Research in Developmental Disabilities 37 (2015) 102–111

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Research in Developmental Disabilities

Predictors of participation change in various areas for

preschool children with cerebral palsy: A longitudinal study
Katie P. Wu a, Yu-fen Chuang b, Chia-ling Chen a,c,*, I-shu Liu c,
Hsiang-tseng Liu c, Hsieh-ching Chen d
a
Department of Physical Medicine and Rehabilitation, Chang Gung Memorial Hospital at Linkou, 5 Fu-Hsing St., Kwei-Shan, Tao-Yuan 333,
Taiwan
b
Department of Physical Therapy, Chang Gung University, 259 Wen-Hwa 1st Rd, Kwei-Shan, Tao-Yuan 333, Taiwan
c
Graduate Institute of Early Intervention, Chang Gung University, 259 Wen-Hwa 1st Rd, Kwei-Shan, Tao-Yuan 333, Taiwan
d
Department of Industrial Engineering and Management, National Taipei University of Technology, 1, Sec. 3, Zhongxiao E. Rd., Taipei 106,
Taiwan

A R T I C L E I N F O A B S T R A C T

Article history: This study identifies potential predictors of participation changes in various areas for
Received 24 July 2014 preschool children with cerebral palsy (CP). Eighty children with CP (2–6 years) were
Received in revised form 9 November 2014 enrolled. Seven potential predictors were identified: age; sex; socioeconomic status, CP
Accepted 9 November 2014 subtype; cognitive function, Function Independence Measure for Children (WeeFIM), and
Available online motor composite variable from 5 motor factors (gross motor function classification system
(GMFCS) level; bimanual fine motor function level; selective motor control score;
Keywords: Modified Ashworth Scale score; and Spinal Alignment and Range of Motion Measure).
Cerebral palsy
Outcome was assessed at baseline and at 6-month follow-up using the Assessment of
Predictor
Preschool Children’s Participation (APCP) including diversity and intensity scores in the
Participation
Preschool children
areas of play (PA), skill development (SD), active physical recreation, social activities (SA),
Longitudinal study and total areas. Dependent variables were change scores of APCP scores at baseline and 6-
month follow-up. Regression analyses shows age and sex together predicted for APCP-
total, APCP-SD diversity and APCP-total intensity changes (r2 = 0.13–0.25, p < 0.001);
cognitive function and WeeFIM were negative predictors for APCP-SA and APCP-PA
diversity changes, respectively. CP subtype, motor composite variable, and socioeconomic
status predicted for APCP changes in some areas. Findings suggest that young boys with
poor cognitive function and daily activity predicted most on participation changes.
ß 2014 Elsevier Ltd. All rights reserved.

1. Introduction

Manifestations of cerebral palsy (CP) include spasticity, loss of selective motor control (SMC), muscle weakness, and
limited range of motion (ROM), which further limit performance at activities of daily living (ADL) and participation in various
activities (Calley et al., 2012; Engel-Yeger, Jarus, Anaby, & Law, 2009). Participation of CP children in skill-based, community-
based, and active physical activities is low (Majnemer et al., 2008). For instance, preschool children with CP with poor motor
function participated less in activities than those with good motor function (Law, King, Petrenchik, Kertoy, & Anaby, 2012).

* Corresponding author at: Department of Physical Medicine and Rehabilitation, Chang Gung Memorial Hospital at Linkou, 5 Fu-hsing St., Kwei-shan, Tao-
yuan 333, Taiwan. Tel.: +886 3 3281200x3846; fax: +886 3 3281320.
E-mail addresses: katiewu1110@gmail.com (K.P. Wu), chuang@mail.cgu.edu.tw (Y.-f. Chuang), clingchen@gmail.com (C.-l. Chen),
linda611kimo@gmail.com (I.-s. Liu), littlemy29@gmail.com (H.-t. Liu), imhcchen@ntut.edu.tw (H.-c. Chen).

http://dx.doi.org/10.1016/j.ridd.2014.11.005
0891-4222/ß 2014 Elsevier Ltd. All rights reserved.
 K.P. Wu et al. / Research in Developmental Disabilities 37 (2015) 102–111 103

Potential predictors, such as age, sex, environmental factors, body function, and activity limitation, for children and youth
with CP, have been proposed to be linked to participation in leisure activities (Shikako-Thomas, Majnemer, Law, & Lach,
2008). High physical ability, young, and female are associated with higher intensity of participation in 205 children with CP
aged 13–21 years (Palisano, Orlin et al., 2011). Gross Motor Function Classification System (GMFCS) levels are related to
participation for children and youth with CP (Brunton & Bartlett, 2010; Palisano et al., 2009; Palisano, Orlin et al., 2011). The
GMFCS level and bimanual fine motor function (BFMF) level are associated with participation for children with CP aged 5–8
years (Beckung & Hagberg, 2002). Physical independence and performance in the mobility domains have predicted well by
movement and manual ability of children with CP aged 6–12 years (Morris, Kurinczuk, Fitzpatrick, & Rosenbaum, 2006). The
CP subtype is related to participation level for children and adolescents with CP (Fauconnier et al., 2009; Kerr, Parkes,
Stevenson, Cosgrove, & McDowell, 2008; Schenker, Coster, & Parush, 2005).
Bartlett and Palisano proposed a model on determinants for motor changes in children with CP. This model targets on the
relationships among child characteristics (e.g. temperament, personality, and cognitive impairments), family ecology, and
health care services (Bartlett & Palisano, 2000). Temperament patterns varied among different CP subtypes (Chen et al.,
2011) and may further influenced their participation. The cognitive impairments and acitivities of daily living (ADL)
limitations were associated with participation in children and adolescents with CP (Fauconnier et al., 2009; Law et al., 2012;
Majnemer et al., 2008). The environmental factors, such as socioeconomic status and family factors, were also associated
with participation in children or youth with CP (Chan, Lau, Fong, Poon, & Lam, 2005; Colver et al., 2012; Law et al., 2012;
Mihaylov, Jarvis, Colver, & Beresford, 2004; Shikako-Thomas, Shevell, Schmitz et al., 2013). Since most studies examined
participation intensity for school children and adolescents with CP, knowledge on preschool participants are therefore
limited.
A 3-year follow-up study indicated that factors associated with change in participation intensity were depended on
activity type, sex and age for 402 children/youth with physical disabilities (King et al., 2009). Wright et al. reported poor-to-
fair relationships between measures of body function and structure, activity, and participation for CP children who were
injected with botulinum toxin type-A (Wright, Rosenbaum, Goldsmith, Law, & Fehlings, 2008). Activity and participation
gains following injection are likely influenced by environmental factors, GMFCS level, or age for ambulatory children with
spastic CP (Wright et al., 2008). Another 2-year study followed on children with CP aged 9–15, indicated that muscle
strength, involved limb distribution, SMC, ROM, and spasticity measured by the modified Ashworth scale (MAS) were linked
to gross motor function measure (GMFM) score corrected by GMFCS level (Voorman, Dallmeijer, Knol, Lankhorst, & Becher,
2007). A 6-month follow-up study showed that GMFCS level and age are robust negative predictors for change in most
developmental domains, such as cognition, language skills, motor function, social function, and self-help in preschool
children with CP (Chen, Hsu, et al. 2013). The Spinal Alignment and Range of Motion Measure (SAROMM) (Bartlett & Purdie,
2005) was a negative predictor for cognitive change (Chen, Hsu, et al. 2013). Relationships between potential predictors and
participation change are complex; however, few studies have investigated the relationship between potential predictors and
participation change in various activities for preschool children with CP.
Clinical demand is increasing for valid and responsive participation measures for preschool children to assess
participation improvement and justify intervention. The Assessment of Preschool Children’s Participation (APCP) (Law et al.,
2012) assesses the level of activity participation for preschool children aged 2–6. Subset data from this study used to
determine the clinimetric properties of APCP have already been published (Chen, Chen, et al. 2013), showing that APCP score
was markedly responsive to change at follow-up (Chen, Chen, et al. 2013). That is, the clinimetric properties of the APCP
measure makes it an appropriate and valid tool to identify participation patterns in terms of diversity and intensity of various
activities for preschool children with CP (C.L. Chen, Chen, et al. 2013).
This study, attempts to identify potential predictors that can predict participation change in various areas for preschool
children with CP. The APCP was selected as the participation measure in this study. This scale contains both diversity and
intensity scales in the areas of play (PA), skill development (SD), active physical recreation (AP), and social activities (SA).
Potential predictors tested in this study were age, sex, socioeconomic status, CP subtype, cognitive function, motor
composite variable (GMFCS level, BFMF level, SMC score, spasticity score, and SAROMM), and ADL. We hypothesize that
different predictor combinations can predict participation change (diversity and intensity) in different areas for children
with CP.

2. Materials and methods

2.1. Participants

Children with CP were recruited from rehabilitation clinics at three hospitals. A physiatrist and a physical therapist
independently determined eligibility for inclusion for each participant. The inclusion/exclusion criteria were reported in our
previous manuscript (Chen, Chen, et al. 2013). Inclusion criteria were diagnosis of CP and age 2 years to 5 years and 11
months. Children with a progressive neurological disorder, genetic or metabolic disorder, or severe concurrent illness or
disease (e.g., active pneumonia or brain tumor) were excluded. Each participant was re-examined at 6 months after the initial
assessment. The physiatrist confirmed the CP diagnosis, CP subtype and limb distribution based on history taking, physical
examination, chart review, or brain imaging findings. Five participants were lost during follow-up for the 85 children that
were initially recruited using convenience sampling (i.e., 1 due to active medical problems, 1 due to death, and contact with
104 K.P. Wu et al. / Research in Developmental Disabilities 37 (2015) 102–111

3 was lost). Finally, 80 children with CP were enrolled (Table 1). During this 6-month study, 76% (n = 61) of participants
received physical therapy, 72% (n = 58) of participants received occupational therapy, and 41% (n = 33) of participants
received speech therapy. The Institutional Review Board for Human Studies at Chang Gung Memorial Hospital approved this
study. Informed consent from each participant was obtained from his/her caregiver.

2.2. Procedure

Test measures, the Comprehensive Developmental Inventory for Infants and Toddlers (CDIIT) (Liao, Wang, Yao, & Lee,
2005), GMFCS, BFMF, MAS, SMC, Spinal Alignment and Range of Motion Measure (SAROMM), Function Independence
Measure for Children (WeeFIM) (Ottenbacher et al., 1996), and APCP, were administered at baseline and participation
outcome measures were re-tested at 6-month follow-up by two trained raters (i.e., physical therapists). Rater training
included careful review of written instructions and repeated practice. A senior certified physical therapist assessed rater
competence. The test–retest and inter-rater reliabilities were 0.98 and 0.98, respectively, for CDIIT; 1.000 and 0.875,
respectively, for the GMFCS levels; 1.000 and 0.875, respectively, for the BFMF levels; 0.855 and 0.865, respectively, for SMC;
and 0.907 and 0.870, respectively, for the SAROMM.

Table 1
Demographic and clinical characteristics of participants (N = 80).

Characteristics Valuea

Mean or N SD or %

Demographic
Age (years) 3.9 1.4
Sex
Male 50 62.5%
Female 30 37.5%
Clinical
GMFCS levels
Level I 23 28.8%
Level II 16 20.0%
Level III 12 15.0%
Level IV 12 15.0%
Level V 17 21.3%
BFMF levels
Level I 16 20.0%
Level II 19 23.8%
Level III 16 20.0%
Level IV 12 15.0%
Level V 17 21.3%
CP subtypes
Unilateral 15 18.8%
Bilateral 65 81.3%
SAROMM 22.8 10.9
MAS 16.4 13.3
SMC
0–2 54 67.5%
3–4 26 32.5%
APCP
Diversity (%)
Total 41.9 20.3
PA 51.0 25.5
SD 36.3 23.7
AP 42.6 20.3
SA 41.5 19.9
Intensity
Total 2.21 1.13
PA 3.03 1.52
SD 1.93 1.40
AP 2.29 1.16
SA 1.87 0.87

N, number of participants; SD, standard deviation; CP, cerebral palsy; GMFCS, gross motor
function classification system; BFMF, bimanual fine motor function; SMC, selective motor
control; MAS, Modified Ashworth Scale; SAROMM, Spinal Alignment and Range of Motion
Measure; APCP, Assessment of Preschool Children’s Participation; PA, play; SD, skill
development; AP, active physical recreation; SA, social activities.
a
Values were expressed as mean  SD for continuous variables and number (%) for
categorical variables.
 K.P. Wu et al. / Research in Developmental Disabilities 37 (2015) 102–111 105

2.3. Outcome measures

The APCP, a questionnaire administered by interview, was the outcome measure (Law et al., 2012); The APCP
questionnaire was initially designed to determine the level of activity participation for children aged 2 years to 5 years and
11 months. To assess participation intensity, frequency with which a child participated in an activity was recorded over the
last 4 months on a 7-point ordinal scale, where 1 represented the lowest frequency of participation in an activity (once in 4
months), while 7 represented the highest frequency of participation in an activity (at least once per day). Participation
diversity is the sum of the total number of reported activities over the 4 months prior to study start. For group data, diversity
is a percentage of activity type to all activities. Intensity is derived by dividing the sum of frequencies for all items by the
number of items in each activity area. Diversity and intensity scores are generated for each item and in the four activity areas,
PA, SD, AP, and SA. The diversity and intensity scores in total area are calculated as the average of the four area scores. The
APCP had fair to excellent concurrent validity (r = 0.39–0.85) and predictive validity (r = 0.46–0.82) for children with CP
(Chen, Chen, et al. 2013). The clinimetric properties, such as minimal detectable change (MDC) and minimal clinically
important difference (MCID), of scales allow clinicians to determine whether a change in score is clinically meaningful (Chen,
Chen, et al. 2013). This study is a secondary analysis of data related to APCP that were published earlier (Chen, Chen, et al.
2013).

2.4. Potential predictors

According to empirical and theoretical considerations, seven potential predictors were selected: age; sex; Social Status
Rating Scale (SSRS) (Rin, Schooler, & Caudill, 1973), CP subtype; cognitive function (CDIIT-COG), motor composite variable,
and WeeFIM. A motor composite variable was derived from five motor factors, including GMFCS level (Palisano et al., 1997);
BFMF level (Beckung & Hagberg, 2002); SMC (Smits et al., 2010) score; MAS score (Bohannon & Smith, 1987); and SAROMM
score (Bartlett & Purdie, 2005), Each CP subtype was classified as unilateral or bilateral (Rosenbaum et al., 2007). A high level
or score for the GMFCS, BFMF, MAS, and SAROMM indicate a poor performance. High scores on the SMC indicate a good
control. A five point SSRS was used to classify the socioeconomic status of family, ranged from level I to level V according to
the education and occupation of key person in their family (Rin et al., 1973). A high level indicates a low socioeconomic
status.

2.4.1. GMFCS levels (levels I–V)

The GMFCS–Expanded and Revised emphasizes the concepts from the World Health Organization’s International
Classification of Functioning, Disability and Health (ICF) (Palisano, Rosenbaum, Bartlett, & Livingston, 2008) considers the
impact of both environment and personal factors on mobility. The 5-level GMFCS grading system aim to determine the best
level representing the child’s or youth’s present abilities and limitations in gross motor function and the need of wheeled
mobility or other assistive technology. Emphasis is on the children’s usual performance in different settings rather than their
capacity. A low level indicates good gross motor mobility. For example, level 1 indicates walk without limitations; level II
indicates walk with some limitations; level III indicates walk using a hand-held mobility device; level IV indicates self-
mobility with limitations that may use powered mobility; and level V indicates transport in a manual wheelchair (Palisano
et al., 2008).

2.4.2. BFMF scale (levels I–V)

The BFMF scale is a five-level scale for bimanual functional limitations (Beckung & Hagberg, 2002). Levels progress as
restrictions on fine motor skills increase. Level I indicates the best bimanual function in which bilateral hands manipulate
without restrictions or one hand may have restrictions in advanced fine motor skills. Levels I–III may indicate one hand
manipulate without restriction while the other hand has increasing performance limitation or at least one hand has
limitations in more advanced fine motor skills. Level V has the least bimanual function in which both hands have only the
ability to hold or worse.

2.4.3. The SMC tests (score 0–4)

The four-point SMC test (Boyd and Graham SMC test) was used to assess the selective dorsiflexion of the ankle: 0 is for no
ankle movement; 1 is for limited dorsiflexion; 2 is for ankle dorsiflexion using the extensor hallucis longus, extensor
digitorum longus, and some tibialis anterior activity; 3 is for the ability to dorsiflex using mainly tibialis anterior activity
with hip and/or knee flexion; and 4 is for the ability to perform isolated dorsiflexion without hip and knee flexion. This SMC
test has a moderate inter-rater reliability (Smits et al., 2010). A higher score indicates a better motor control.

2.4.4. MAS
The six-point MAS (Bohannon & Smith, 1987) is administered to assess resistance during passive muscle stretching. The
MAS grades spasticity as follows: 0, no increase in muscle tone; 1, slight increase in muscle tone with a catch and release or
minimal resistance at the end of the ROM; 1+, slight increase in muscle tone in less than half of the ROM; 2, greater increase
in muscle tone through most of the ROM with easy passive movement; 3, marked increase in muscle tone with difficult
passive movement; and 4, rigid limb in flexion or extension. The MAS score is used to assess the extent of muscle tone in
106 K.P. Wu et al. / Research in Developmental Disabilities 37 (2015) 102–111

upper extremities (i.e., elbow flexor, pronator, wrist flexors, finger flexor, and thumb adductor) and lower extremities (i.e.,
hip adductor, hamstrings, gastrocnemius and soleus) on bilateral sides. The MAS total score is the sum of for the bilateral
upper and lower extremities. The intra-observer reliability of the MAS was low to average (Numanoglu & Gunel, 2012). A
higher score indicates a greater spasticity.

2.4.5. SAROMM (score 0–4)

The five-point SAROMM contains 26 items, including 4 items for spinal alignment and 11 items for ROM and muscle
extensibility tested bilaterally (Bartlett & Purdie, 2005). A score of 0 represents the ability to align normally without passive
limitations and a score of 4 indicates that that a subject has severe deviations in spinal alignment, limitations in joint ROM,
and/or muscle extensibility. The SAROMM total score is the sum of spinal alignment and ROM scores (possible range, 0–104).
The intraclass correlation coefficients for interrater and test–retest reliabilities for all SAROMM subscales and total scores for
children and adolescents with CP are all >0.80 (Bartlett & Purdie, 2005). A higher score indicates a worse spinal alignment
and ROM.

2.4.6. WeeFIM
The WeeFIM (Ottenbacher et al., 1996) is an 18-item, 7-level ordinal scale instrument that is categorized into 2 main
functional groups: ‘‘Dependent’’ (scores 1–5, helper requires) and ‘‘Independent’’ (scores 6–7, no helper requires). It has
three functional subscales: self-care (WeeFIM-SC; eight items), mobility (five items), and cognition (five items). Level 1
indicates total assistance while Level 7 indicates no assistance for the child and the child can complete the task
independently without requiring a device. The WeeFIM has excellent reliability (Ottenbacher et al., 1996). A higher score
indicates a better ADL.

2.4.7. CDIIT
The CDIIT (Liao et al., 2005) is widely used in Taiwan and includes five developmental subtests. The developmental age
(DA) for the cognitive subtests (CDIIT-Cog) was selected for this study. The CDIIT has acceptable test–retest reliabilities
(intra-class correlation coefficient (ICC > 0.76), inter-rater reliability (ICC > 0.76), and validity in children (Liao et al., 2005). A
higher score indicates a better cognitive function.

2.5. Statistical analysis

The change score in outcome measure (APCP), determined by subtracting pretest score from posttest score, is the
dependent variable. A principal components analysis (PCA) was used to extract a motor composite variable from five motor
factors (GMFCS level, BFMF level, reverse scores of SMC, MAS scores, and SAROMM scores). Predictors for APCP change were
identified in two steps. First, predictors (age, sex, SSRS, CP subtype, motor composite variable, CDIIT-Cog, and WeeFIM) at
baseline were examined for associations with change scores for APCP outcome measures (diversity and intensity scales) by
using the Pearson correlation coefficient (r). The criterion for predictors inclusion in regression analysis was p  0.25 (Groff,
Lundberg, & Zabriskie, 2009). Second, predictors in regression analysis were subjected to a forward stepwise procedure to
generate a linear regression model for APCP change in each area. Adjusted r2, p values, and regression coefficients (b) were
used to assess goodness-of-fit in the regression models. Regression diagnostics were also applied to examine
multicollinearity (i.e., variance inflation factor (VIF) among predictors in the models.

3. Results

Table 1 lists demographic and clinical characteristics of the 80 participants. Table 2 groups participants according to
change status (improvement, no change, or deterioration) in each domain of the APCP at follow-up. Most participants
improved both in diversity and intensity scores in all areas at 6 months.
The 5 motor factors, including GMFCS level, BFMF level, reverse scores of SMC, MAS scores, and SAROMM scores, were
entered as variables in PCA to extract the motor composite variable. The first component (GMFCS level) accounted for 80% of
the variances. Table 3 lists Pearson coefficients for the correlation between the seven predictors and the change scores for
outcome measures (between baseline scores and those at follow-up). Three predictors, age, SSRS, and CDIIT-Cog were
entered into the APCP-AP intensity model; age, sex, and CP subtypes were entered into the APCP-SA intensity model. Four
predictors, age, sex, and CDIIT-Cog, and WeeFIM were entered into the APCP-total, APCP-SD diversity, and APCP-PA intensity
models; age, sex, SSRS, and CDIIT-Cog were entered into the APCP-AP diversity model; age, sex, and CDIIT-Cog, and motor
composite variable were entered into the APCP-SD intensity model. All predictors except for SSRS and CP subtypes were
entered into the APCP-PA diversity model. All predictors except for SSRS were entered into the APCP-SA diversity model.
Values of all variables (VIF < 1.1) were within normal ranges (VIF  5), confirming multicollinearity assumption held.
Table 4 presents the results of stepwise multiple regression analyses. Age and sex together were predictors in the APCP-
total, APCP-SD diversity and APCP-total intensity models (r2 = 0.13–0.25, p < 0.001). WeeFIM was a predictor in the APCP-PA
diversity model (r2 = 0.08, p < 0.01). CDIIT-Cog and CP subtypes were predictors in the APCP-SA diversity model (r2 = 0.13,
p < 0.01). Age, sex, and motor composite variable were strong predictors in the APCP-SD intensity models (r2 = 0.22,
p < 0.001). Age and SSRS were predictors in APCP-AP intensity model (r2 = 0.07, p < 0.05). Age and CP subtype alone was a
 K.P. Wu et al. / Research in Developmental Disabilities 37 (2015) 102–111 107

Table 2
Number of participants according to status of change in the motor outcome measures.

Outcome measure Status of change

APCP Improvement No change Deterioration

N N N

Diversity
Total 63 4 13
PA 51 17 12
SD 57 14 9
AP 34 26 20
SA 45 19 16
Intensity
Total 65 1 14
PA 54 10 16
SD 66 2 12
AP 49 5 26
SA 58 6 16

N, number of participant; APCP, Assessment of Preschool Children’s Participation; PA, play; SD, skill
development; AP, active physical recreation; SA, social activities.

Table 3
Relationships between the potential predictors and the change scores of the APCP outcome measures.

Predictors Pearson’s r
APCP

Diversity Intensity

Total PA SD AP SA Total PA SD AP SA

Demographic
Age 0.43* 0.28* 0.38* 0.21* 0.22* 0.38* 0.28* 0.39* 0.24* 0.14*
Sex 0.32* 0.22* 0.29* 0.14* 0.15* 0.28* 0.21* 0.27* 0.13 0.17*
Socioeconomic status 0.06 0.03 0.03 0.15* 0.03 0.09 0.08 0.05 0.16* 0.04
Clinical
CP subtypes 0.12 0.13 0.09 0.11 0.20* 0.13 0.12 0.10 0.13 0.29*
Motor composite variable 0.05 0.17* 0.13 0.01 0.14* 0.09 0.10 0.18* 0.10 0.06
CDIIT-Cog 0.38* 0.26* 0.27* 0.17* 0.29* 0.27* 0.25* 0.24* 0.16* 0.11
WeeFIM 0.25* 0.30* 0.13* 0.09 0.15* 0.13 0.26* 0.08 0.04 0.03

CP, cerebral palsy; APCP, Assessment of Preschool Children’s Participation; PA, play; SD, skill development; AP, active physical recreation; SA, social
activities; CDIIT-Cog: Comprehensive Developmental Inventory for Infants and Toddlers-cognitive function; WeeFIM: Function Independence Measure for
Children.
* p-Values < 0.25.

predictor in APCP-PA and APCP-SA intensity models, respectively (r2 = 0.07, p < 0.05). However, no predictors were entered
into the final APCP-AP diversity model. The 9 final regression equations are as follows:

 Total diversity = (30.4) (3.1) age (6.5) sex

 PA diversity = (20.1) (0.2) WeeFIM
 SD diversity = (39.6) (3.9) age (8.6) sex
 SA diversity = (36.5) (0.3) CDIIT-Cog (11.1) CP subtypes
 Total intensity = (1.9) (0.2) age (0.4) sex
 PA intensity = (1.7) (0.2) age
 SD intensity = (2.3) (0.2) age (0.5) Sex (0.2) motor composite variable
 AP intensity = (1.6) (0.2) age (0.2) SSRS
 SA intensity = (1.8) (0.6) CP subtype

4. Discussion

To the best of our knowledge, this study is the first to identify predictors for participation change in various areas for
preschool children with CP. This study demonstrated that different factor combinations can indeed predict participation
change in various areas. For example, age and sex combined were the strongest predictors of participation changes in total
areas. Cognitive function, WeeFIM, CP subtype, motor composite variable, and socioeconomic status predicted for APCP
108 K.P. Wu et al. / Research in Developmental Disabilities 37 (2015) 102–111

Table 4
Forward stepwise multiple regression analyses of the predictors for the changes in the APCP measures.

Dependent variables Independent variables Coefficient (b) 95% CI lower 95% CI upper Adjusted r2 F VIF p

Diversity
Total 14.1 <0.001
Constant 30.4 22.2 38.7
Age 3.1 4.6 1.6 0.171 1.00
Sex 6.5 10.9 2.2 0.248 1.00
PA 7.7 0.007
Constant 20.1 12.7 27.4
WeeFIM 0.2 0.3 0.0 0.078 1.00
SD 10.9 <0.001
Constant 39.6 27.6 51.7
Age 3.9 6.0 1.8 0.135 1.00
Sex 8.6 14.9 2.23 0.201 1.00
SA 6.6 0.002
Constant 36.5 17.8 55.2
CDIIT-Cog 0.3 0.4 0.1 0.074 1.02
CP subtypes 11.1 20.5 1.7 0.125 1.02

Intensity
Total 10.1 <0.001
Constant 1.9 1.3 2.4
Age 0.2 0.3 0.1 0.131 1.00
Sex 0.4 0.7 0.1 0.188 1.00
PA 6.7 0.011
Constant 1.7 0.9 2.4
Age 0.2 0.4 0.1 0.068 1.00
SD 8.28 <0.001
Constant 2.3 1.6 3.1
Age 0.2 0.4 0.1 0.140 1.00
Sex 0.5 0.8 0.1 0.194 1.00
Motor composite variable 0.2 0.3 0.0 0.217 1.00
AP 3.7 0.280
Constant 1.6 0.6 2.6
Age 0.2 0.3 0.0 0.044 1.01
Socioeconomic status 0.2 0.4 0.0 0.065 1.01
SA 6.7 0.011
Constant 1.8 0.9 2.7
CP subtypes 0.6 1.1 0.2 0.068 1.00

CP, cerebral palsy; APCP, Assessment of Preschool Children’s Participation; PA, play; SD, skill development; AP, active physical recreation; SA, social
activities. CDIIT-Cog: Comprehensive Developmental Inventory for Infants and Toddlers-cognitive function; WeeFIM: Function Independence Measure for
Children.

changes in some areas. Thus, participation intensity is influenced by multiple child and family determinants (Palisano,
Chiarello et al., 2011). Social and community participation of children (6–12 years) and youth (13–21 years) with CP are
associated with age and GMFCS level (Palisano et al., 2009). Young children with a good GMFCS level tended to participate in
many activities (Imms, Reilly, Carlin, & Dodd, 2009). These findings suggest that demographic data, socioeconomic status of
the family, body function, and activity level predict participation change in different areas. The age, sex, cognition function,
and ADL were valuable predictors for participation change in most areas for children with CP. Furthermore, socioeconomic
status, motor composite variable, and CP subtype can modulate participation change in certain areas. Identifying these
predictors is important for timely intervention for children with CP who may benefit most from therapy.
In this study, the CDIIT-Cog and WeeFIM were negative predictors for APCP-SA and APCP-PA diversity changes,
respectively. The reasons may due to that children with good cognitive function and ADL had high participation level at
baseline. Consequently, these children had a small participation change at follow-up. Previous studies showed the cognition/
speech functions (Hammal, Jarvis, & Colver, 2004; Morris et al., 2006; Voorman et al., 2006) were related to participation
levels. Participation and activity performance increase as motor disability and/or additional neuroimpairments (speech and
language impairments and learning disability) decrease in children with CP (6–13 years) (Schenker et al., 2005). Thus,
cognitive impairments and ADL limitations decrease participation in children and adolescents with CP (Fauconnier et al.,
2009; Law et al., 2012; Majnemer et al., 2008). These findings suggest that children with poor cognitive function and ADL can
make a great gain in participation change.
Young boys as a variable predict participation change well in most areas for children with CP. In this study, age and
sex together predict change in participation diversity and intensity of total and skill development areas with a variance of
19–25%. Low participation level of boys at baseline may contribute to greater participation gains obtained in this group at
follow up. Studies support this finding for children and youth with CP (King et al., 2013; Palisano, Chiarello et al., 2011;
Shikako-Thomas, Shevell, Lach et al., 2013). Preschool girls participated in a broader range of activities and with a higher
frequency than boys (Law et al., 2012). For adolescents with CP (aged 12–20 years old), girls engaged in more self-
improvement activities than boys (Shikako-Thomas, Shevell, Lach et al., 2013). Age of 6–12 is associated with high-intensity
 K.P. Wu et al. / Research in Developmental Disabilities 37 (2015) 102–111 109

participation (Palisano, Chiarello et al., 2011). The youngest age group participates in most recreational activities for those
aged 6–20 (King et al., 2013). Generally, participation decreases as youth grow into adolescence (12–20 years old) (Shikako-
Thomas, Shevell, Lach et al., 2013). A 3-year follow-up study showed that factors associated with change in participation
intensity are a function of a child’s age and sex for children/youth with physical disabilities aged 6–15 (King et al., 2009).
These analytical findings indicate there is a need for early intervention to enhance participation change for children with CP.
It is the GMFCS level, not the SMC, MAS, and SAROMM scores, accounts more importantly in predicting participation
change in children with CP. In this study, the motor composite variable predicts participation diversity change in skill
development areas. GMFCS levels was extracted as a first component from five motor factors via PCA analysis and accounted
for 80% of the variance. This may due to the fact that the GMFCS level reflects the severity of motor impairment. Correlations
among MAS, ROM, and SMC scores (Ostensjo, Carlberg, & Vollestad, 2004) and GMFCS level in children with CP were
complex. A 2-year longitudinal study found significant differences in GMFM item scores (corrected for the GMFCS) for
different levels for limb distribution, SMC, ROM, and MAS in children with CP aged 9–15 years (Voorman et al., 2007).
Previous studies also demonstrated that GMFCS level was correlated with participation for CP children and youth (Imms
et al., 2009; King et al., 2013; Schenker et al., 2005; Voorman et al., 2006). Children/youth with GMFCS level IV/V had low
levels of participation in recreational, active physical, and self-improvement activities (King et al., 2013). Another study
showed that the GMFCS level was strongly associated with performance in domestic activities of CP children aged 9–13
(Voorman et al., 2006). Therefore, GMFCS level may be applied to predict participation change early in a child’s life in a
simple and time-efficient manner.
Children with the unilateral CP subtype had greater changes in the social diversity and intensity than those with bilateral
CP subtype. In this study, CP subtype can predict changes in social diversity and intensity with a variance of 5–7%. The likely
reasons are that developmental skills, such as cognition, speech, and social function, differed between CP subtypes (Lee et al.,
2010). Functional impairments in children with CP further limit their activities and participation. Similar experimental
results were reported in previous studies (Fauconnier et al., 2009; Hammal et al., 2004; Kerr et al., 2008; Schenker et al.,
2005). For instance, participation level differed significantly by clinical CP subtype for children and youth with CP (Kerr et al.,
2008; Schenker et al., 2005). However, no definite conclusion was drawn due to the relatively small variance for CP subtype
in predicting change in social participation.
The GMFCS level is more important factor to predict participation changes than BFMF level for children with CP. In this
study, the PCA extract the GMFCS levels, not BFMF levels, as a main component for a composite motor variable. Analytical
results obtained by this study were compatible with those in previous studies, (Imms et al., 2009; King et al., 2013; Schenker
et al., 2005; Voorman et al., 2006), although some studies showed that level for fine motor skills were also associated with
degree of participation (Imms et al., 2009; Shikako-Thomas, Shevell, Lach et al., 2013). Adolescents with CP having severe
manual ability participated less in all activity types except for skill-based activities than those with good manual ability
(Shikako-Thomas, Shevell, Lach et al., 2013). Participation in informal activities tended to be greater for children with CP
aged 10–12 who had high manual ability than those with low manual ability (Imms et al., 2009). Diversity and intensity of
participation were similar for CP children aged 10–12 in each Manual Ability Classification System level, except for
participants in Level V (Imms, Reilly, Carlin, & Dodd, 2008). Differences among studies may be related to the use of different
outcome measures (change score vs. absolute score), activity types, participant age, sex, and CP characteristics. Findings
obtained by this study may suggest that gross motor training is more important to enhance skill development than fine
motor training.
The socioeconomic status is a positive predictor for APCP-AP intensity change in children with CP. It is possible that
children who had higher socioeconomic family can participate in more activities. Previous studies also revealed the
socioeconomic status and family factors were related to participation in children or youth with CP (Chan et al., 2005; Colver
et al., 2012; Law et al., 2012; Mihaylov et al., 2004; Shikako-Thomas, Shevell, Schmitz et al., 2013). These findings suggest
that early identification and planning treatment strategies may enhance participation changes for those with low
socioeconomic family.
No key predictors existed for the APCP-AP diversity model and some predictors had only low variance to predict in some
participation areas, These results may relate to some potential predictors were not addressed in this study. Participation
changes were not only influenced by age, sex, GMFCS level, and CP subtype, but were also related to participant
characteristics, family factors, (Palisano, Chiarello et al., 2011; Shikako-Thomas et al., 2008) and environmental factors
(Palisano, Orlin et al., 2011; Shikako-Thomas et al., 2008; Wright et al., 2008). For example, the other proposed predictors of
participant characteristics were motivation and behavior (Palisano, Chiarello et al., 2011; Palisano, Orlin et al., 2011;
Shikako-Thomas et al., 2008), and presence of epilepsy (Hammal et al., 2004; Morris et al., 2006; Voorman et al., 2006). The
contextual factors were also related to participation for CP children. Therefore, unexplained variance suggests that other
important determinants should be included in future studies.
The primary limitation of this study is the limited number of potential predictors (mainly related to movement and
mobility impairments); that is, only seven potential predictors were examined. Participant motivation and behavior,
environmental factors, and family function were not included due to the limited sample size. Moreover, based on the
relatively small variance for regression analysis for social, play, and active physical models, no definite conclusion can be
drawn. Future studies with a larger sample size are needed to validate other potential predictors for participation
outcome. Despite these limitations, this study identified predictors for participation change in various areas for
preschool CP children.
110 K.P. Wu et al. / Research in Developmental Disabilities 37 (2015) 102–111

5. Conclusions

As hypothesized, this study shows that different factor combinations predicted change in participation diversity and
intensity in various areas for CP preschool children. The demographic data, socioeconomic status of the family, body
function, and activity level predict participation change in different areas. Young (age) boys (sex) with poor cognitive
functions and ADL may benefit the most in participation change. Furthermore, socioeconomic status, motor functions, and
CP subtype may modulate participation change in certain areas.
This is the first study to identify potential predictors for participation changes in preschool children with CP. It is
noteworthy that young boys with poor cognitive functions and ADL stand out as a group for aggressive early intervention, the
treatment for participation changes makes the most significant differences. Potential predictors identified by this study help
clinicians to screen preschool children with CP in need of participation intervention. Future research targeting participation
outcome for children with CP may include an expanded age distribution, other potential predictors, and a longer follow-up
period to better address change in participation diversity and intensity.

Acknowledgments

This work was supported by the Ministry of Science and Technology, Taiwan [NSC 102-2410-H-182-018, NSC 101-2314-
B-182-004-MY3] and Chang Gung Memorial Hospital, Taiwan [CMRPG 391671-3].

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