do, it seems that she doesn’t
see my condition, then she says: ‘You, sit down here! … because
you can’t do that!’ Then, in our second examination she gave me
a 5, because I didn’t do the practical exam …” (child 3, male, 9
years, GMFCS II).
On the other hand, another child reported positive expe-
riences regarding her classmates’ attitudes, as shown in the fol-
lowing statement: “… my classmates even encouraged me to join
them in this trip, but I didn’t end up going …” (child 15, female,
16 years, GMFCS IV). Nevertheless, many children reported
negative experiences with peers, which prevented them from
participating in games and other unstructured play, as well illus-
trated in the following statements: “my schoolmates, they didn’t
let me play with them. I don’t know why, they were playing ‘tag’
and they said that I couldn’t play with them” (child 2, female,
9 years, GMFCS I).
Other negative experiences were reported by the following
child: “Once it happened to me while I was playing tag. I almost
fell off my chair, but I didn’t fall...So this other kid said: Come
on, get out, leave! And I really felt bad about that …” (child
6, female, 10 years, GMFCS III). Failure to participate in cer-
tain games triggered feelings of sadness, as expressed by the fol-
lowing child: “I was playing and my classmates told me to be
careful, that I could fall down, that’s why I couldn’t play. But I
know I was not going to fall down, so I felt really bad about
that …” (child 13, male, 14 years, GMFCS I).
Physical support provided by family, friends, and other pro-
fessionals was perceived by children as an important facili-
tator to participation in sports and socialization activities, as
explained in this child’s quote: “Well, I spent one week in
Andorra, skiing with my father, my mother, my brother and
Pediatric Physical Therapy
some friends. I had a great time, because I was able to stand
on the skis and I could ski a little bit. It was the first time that I
skied. I had been there a few times before, but my father always
had to hold me. But this time, the ski instructor was by my side
with a ski stick, and I was skiing by myself, so I was very happy”
(child 11, male, 13 years, GMFCS II).
The Services, Systems, and Policies were also present in chil-
dren’s speeches, with health services being especially exalted as
an important facilitator to improve function and participation
in certain activities, as evidenced in the speech of the following
child: “I was operated on in Murcia by Russian doctors, it helped
me to get more balance with my feet, now I find it less difficult
to play the things I usually play. Like jumping rope, running
with my friends, playing hide-and-seek, and so on …” (child 1,
female, GMFCS I). Another child reported a similar positive
experience: “I was also operated on and that helped me so much
because then I could stand better with my feet on the floor”
(child 15, female, 7 years, GMFCS IV).
In contrast, children reported dissatisfaction with the excess
of rehabilitation during their lifetime, as well as with the type of
treatment for generating physical pain and long periods of con-
valescence, as evidenced in the following child’s quote: “Since
I was a young child I’ve had to see doctors, to undergo med-
ical treatments, it’s always the same … it’s tiring … the same
room …” (child 3, male, 9 years, GMFCS II). Another child
expressed a similar negative experience: “I would change the
medical treatment itself, so that they’d stop giving me injections,
with this toxin thing … that I have to stay at home … it’s so
boring …” (child 16, male, 17 years, GMFCS III).
Participation experiences expressed by children allowed us
to create a model of barriers and facilitators for participation in
leisure activities of Spanish children with CP according to the
ICF, considering the most frequent categories (Figure).
DISCUSSION
This qualitative study adds to the literature by more deeply
exploring the barriers and facilitators of leisure activities for chil-
dren and adolescents with CP, considering the perspectives of
the children. The results found in this study point to aspects
that should be considered for planning social and health poli-
cies aimed at reducing the social disadvantage experienced by
children with CP in Spain and in improving the results of par-
ticipation in leisure activities. Children mentioned more bar-
riers than facilitators as aspects that influenced participation
in leisure activities and also reported problems related to body
functioning.
Function and Body Structure
Body Function and Structures categories were in the expe-
riences related to participation in leisure activities of children
with CP heard in this study. For example, they cited the Struc-
ture of upper extremity and Structure of lower extremity cate-
gories as being possible to improve functionality and participa-
tion in leisure activities, expressing a desire to have “new legs
and hands” to do more skiing, dancing, or shoot with a bow
and an arrow. Güeita-Rodríguez et al37 evaluated the function
of children with CP from the ICF perspective and also identified
that the lower and upper limb categories were the most cited by
children in relation to the body structure domain.

Fig. Model of facilitators and barriers to participation in leisure activities of Spanish children with cerebral palsy according to the International Classification of Functioning,
Disability and Health. For this figure, only those categories that were mentioned at least twice by the children were considered.

Pediatric Physical Therapy I Want to Play 197

Copyright © 2020 Academy of Pediatric Physical Therapy of the American Physical Therapy Association.
Unauthorized reproduction of this article is prohibited.
 The desire for structural changes in the body was also
observed in the study by Vargus-Adams and Majnemer,42 in
which all groups indicated a desire to see changes in their body
functions and structures related to strength, movement, pain,
and mental function. Such desires may reflect that the children
included in the study do not feel welcome or accepted by their
peers with no disabilities because they do not fit into social stan-
dards considered appropriate and they do not feel integrated
into society.
Because of the presence of functional and structural barriers,
children with disabilities generally participate more in activi-
ties at home, alone or with siblings, and are less involved in
active, skill-based, and self-overcoming physical activities than
children without disabilities.6,22,43,44 These data are relevant
to clinical practice because knowing the child’s context and
the needs, desires, and motivations can change the course of
the intervention process and make it more dynamic. Devel-
oping active and context-based tasks, in addition to fostering
learning, neuroplasticity, and skill transfer to different contexts,
will increase levels of child participation in society.45-47
Environmental Factors
Friends were considered by the majority of the children as a
facilitator for participation, as they reported having a good rela-
tionship with their schoolmates and social interaction and that
friends often helped them participate in leisure activities. One
explanation for this positive relationship between children and
their friends is the creation of a bond, awareness, and education
about the needs of people who have disabilities. By knowing
a child with CP and recognizing his or her needs, the children
who live around him or her and become more helpful and atten-
tive. Friends’ positive attitudes promote socialization and inclu-
sion of children who have CP and play an important role in
participation.43,48 According to some authors, positive attitudes
are more related to extended, direct, and high-quality contact
with colleagues with disabilities than frequent contact with these
children.49,50
Negative attitudes from friends can significantly impact the
child’s sociocultural and emotional development.51,52 In our
study, the category of individual attitudes of acquaintances,
colleagues, neighbors, and community members was listed by
children as an important barrier to participation by expressing
significant experiences of bullying and discrimination by col-
leagues and teachers. Similar data were found in a recent study
in Thailand, where caregivers perceived that nonacceptance of
peers was a barrier to the participation of children who have
CP.53 A lack of understanding about CP can produce embarrass-
ment and prevent children from participating in leisure activities
and sports. In addition, conflicting relationships between chil-
dren and people in their social context can generate social iso-
lation, exclusion, intimidation, and distancing of the child from
the context of the school and the community.24,54
The attitudes of professionals were also evidenced in this
study as a barrier to participation. Some professionals were
unprepared to accommodate and/or integrate diversities, as well
as to include children in nonsegregated physical activities. Social
exclusion within the school by teachers and colleagues is a
198 Longo et al
Copyright © 2020 Academy of Pediatric Physical Therapy of the American Physical Therapy Association.
Unauthorized reproduction of this article is prohibited.
reality that needs to be addressed at different levels of care,
especially in developing countries.55 Rigid adherence to tradi-
tional curricula, methods of training for teachers with no focus
on disability, and lack of accommodation of children’s needs
reduce the opportunities for participation of students who have
disabilities.56,57 Therefore, schools should have a responsibility
to promote and stimulate activities and strategies that strengthen
links between children with and without disabilities and thus
improve attitudes and support. The culture of support for chil-
dren with disabilities developed in schools can facilitate changes
in children’s and teachers’ behavior and attitudes, making the
school environment welcoming, receptive, and fun for children
with CP.
Health services were identified by some children as facilita-
tors for providing comprehensive follow-up in the rehabilitation
process. They were considered barriers due to excessive time
spent on interventions over the years and limiting experiences
related to leisure activities. The excess of health services that is
offered to children can also limit the practice of physical activity.
Research indicates that low participation in physical activities is
due to prejudice, unprepared professionals, and lack of activi-
ties adapted for children who have disabilities, acting as a barrier
that affects children’s ability to progress function.37,58
Immediate family was the only environmental factor con-
sidered as a facilitator by all children in the study, emphasizing
the importance of strengthening family-centered care. Children
recognize the love, support, and positive attitudes of their close
family and report not feeling different or inferior when they are
in the family context.33 Family support is invaluable for children
in building self-confidence and encouraging children to partici-
pate in leisure activities.53,55 To increase the potential of family
care to the child, it is recommended that health professionals
involve the family in ongoing conversations to create bonds and
to better understand the child’s needs.59
Products and technology are both facilitators and bar-
riers. Assistive technology can provide children with greater
independence, formal communication, mobility, and social
inclusion.33,42,55 However, deprivation of access to such
resources due to lack of income, infrastructure, architecture, sys-
tems, and public policies converts assistive technology into a
barrier to participation.44
Final Considerations
Our study is the first to evaluate the perception of children
with CP in Spain on barriers and facilitators to participate in
leisure activities, wherein it was possible to observe that the most
disabling barriers are related to environmental factors such as
products and technology, support, attitudes, and health services.
These results provide important information about the context
of children who have CP in Spain and facilitate clinical decision
making to improve participation.
It is necessary that government, professionals, and families
come together to elaborate viable goals that enable facing these
environmental barriers. Like other European countries, Spain
must strengthen its public policies in order to favor the par-
ticipation of children who have disabilities and expand access
to leisure activities. Professionals should use evidence-based
Pediatric Physical Therapy
methods to identify barriers and facilitate their participation in
leisure activities, as well as guide parents about existing policies
and benefits that may assist the family and the child. Parents
should be aware of the needs of children and seek knowledge to
defend the rights of children who have disabilities. This union
of forces could increase the access of children who have CP to
full and unsegregated participation.
Designing rehabilitation interventions centered on the ICF
model remains a challenge in different settings around the
world, especially in some specific contexts. However, it is a
necessary change to broaden the view on children who have
disabilities, to identify aspects related to this context, and to
offer strategies that facilitate participation.46,59 A strategy of
knowledge translation that has been widely diffused by its “user-
friendly” characteristics is the “F-words,” which are grounded
in, and aim to operationalize, the ICF model. This framework
was adapted by mapping onto it 6 “F-words” (function, fitness,
fun, friends, family, and fun and future) that correspond to the
domains of ICF body functions, body structure, activities and
participation, and environmental factors and represent an easy
and practical way for health professionals, family members, and
patients to discuss rehabilitation targets covering all elements
of the ICF.7 In fact, ICF-focused evaluation and intervention
models can guide goal setting and eliminate barriers that pre-
vent child participation.33,60
This study is pioneering in Spain and yet presents limita-
tions related to the number of participants and focus groups,
although the aspect of saturation used in qualitative research
has been considered. Further studies should be undertaken
including children and adolescents who have CP from other
autonomous communities, as well as parents and rehabilitation
professionals, in order to broaden the understanding of barriers
and facilitators related to participation in leisure activities.
Finally, the experiences presented by Spanish children who
have CP included in the study regarding participation in leisure
activities provide important perspectives for designing inter-
ventions for children and adolescents who have CP and call
for changes centered on environments. Recognizing the chal-
lenges posed by the environment and the society and removing
the barriers that prevent child participation may be more effec-
tive strategies than trying to modify the body’s functioning and
structures.
REFERENCES
1. McManus V, Michelsen SI, Parkinson K, et al. Discussion groups
with parents of children with cerebral palsy in Europe designed to
assist development of a relevant measure of environment [published
online ahead of print January 31, 2006]. Child Care Health Dev.
2006;32(2):185-192.
2. Donkervoort M, Roebroeck M, Wiegerink D, van der Heijden-
Maessen H, Stam H; Transition Research Group South West
Netherlands. Determinants of functioning of adolescents and young
adults with cerebral palsy. Disabil Rehabil. 2007;29(6):453-463.
doi:10.1080/09638280600836018.
3. Imms C, Reilly S, Carlin J, Dodd K. Diversity of participation in chil-
dren with cerebral palsy. Dev Med Child Neurol. 2008;50(5):363-369.
doi:10.1111/j.1469-8749.2008.02051.x.
4. World Health Organization. International Classification of Functioning,
Disability and Health-–Children and Youth Version. 1st ed. Geneva,
Switzerland: World Health Organization; 2007.
Pediatric Physical Therapy
Copyright © 2020 Academy of Pediatric Physical Therapy of the American Physical Therapy Association.
Unauthorized reproduction of this article is prohibited.
5. World Health Organization. International Classification of Functioning,
Disability and Health: ICF. Geneva, Switzerland: World Health Organi-
zation; 2001.
6. Di Marino E, Tremblay S, Khetani M, Anaby D. The effect of
child, family and environmental factors on the participation of
young children with disabilities. Disabil Health J. 2018;11(1):36-42.
doi:10.1016/j.dhjo.2017.05.005.
7. Rosenbaum P, Gorter JW. The “F-words” in childhood disability: I swear
this is how we should think. Child Care Health Dev. 2012;38(4):457-
463. doi:10.1111/j.1365-2214.2011.01338.x.
8. Coatsworth JD, Sharp EH, Palen LA, Darling N, Cumsille P, Marta
E. Exploring adolescent self-defining leisure activities and identity
experiences across 3 countries. Int J Behav Dev. 2005;29(5):361-370.
doi:10.1080/01650250500166972.
9. Passmore A, French D. The nature of leisure in adolescence: a focus
group study. Br J Occup Ther. 2003;66(9):419-426. doi:10.1177/
030802260306600907.
10. Shikako-Thomas K, Dahan-Oliel N, Shevell M, et al. Play and be happy?
Leisure participation and quality of life in school-aged children with
cerebral palsy. Int J Pediatr. 2012;2012:1-7. doi:10.1155/2012/387280.
11. Wilkes S, Cordier R, Bundy A, Docking K, Munro N. A play-based
intervention for children with ADHD: a pilot study. Aust Occup Ther
J. 2011;58(4):231-240. doi:10.1111/j.1440-1630.2011.00928.x.
12. Adolfsson M, Malmqvist J, Pless M, Granuld M. Identifying child func-
tioning from an ICF-CY perspective: everyday life situations explored in
measures of participation. Disabil Rehabil. 2011;33(13-14):1230-1244.
doi:10.3109/09638288.2010.526163.
13. Anaby D, Law M, Coster W, et al. The mediating role of the environment
in explaining participation of children and youth with and without dis-
abilities across home, school, and community. Arch Phys Med Rehabil.
2014;95(5):908-917. doi:10.1016/j.apmr.2014.01.005.
14. Colver A, Thyen U, Arnaud C, et al. Association between partic-
ipation in life situations of children with cerebral palsy and their
physical, social, and attitudinal environment: a cross-sectional multi-
center European study. Arch Phys Med Rehabil. 2012;93(12):2154-2164.
doi:10.1016/j.apmr.2012.1007.1011.
15. Anaby D, Hand C, Bradley L, et al. The effect of the environment on
participation of children and youth with disabilities: a scoping review.
Disabil Rehabil. 2013;35(19):1589-1598. doi:10.3109/09638288
.2012.748840.
16. Anaby D. Towards a new generation of participation-based interven-
tions for adolescents with disabilities: the impact of the environment
and the need for individual-based designs. Dev Med Child Neurol.
2018;60(8):735-736. doi:10.1111/dmcn.13749.
17. Corbella MB, de Melo ELG, Baz MBO, et al. Participación de niños y
adolescentes con parálisis cerebral en actividades de o cio. Rev Española
sobre Discapac Intelect. 2011;42(3):23-34.
18. Law M, Anaby D, DeMatteo C, Hanna S. Participation patterns of
children with acquired brain injury. Brain Inj. 2011;25(6):587-595.
doi:10.3109/02699052.2011.572945.
19. Ullenhag MA, Bult MK, Nyquist A, et al. An international comparison
of patterns of participation in leisure activities for children with and
without disabilities in Sweden, Norway and the Netherlands. Dev Neu-
rorehabil. 2012;15(5):369-385. doi:10.3109/17518423.2012.694915.
20. King G, Imms C, Palisano R, et al. Geographical patterns in the recre-
ation and leisure participation of children and youth with cerebral
palsy: a CAPE international collaborative ne2rk study. Dev Neurorehabil.
2013;16(3):196-206. doi:10.3109/17518423.2013.773102.
21. Badia M, Begoña Orgaz M, Gómez-Vela M, Verdugo MA, Ullán AM,
Longo E. Do environmental barriers affect the parent-reported quality
of life of children and adolescents with cerebral palsy? Res Dev Disabil.
2016;49-50:312-321. doi:10.1016/j.ridd.2015.12.011.
22. Longo E, Badia M, Orgaz BM. Patterns and predictors of partici-
pation in leisure activities outside of school in children and ado-
lescents with cerebral palsy. Res Dev Disabil. 2013;34(1):266-275.
doi:10.1016/j.ridd.2012.08.017.
23. Badia M, Longo E, Orgaz MB, Gómez-Vela M. The influence of par-
ticipation in leisure activities on quality of life in Spanish children and
adolescents with cerebral palsy. Res Dev Disabil. 2013;34(9):2864-2871.
doi:10.1016/j.ridd.2013.06.017.
I Want to Play 199
24. Lindsay S, Mcpherson AC. Strategies for improving disability aware-
ness and social inclusion of children and young people with cerebral
palsy. Child Care Health Dev. 2012;38(6):809-816. doi:10.1111/j.1365-
2214.2011.01308.x.
25. Claassen AAOM, Gorter JW, Stewart D, Verschuren O, Galuppi BE,
Shimmell LJ. Becoming and staying physically active in adolescents with
cerebral palsy: protocol of a qualitative study of facilitators and bar-
riers to physical activity. BMC Pediatr. 2011;11:1-8. doi:10.1186/1471-
2431-11-1.
26. Jaarsma EA, Dijkstra PU, de Blécourt ACE, Geertzen JHB, Dekker R.
Barriers and facilitators of sports in children with physical disabili-
ties: a mixed-method study. Disabil Rehabil. 2015;37(18):1617-1625.
doi:10.3109/09638288.2014.972587.
27. Longo E, Badia M, Orgaz MB, Gómez-Vela M. Comparing parent and
child reports of health-related quality of life and their relationship with
leisure participation in children and adolescents with cerebral palsy. Res
Dev Disabil. 2017;71:214-222.
28. Dahan-Oliel N, Shikako-Thomas K, Majnemer A. Quality of life and
leisure participation in children with neurodevelopmental disabilities:
a thematic analysis of the literature? Qual Life Res. 2012;21(2):427-439.
29. Pope C, van Royen P, Baker R. Qualitative methods in research
on healthcare quality. Qual Saf Heal Care. 2002;11(2):148-152.
doi:10.1136/qhc.11.2.148.
30. Sandelowski M. Whatever happened to qualitative description? Res Nurs
Health. 2000;23(4):334-340.
31. Shields N, Synnot A. Perceived barriers and facilitators to participation
in physical activity for children with disability: a qualitative study. BMC
Pediatr. 2016;16(1):1-10. doi:10.1186/s12887-016-0544-7.
32. Longo E, Badia M, Orgaz B, Verdugo MA. Cross-cultural val-
idation of the children’s assessment of participation and enjoy-
ment (CAPE) in Spain. Child Care Health Dev. 2012;40(2):231-241.
doi:10.1111/cch.12012.
33. Schiariti V, Sauve K, Klassen AF, O’Donnell M, Cieza A, Mâsse LC. “He
does not see himself as being different”: the perspectives of children
and caregivers on relevant areas of functioning in cerebral palsy. Dev
Med Child Neurol. 2014;56(9):853-861. doi:10.1111/dmcn.12472.
34. Cieza A, Brockow T, Ewert T, et al. Linking health-status measurements
to the International Classification of Functioning, Disability and Health.
J Rehabil Med. 2002;34(5):205-210.
35. Cieza A, Fayed N, Bickenbach J, Prodinger B. Refinements of the
ICF Linking Rules to strengthen their potential for establishing com-
parability of health information. Disabil Rehabil. 2016:41(5):574-583.
doi:10.3109/09638288.2016.1145258.
36. Cieza A, Geyh S, Chatterji S, Kostanjsek N, Ustun B, Stucki G. ICF
linking rules: an update based on lessons learned. J Rehabil Med.
2005;37(4):212-218.
37. Güeita-Rodríguez J, García-Muro F, Rodríguez-Fernández ÁL, Lam-
beck J, Fernández-de-las-Peñas C, Palacios-Ceña D. What areas of func-
tioning are influenced by aquatic physiotherapy? Experiences of parents
of children with cerebral palsy. Dev Neurorehabil. 2018;21(8):506-514.
doi:10.1080/17518423.2017.1368728.
38. Mahdi S, Viljoen M, Massuti R, et al. An international qualitative study
of ability and disability in ADHD using the WHO-ICF framework. Eur
Child Adolesc Psychiatry. 2017;26(10):1219-1231.
39. Fava L, Muehlan H, Bullinger M. Linking the DISABKIDS modules for
health-related quality of life assessment with the International Classi-
fication of Functioning, Disability and Health (ICF). Disabil Rehabil.
2009;31(23):1943-1954. doi:10.1080/09638280902874188.
40. Schiariti V, Fayed N, Cieza A, Klassen A, O’donnell M. Content com-
parison of health-related quality of life measures for cerebral palsy
based on the International Classification of Functioning. Disabil Rehabil.
2011;33(15-16):1330-1339. doi:10.3109/09638288.2010.531371.
41. Carpenter C, Suto M. Qualitative Research for Occupational and Physical
Therapists: A Practical Guide. Oxford: Bl; 2008.
42. Vargus-Adams JN, Majnemer A. International Classification of Func-
tioning, Disability and Health (ICF) as a framework for change
200 Longo et al
Copyright © 2020 Academy of Pediatric Physical Therapy of the American Physical Therapy Association.
Unauthorized reproduction of this article is prohibited.
revolutionizing rehabilitation. J Child Neurol. 2014;29(8):1030-1035.
doi:10.1177/0883073814533595.
43. Nelson F, Masulani-Mwale C, Richards E, Theobald S, Gladstone M.
The meaning of participation for children in Malawi: insights from
children and caregivers. Child Care Health Dev. 2017;43(1):133-143.
doi:10.1111/cch.12422.
44. Fernandez Y, Ziviani J, Cuskelly M, Colquhoun R, Jones F. Par-
ticipation in community leisure programs: experiences and per-
spectives of children with developmental difficulties and their
parents. Leis Sci. 2018;40(3):110-130. doi:10.1080/01490400.2017
.1408509.
45. Novak I. Evidence-based diagnosis, health care, and rehabilitation for
children with cerebral palsy. J Child Neurol. 2014;29(8):1141-1156.
doi:10.1177/0883073814535503.
46. Darrah J, Law MC, Pollock N, et al. Context therapy: a new interven-
tion approach for children with cerebral palsy. Dev Med Child Neurol.
2011;53(7):615-620. doi:10.1111/j.1469-8749.2011.03959.x.
47. Law M, Darrah J. Emerging therapy approaches: an emphasis on func-
tion. J Child Neurol. 2014;29:1101-1107.
48. Dahan-Oliel N, Shikako-Thomas K, Mazer B, Majnemer A. Adolescents
with disabilities participate in the shopping mall: facilitators and bar-
riers framed according to the ICF. Disabil Rehabil. 2016;38(21):2102-
2113. doi:10.3109/09638288.2015.1114033.
49. Schwab S. The impact of contact on students’ attitudes towards
peers with disabilities. Res Dev Disabil. 2017;62:160-165. doi:10.1016/j
.ridd.2017.01.015.
50. Armstrong M, Morris C, Abraham C, Tarrant M. Interventions util-
ising contact with people with disabilities to improve children’s attitudes
towards disability: a systematic review and meta-analysis. Disabil Health
J. 2017;10(1):11-22. doi:10.1016/j.dhjo.2016.10.003.
51. Rosenbaum P. Improving attitudes towards children with disabili-
ties in a school context. Dev Med Child Neurol. 2010;52(10):889-890.
doi:10.1111/j.1469-8749.2010.03723.x.
52. Godeau E, Vignes C, Sentenac M, et al. Improving attitudes towards
children with disabilities in a school context: a cluster randomized inter-
vention study. Dev Med Child Neurol. 2010;52:e236-e242.
53. Earde PT, Praipruk A, Rodpradit P, Seanjumla P. Facilitators and bar-
riers to performing activities and participation in children with cere-
bral palsy: caregivers’ perspective. Pediatr Phys Ther. 2018;30(1):27-32.
doi:10.1097/PEP.0000000000000459.
54. Lindsay S, Mcpherson AC. Experiences of social exclusion and bullying
at school among children and youth with cerebral palsy. Disabil Rehabil.
2012;34(2):101-109. doi:10.3109/09638288.2011.587086.
55. Davis E, Shelly A, Waters E, et al. Quality of life of adolescents
with cerebral palsy: perspectives of adolescents and parents. Dev
Med Child Neurol. 2009;51(3):193-199. doi:10.1111/j.1469-8749.2008
.03194.x.
56. Bourke-Taylor HM, Cotter C, Lalor A, Johnson L. School success
and participation for students with cerebral palsy: a qualitative study
exploring multiple perspectives. Disabil Rehabil. 2017;40(18):2163-
2171. doi:10.1080/09638288.2017.1327988.
57. Egilson ST, Traustadottir R. Participation of students with physical dis-
abilities in the school environment. Am J Occup Ther. 2009;63(3):264-
272. doi:10.5014/ajot.63.3.264.
58. Whiteneck G, Meade MA, Dijkers M, Tate DG, Bushnik T, Forch-
heimer MB. Environmental factors and their role in participation
and life satisfaction after spinal cord injury. Arch Phys Med Rehabil.
2004;85(11):1793-1803. doi:10.1016/j.apmr.2004.04.024.
59. Goldstein DN, Cohn E, Coster W. Enhancing participation for children
with disabilities: application of the ICF enablement framework to pedi-
atric physical therapist practice. Pediatr Phys Ther. 2004;16(2):114-120.
doi:10.1097/01.PEP.0000127567.98619.62.
60. Schiariti V, Mâsse LC. Relevant areas of functioning in children with
cerebral palsy based on the International Classification of Functioning,
Disability and Health coding system: a clinical perspective. J Child
Neurol. 2015;30(2):216-222. doi:10.1177/0883073814533005.
Pediatric Physical Therapy