Therapeutic Recreation Journal

Vol. LII, No. 2 • pp. 154–169 • 2018

https://doi.org/10.18666/TRJ-2018-V52-I2-8344

Regular Paper

A Network Analysis of Youth with Physical

Disabilities Attending a Therapeutic Camp

Shay Dawson
Abstract
Bryan McCormick
Jing Li
Pediatric clients with physical disabilities are at-risk
for psychosocial stress compared to peers without
health conditions. Therapeutic camps are one program
known to provide positive psychosocial outcomes
yet effects tend to extinguish over time. The value
of therapeutic camps in improving true reciprocal
friendship opportunities while enhancing important
matters discussant groups is unknown. The aim of this
study was to explore the impact camp participation had
on enhancing reciprocal relationships and important
matters discussant group alters, test for significant
differences reported by children and adolescents, and
examine the distribution of reported alters within
networks. An important matters discussant group name
generator centered on four hierarchical role-relation
prompts along with one exchange relation approach
question. The name generator was administered to
76 youth with physical disabilities 8-18 years of age
attending a two week residential camp. Statistically
significant differences were found for adolescents
seeking out non-relative peer supports in comparison
to children. No difference was found in years attending
camp and network composition despite 21% of the
overall networks comprised of camp contacts indicating
a possible social inoculation effect regardless of years
attending. Distribution of important matters alters

Shay Dawson is an adjunct faculty member in the Department of Recreation, Park and
Tourism Studies at Indiana University.
Bryan McCormick is a professor in the Department of Rehabilitation Sciences at Temple
University.
Jing Li is a doctoral student in the Department of Biostatistics at Indiana University.
Please send correspondence to Shay Dawson, sldawson@indiana.edu

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appears to be skewed toward relatives. Future implications focus on testing and

improving the therapeutic camp model to address the extinguishing psychosocial
effects post camp by capitalizing on the potential rapid social inoculation that may be
currently confined to short term residential experiences.

Keywords
Friendship reciprocity, network analysis, pediatric, physical disability, social inoculation,
therapeutic camp

Introduction
There is a strong need for interventions that counter the psychosocial effects of
pediatric health conditions (Groce, 2004; Haring & Breen, 1992; Meijer, Sinnema,
Bijstra, Mellenbergh, & Wolters, 2000). Several noted areas of concern in this
population include increased isolation, lack of social acceptance, discontent with
social and leisure participation, and higher rates of suicidal ideation (Chavira, Accurso,
Garland, & Hough, 2010; Haring & Breen, 1992; Knapp, Devine, Dawson, & Piatt,
2015; Raghavendra, Newman, Grace, & Wood, 2013). Medical specialty camps are one
potential psychosocial support intervention that has been shown to provide short-
term support outcomes for youth during residential camp experiences. However, there
is also a documented need to improve the current medical camp program model to
counter the extinguishing psychosocial effects commonly seen in the data as these
same campers return to integrated home communities (Dawson, 2017; Plante, Lobato,
& Engel, 2001). New and innovative research approaches are needed to better capture
the dynamics of the social connections youth may or may not make while participating
in residential medical camps.
Social network analysis is a relatively new research approach in the social sciences
that attempts to scientifically capture and map the social connections of individuals.
Information from this research approach has the potential to inform camp directors
and social scientists concerned with providing camp programs that positively affect
pediatric campers the 51 weeks of the year outside of the typical residential experience.
The current study examined the social networks of youth with physical disabilities
attending a residential medical camp through an egocentric social network analysis
approach using a name generator.
Name generators are able to capture supportive people identified within a client’s
social network (i.e., the people they go to for important matters in life). This approach is
one of the first to explore if camp staff and peer campers become embedded within the
important matters networks of the pediatric participants after attending a residential
medical camp.
Social Psychology of Pediatric Disability
A meta-analysis of 954 pediatric studies that included a total of 104,867 subjects
identified greater overall functional impairment in the social, academic, and physical
domains for youth diagnosed with a physical disability (Pinquart & Teubert, 2011).
Youth with physical disabilities may be at particular risk in the social domain as they are
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less involved in social activities due to barriers associated with their health condition
(Meijer et al., 2000). The long-term ramifications of diagnoses such as spina bifida,
muscular dystrophy, and cerebral palsy remain problematic for pediatric clients as the
majority will live at the poverty level, have low college attendance rates, less social
participation, and decreased vocational attainment once they become adults (Indjov,
2007; Maslow, Haydon, McRee, Ford, & Halpern, 2011; McDonald & Raymaker, 2013).
It is critical that children and adolescents have opportunities to engage in programs
that counter the potentially negative social psychological implications of disability by
improving coping skills and feeling supported during times of stress related to their
disability (McGrath, Brennan, Dolan, & Barnett, 2014). The constructs of liminality,
loneliness, and friendship reciprocity are specific areas that could be addressed in this
population through an improved medical camp program model.
Liminality, Loneliness, and Friendship Reciprocity
Liminality, a term originating from anthropology, refers to a middle stage of
transition and ritual in which a person is between social groups (Van Gennep, 2011).
Liminality has been applied to physical disability in that individuals are fully healthy
yet are seen by society as being ill due to their diagnoses (e.g., perception that using a
wheelchair indicates being medically fragile or ill when the client may be quite healthy
and active). These same individuals may be physically present in society yet not actively
included in the social settings, economic marketplace, and the physical architecture
of that society (Murphy, Scheer, Murphy, & Mack, 1988; Willett & Deegan, 2001). For
example, youth may be able to participate in an integrated school system due to the
accessibility of the facility and the laws regulating inclusion, yet not fully integrated
into the social fabric within the social network of the student body. Medical camps may
provide unique opportunities for participants to experience being part of the majority
due to the disability specific nature of these programs. For some, this short term camp
experience may be the only time each year in which they do not experience liminality.
Providing periodic access to supportive relationships formed at residential medical
summer camps may be one approach to addressing liminality during the inclusive and
integrated school year.
Loneliness is a construct that has been noted for clinically significant impacts
on the health of clients including their physical and mental functioning (Heinrich &
Gullone, 2006). Loneliness is the negative feeling an individual perceives when that
individual does not receive their desired social interactions. However, it is important to
note that loneliness is perception oriented as solitary individuals may not feel loneliness
while those with numerous connections can feel lonely (i.e., an individual’s perception
of the quality of their connections is key) (Hawkley & Cacioppo, 2010). Loneliness
is associated with a variety of health problems such as anxiety, low self-esteem,
depression, drug abuse, suicidal ideation, compromised immune system functioning,
higher mortality rates, cardiovascular disease, and higher levels of emergency room
visits (Hawkley & Cacioppo, 2010; Hopps, Pepin, Arseneau, Frechette, & Begin, 2001;
Qualter et al., 2013). Individuals with physical disabilities have higher loneliness scores
compared to peers without disabilities while also displaying social anxiety, poor social
skills, and physical independence associated with those same loneliness scores (Hopps
et al., 2001; Rokach, Lechcier-Kimel, & Safarov (2006). Medically specific camps may

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provide an opportunity to counteract potential perceptions and feelings of loneliness in

this same population yet the current medical camp model may be limited in providing
access to helpful social relationships outside of 1-2 weeks of programming during the
summer.
Reciprocal friendships may be understood as an equal relationship between two
people in that both believe the other to be a friend while sharing similar levels of
support with one another. Friendship reciprocity has also been noted as the opposite
of loneliness, as impactful to one’s well-being, and increasingly important as children
move into adolescence (Buunk & Prins, 1998). Reciprocal relationships can result in
tangible social and emotional support (Cauce, 1986; Vaquera & Kao, 2008). Those
that lack reciprocity in relationships have been noted as having poorer health, such
as elevated depression levels (Chandola, Marmot, & Siegrist, 2007). Youth with
physical disabilities are noted as participating less in activities compared to youth
without disabilities (La Greca, 1990) and appear to have smaller social networks (Haas,
Schaefer, & Kornienko, 2010; La Greca, 1990). Although currently untested, residential
medical specialty camps may provide an opportunity to build and enhance reciprocal
relationships in a unique environment rich with positive social comparisons and
perceptions of a supportive community (Dawson, Knapp, & Farmer, 2012; Dawson &
Liddicoat, 2009).
Taken together, the three distinct yet related constructs of loneliness, liminality,
and friendship reciprocity provide a theoretical foundation for understanding the
potential need for social support oriented interventions for youth with physical
disabilities. Without such intervention, youth experiencing physical disabilities may
be at risk for negative long term health outcomes. The following research explores
the effect of one pediatric intervention, a residential medical camp, in addressing the
psychosocial ramifications of childhood disability from a social network perspective.
Medical Camp Outcomes
Medical camps designed for youth with a specific medical diagnosis may be a place
that provides opportunities for psychosocial support. Epstein, Stinson, and Stevens
(2005) reviewed 18 studies on camp as a method of improving quality of life and
found supportive evidence in a sample of 1,270 participants. A national study on 19
camps found that friendship development skills, competence, connection, and social
acceptance were positive outcomes from participation (Devine & Dawson, 2014).
Quantitative studies have found improvements in self- esteem, social acceptance,
health related quality of life, connectedness, goal-directed behavior, and hope while
qualitative phenomenological inquiry has yielded insights into the strong connection
gained by being with similar peers, identifying camp as a home, and as a vehicle for
providing community (Dawson, Knapp, & Farmer, 2012; Dawson & Liddicoat, 2009;
Devine & Dawson, 2010; Devine & Dawson, 2014; Devine, Piatt, & Dawson, in review;
Woods, Mayes, Bartley, Fedele, & Ryan, 2013).
Although short-term residential camp experiences have been shown to provide
tangible psychosocial benefits, critiques of the medical camp model focus on the
extinguishing psychosocial effects that tend to take place once the camper returns
to more integrated home and school settings. For example, Knapp, Devine, Dawson,
and Piatt (2015) found that youth with physical disabilities expressed high frustration
over not having similar social opportunities in their home communities during

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interviews conducted six months after camp ended. A recent meta-analysis of 31

camps using quantitative measures found that children’s psychosocial self-perceptions
yielded positive and statistically significant improvements from the residential camp
experience yet extinguishing effects were present as children returned home (Odar,
Canter, & Roberts, 2013). Plante, Lobato, and Engel (2001) reviewed pediatric group
interventions and found camps to be one of five major categories of treatment typically
provided, yet identified the decaying psychosocial effects of camp participation upon
return to home communities as problematic in the current medical camp model. In
short, positive psychosocial gains are a common outcome of medical camp participation
from the start to end of residential camp participation. However, the current program
model has failed to address the extinguishing effects that are also routinely present in
the months after camp. If this issue can be mitigated through an improved medical
camp model, major improvements in the long-term psychosocial health of youth with
health conditions may be possible through medical camp interventions that serve
thousands of pediatric patients nationally.
Social inoculation has been defined as creating a socially conducive environment
rich with positive social connections for health (Evans & Getz, 2003; Pilisuk, 1982). It
is feasible that the small but significant outcomes routinely identified in camp studies
can be explained by a social inoculation effect. For example, residential campers
may attend camp and rapidly make friendships with others that have similar health
conditions while taking part in a supportive and accessible program. This may result in
positive psychosocial gains from the start of camp to the end of camp. However, upon
return to integrated home settings, the positive effects appear to extinguish (Dawson,
2017). A new research approach is needed to further discover how to improve the
medical camp program model. The following study aims to explore the social networks
of youth with physical disabilities attending a two-week residential medical camp to
better understand the extinguishing social effects of these programs.
Social Network Analysis as a Research Approach
Social network analysis is a rather new approach in the social sciences. It has yet
to be widely utilized in recreational therapy practice. However, the nature and scope
of this research approach may have strong applicability to recreational therapy and
medical camps as it captures the essence of social connections. There are two major
approaches within social network analysis, including egocentric and whole network
studies. Whole network research examines the social connections in one social setting
with all subjects (e.g., connections between students attending a school or employees
at a place of work). A second approach, egocentric network analysis, maps the social
connections of individuals through name generators. Name generators provide a means
of identifying the specific people (alters) that the client (ego) goes to for important
matters or those they connect with through social and recreational companionship.
The egocentric approach also captures the role relation (e.g., mom, sibling, camp peer)
these alters play in the lives of the ego. There are several terms that are germane to
social network analysis that readers should be aware of. They include the ego, alter,
reciprocal relationships, important matters, and role relation. The following further
defines the terms commonly used by social network researchers that are applicable to
the current study.

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Network Analysis Terms

Ego – the subject that is the main focus of the network.
Alter – identified by the ego as a person within their network that they go to
for important matters or companionship.
Egocentric network analysis – social science research approach that seeks
to identify the personal network of one person (ego) including all identified
alters.
Role relation – the role the alter plays in the life of the ego (e.g., a parent,
friend, medical professional, camp peer, or teacher).
Important matters – important positive or negative topics that an ego dis-
cusses with an alter about their life.
Important matters name generator – social network research instrument to
elicit the names of the alters that the ego goes to for important matters.
Important matters discussant group – a comprehensive list of identified al-
ters that the ego identifies through the egocentric name generator.
Reciprocal relationships – mutually beneficial relationships in which the ego
goes to the alter and the alter in return goes to the ego for important matters.

Setting
An egocentric social network analysis was conducted at a 2,400-acre outdoor
center that is universally designed to enhance physical access to trails, cabins, and
programming. This medical specialty camp is well established with 60 consecutive
years of providing residential camp experiences to youth with physical disabilities. It
is affiliated with a regional children’s hospital and provides care at a one staff-to-three
camper ratio. The camp is staffed by five nurses, three physicians, and 80 students
studying medical or therapeutic disciplines in college while Certified Therapeutic
Recreation Specialists (CTRSs) are employed as the director and assistant directors.
Programming consists of horseback riding facilitated by PATH certified instructors,
climbing tower, alpine tower, zip line, pool, lake, canoeing, traditional camp outs,
adventure therapy, scuba diving, jeep rides, water skiing, skits, camp songs, archery,
leadership activities, music, and art activities. There is also a full challenge day in which
campers attempt personal physical challenges on property in order to meet their self-
identified goals.
The therapeutic recreation process of assessment, camper care plan, camp
interventions, and evaluation is conducted within this camp by recreational therapy
interns under the direction of a CTRS. Each camper completes an assessment related
to psychosocial indicators such as friendships, healthy leisure lifestyle engagement,
connection opportunities with others that have the same disability, and social acceptance
during the pre-camp application phase. Next, individual goals are created for each
camper one week in advance of their arrival while the camp setting and activities are
tailored toward the goals of the campers. Progress made on goals are assessed daily by
cabin staff and overall at the end of each camp session by recreation therapy interns.
A camper discharge plan is established at the end of the camp and provided to both
the parent and camper on progress made and continued growth opportunities for the
future.

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Method
Prior to taking part in the study, each camp family was sent IRB-approved informed
consent paperwork as part of the application packet several months before the start of
camp. During check-in, a researcher discussed the study with each camper and his/her
guardian. Informed consent from the guardian and assent from the pediatric camper
were recorded. In total, 90 camp participants attended with 76 agreeing to fill out a
five-question important matters name generator during camp for a response rate of
84%. Clients were 8-18 years of age with the female and male breakdown near 50%.
Diagnoses included those with muscular dystrophy, spinal muscular atrophy, cerebral
palsy, and spina bifida. The majority of campers originated from Midwestern states
with approximately 5% residing on the east coast.
The name generator defined the term important matters for the youth and then
asked to whom they go to for important matters. Each camper had the opportunity
to identify up to four alters they go to for important matters in rank order (e.g., one
being the first person they go to, two being the second person, etc.). Once supportive
alters were identified by the camper, the role each alter plays in the life of the camper
as well as the setting the alter is found in was also recorded (e.g., a teacher is an alter
and they are found in the school setting). Although the role relation approach is
more time consuming, the noted depth of information is helpful in understanding
the complexity of the ego’s social network (Kogovšek & Hlebec, 2009). This was also
critical in the analyses phase of the research study. The fifth question asked the camper
if anyone comes to them for important matters. This allowed researchers to compare
alters identified by the fifth question with alters identified in the first four questions
to determine if a reciprocal relationship was present. The name generator was given
to campers in cabin groups on the seventh day of the thirteen-day residential medical
specialty camp within cabin groups of approximately 8-12 campers per group. An
explanation was first given to the campers by the researcher and the campers filled
out the name generator independently unless they requested assistance from a staff
member.
An important matters discussant group name generator was created specifically
for this population based on previous empirical data supporting the creation of
sound ego centered social network tools (Hlebec, & Kogovšek, 2013; Kogovšek &
Hlebec, 2009; Marin & Hampton, 2007; Pustejovsky & Spillane, 2009). The “whom
do you discuss important matters” approach was used as it is less time consuming and
straightforward, which meets the needs of these pediatric campers with disabilities and
has been noted by Marin and Hampton (2007) as having the potential to capture a large
portion of social networks. The fifth question centered on name generators that elicit
the “exchange approach” (Marin & Hampton, 2007) to better understand if the ego
exchanges support with any of the previously identified four alters (i.e., are reciprocal
relationships present). Marin and Hampton (2007) identify exchange questions as a
strong method of eliciting reliable and valid data. The name generator utilized in this
study was specifically created as an exploratory pilot test to determine if this type of
study would be feasible with youth that have physical disabilities in an active medical
camp setting. Additionally, it was created to determine if a longer more established
egocentric instrument such as the Health and Social Network Battery could be used in
the future (Perry & Pescosolido, 2010; Pescosolido, Brooks-Gardner, & Lubell, 1998;
Pescosolido & Wright, 2004).
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Analysis
Data were categorized by establishing the frequency of the types of alters identified
in the first four questions related to the alters campers go to for important matters, e.g.,
a count of relatives, camp contacts, professionals, and friends where identified for each
of the four potential alter slots. A true reciprocal relationship was defined as an identical
person match within exchange and role questions (e.g., exact name in question 5 also
present from one of the questions in 1-4). Relaxed reciprocal relationship was based
on identifying a matched role not a specific person (e.g., role of friend identified in
question 5 and in one of the 1-4 questions).
Due to a small sample size and violations from normality assumption of the data,
the requirements for the t-test or ANOVA for independent samples was not satisfied,
thus a Wilcoxon rank-sum and Kruskal-Wallis non-parametric tests were performed
instead. Using non-parametric approaches in health care research is common due to
unusual distributions and small sample sizes (Pett, 2016). The Wilcoxon rank-sum
test was used to examine any potential difference between children and adolescents in
non-relative peers or camp-related alters that were identified. The Kruskal-Wallis test
was conducted to see if there was a significant difference in the years attending camp
of different true and relaxed reciprocal relationships. Finally, a Chi-Square Goodness
of Fit test was performed to examine if proportions were equally distributed at 0.25
for the four potential options. Statistical analyses were performed using SAS 9.3 (SAS
Institute, Cary, NC). P < 0.05 was considered statistically significant. Alter frequencies
were identified for the important matters and reciprocal exchange relationships
through descriptive statistics.

Results
Using the Wilcoxon rank-sum non-parametric test elicited a difference in
adolescents going to non-relative peers and friends at a significant difference compared
to children (one-sided p = 0.02). The difference between children and adolescents in
terms of the probability of campers going to camp-related alters for important matters
was not significant (p = 0.51). Hence, there is not enough evidence to support there
is a difference between the percentage of children and adolescents in going to camp-
related people for important matters. Kruskal Wallis test results (p = 0.78 and p = 0.64)
showed there is not sufficient evidence to support a difference in the distribution of
years attending camp for three reported (both true and relaxed) reciprocal relationship
roles. The authors also failed to conclude there is a difference between years of attending
camp for campers with true or relaxed reciprocal relationship and campers without
corresponding reciprocal relationship (p = 0.75 and p = 0.65).
Using a Chi-Square Goodness of Fit Test elicited several findings that are
significant. Preferences were not equally distributed for important matter one (Chi-sq
statistic c2 (3,N = 76) = 83.99, p < 0.001), important matter two (c2 (3,N = 73) = 31.49,
p < 0.001), important matter three (c2 (3,N = 71) = 18.86, p < 0.001), and important
matter four (c2 (3,N = 63) = 10.15, p = 0.02 <0.05). In examining who goes to the camper
for important matters, preference was not equally distributed (c2 (3,N = 46) = 16.4348,
p=0.001). True reciprocal relationships were equally preferred (distributed) for the four
possible roles (c2 (2,N = 18) = 2.33, p = 0.31 ) as well as for the relaxed reciprocal
relationship question (c2 (2,N = 36) = 0.5, p =0.78).

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 Dawson, McCormick, and Li

Descriptive statistical frequencies are reported in the tables below. Different role
relations for important matters 1st–4th options individually and combined, and “who
goes to you for important matters” question are shown in Table 1. Those identified
within the egos’ alters include relatives (51.96%), camp relationships (21.71%),
community friends (14.95%) and professionals (11.39%). Table 2 presents the
distribution of role relations for both true and relaxed reciprocal relationship. Figure
1 displays reciprocal exchange role frequencies. Figure 2 illustrates the non-significant
relationship when comparing relative frequency of peer support preferences between
children and adolescents camps (Z = 0.67, p = 0.51).

Table 1
Distribution of Role Relations
Table 1. Distribution for Important
of role relations Matters
for important 1st1-st 4th
matters - 4th Options Individuallyand
options individually and
Combined, and “Who
combined, andGoes
“who to You
goes to for
youImportant Matters”
for important matters”Question
question.

Role relations n(%)

Camp Friend Professional Relative
Important matter 1 (N=76) 10 (13.16) 8 (10.53) 6 (7.89) 52 (68.42)
Important matter 2 (N=73) 12 (16.44) 11 (15.07) 11 (15.07) 39 (53.42)
Important matter 3 (N=71) 21 (29.58) 12 (16.90) 7 (9.86) 31 (43.66)
Important matter 4 (N=63) 18 (29.51) 11 (18.03) 8 (13.11) 24 (39.34)
Important matters 1st – 4th 61 (21.71) 42(14.95) 32(11.39) 146(51.96)
options combined (N=281)
Who goes to you for 13 (28.26) 18 (39.13) 0 (0.00) 15 (32.61)
important matters (N=46)

Table 2
Table 2. Distribution
Distribution of role relations
of Role Relations when when reciprocal
Reciprocal relationship
Relationship canbe
Can beDefined
defined based
Basedonon
participant
Participant responses
Responses (N=42).
(N=42)
Existence of reciprocal relationship n(%)
No Yes, role relations:
Camp Friend Relative
True reciprocal relationship 24 (57.14) 9 (21.43) 5 (11.90) 4 (9.52)
Relaxed reciprocal relationship 6 (14.29) 11 (26.19) 11 (26.19) 14 (33.33)

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 Network Analysis

Figure  1.  Distribution  of  reciprocal  exchange  roles.  Left:  true  reciprocal  relationship.  Right:
Figure r1.
reciprocal   Distribution
elationship     of reciprocal exchange roles. Left: true reciprocal
relationship. Figure  1.  Distribution  
Right: relaxed reciprocal o f  reciprocal  exchange  roles.  Left:  true
relationship

reciprocal  relationship    

Figure  2.  Distribution  of  percentage  of  peer  support  preference  for  children  and  adolescen

 
Figure 2. Distribution of percentage of peer support preference for children
Figure  2.  Distribution  of  percentage  of  peer  support  prefere
and adolescents camps.

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 Dawson, McCormick, and Li

Discussion
Important matters alters for the 1st-4th person identified were not equally
distributed at the 0.25 expected ratio and thus statistically significant at an alpha of
0.05. Descriptive statistics showed that relatives are heavily identified in each of the
four roles with camp contacts reported most frequently after relatives. An inverse
relationship appears to be visible in that as the frequency of relatives goes down from
the 1st-4th position, camp relationship frequencies increase (see bar graph). True
reciprocal relationship frequencies were reported by only 42.86% of the sample with
some participants choosing to not fill anything in for these responses. It is difficult to
determine if this is due to test fatigue or if the client was unable to identify a person that
comes to them for support. Those that did respond reported reciprocal relationships as
coming from camp contacts 50% of the time.
Youth with physical disabilities are noted as a high risk population and may benefit
greatly from support programs that can consistently increase the number of quality
support contacts within their social networks while adding much needed reciprocal
relationships (Pinquart & Teubert, 2011; Vaquera & Kao, 2008). Adjusting the medical
camp program to consistently create an environment that fosters meaningful friendships
for participants may have tremendous positive therapeutic and quality of life outcomes.
However, there is little evidence that camps are targeting this as an outcome within
residential camp designs while it is also uncommon for programs to offer follow-on
programs to support relationships established at camp. As a result, camp may initially
be excellent at improving the social networks of campers yet provide few if any ways
to access the newly created social network connections. In the case of the camp under
investigation, campers come from over 40 different counties and several different states.
With 90 campers total spread across this large geographic area, it may be too great of a
barrier to stay in touch the other 50 weeks of the year without some intervention that
addresses this issue specifically. Put more simply, camp may accelerate relationships
during the residential experience regardless of years attending, yet provide little if any
methods to access these newly formed social network relationships upon return to
home communities.
The number of years spent at camp does not appear to impact the types of reciprocal
relationships or frequencies reported in this camp. This is a somewhat surprising
finding that may be explained in that once entering into camp with other youth that
share similar diagnoses, connections may be established quickly. Perhaps this is best
explained as a social inoculation experience. However, it also points to the need for
follow-on booster programs that continue to offer access to the support network upon
return to home communities. This finding highlights the frustrations with a lack of
similar resources in home settings compared to camp as detected by Knapp et al. (2015)
when interviewing campers six months after camp ends. One reason for this may be
that the reported important matters camp alters and reciprocal camp relationships are
not readily accessible outside of the initial residential camp setting. Many of the youth
in this study return to rural home settings across the state and are, at times, located
hours from one another. Long-distance relationships are then the norm with very
little if any in-person social contact until camp comes around one year later. For those
campers aging out, it may be the actual end to any physical contact with the established
social network connection made initially at camp.

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Study results also indicated that adolescents report non-relative peer contacts
within their important matters networks more frequently than children. This appears
to be developmentally appropriate (Arnon, Shamai, & Ilatov, 2008) yet a significant
finding for pediatric populations experiencing physical disabilities. It may be important
then to target adolescent clients with disabilities to offer non-relative approaches to
connection and support during this stage of life specifically. Developing an adolescent
specific follow-on program post camp may be an advantageous strategy in capitalizing
on these established camp networks as well as the natural desire to connect to non-
relatives.
Implications for Future Practice
Follow-on booster strategies should be developed that extend access to the social
networks and reciprocal friendships that are potentially established rapidly at camp.
For example, camp directors may consider the creation of a year-long camp mentoring
program that connects successful adults with physical disabilities to adolescent campers.
The mentor and camper could meet during the residential component of camp and stay
connected after camp ends. A mentorship program may be best developed through
the recruitment of graduating campers that display leadership and mentoring ability
as youth. Providing guided and supervised monthly online support groups within
established cabin cohorts along with inviting adult mentors to attend online programs
could provide structure to this booster approach. Camp directors and health care
providers may also consider providing specific programming opportunities at camp
that enhance social networks and reciprocal friendship development. Recreational
therapists should consider assessing the social domain and establishing care plan goals
to address friendship development, reciprocal relationships, and providing support to
one another. Programming ideas may include prescriptive activities that highlight the
benefits of social connections when experiencing health conditions, opportunities to
share about disability experiences, and initiatives that build teamwork and trust. Leisure
and recreation opportunities to informally share and autonomously connect with
others in a self-determined fashion should also be protected in camp programming.
Leisure settings are known to be a formidable vehicle for socialization, acceptance, and
promoting group belonging (Arnon et al., 2008; Csikszentmihalyi, 1981; Kyle & Chick,
2002). Camp may also be an opportunity to establish family to family connections
as well as friendship connections that last throughout the year. Camp directors may
consider identifying key camper relationships established at camp, providing contact
information to parents for those social connections, and encouraging families to
connect after camp to foster relationship growth in home communities. Lastly, targeted
parent education centered on the value of maintaining camp peer relationships outside
of the camp setting should be considered as parents may not fully understand the value
and need for these socially supportive relationships.
Limitations
A role-relation approach to name generators has been noted to be susceptible to
reliability and validity issues due to the interpretation of roles across populations and
should be noted here as a possibility (Marin & Hampton, 2007). Limiting the response
of alters to a maximum of four may have also limited understanding the full important
matters networks of these campers (Hlebec & Kogovšek, 2013). A range difference from
2-13 alters has been noted in the literature (Brashears, 2011; Marin & Hampton, 2007)

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as the average size of social networks. Future studies should consider using the Health
and Social Network Battery (Perry & Pescosolido, 2010) as it appears to be feasible
for use with this population. Both memory recall and acquiescing have been noted as
potential and common contributors to name generator bias (Pustejovsky & Spillane,
2009) and could have taken place given the presence of camp peers and staff. Lastly, the
reciprocal relationship question yielded only a 42% response rate with many campers
not identifying anything for this question. This should be addressed in the future
by specifically asking to what degree the identified alter goes to them for important
matters (e.g., often, occasionally, or hardly ever). There may be inherent bias in the
manner in which the reciprocal relationship question was framed. Caution should be
used in drawing statistical conclusions from this finding until further analysis can be
conducted.

Conclusions
Medically specific camps may enhance social networks for youth with physical
disabilities during residential experiences. This includes the potential to accelerate
friendships and support connections that may tend to be otherwise dominated by
relatives. Medical camps may also act as a social inoculation experience as first-year
campers tend to report similar network benefits from camp compared to those attending
multiple years. Social network analysis may be a potentially beneficial approach to
identifying reasons why the current medical camp model tends to consistently produce
extinguishing psychosocial effects in the months after the residential experience that
routinely produces positive psychosocial gains (Dawson, 2017; Plante et al., 2001).
To date, research is limited as to what specifically is needed in order to improve the
medical camp programming model. Future work should begin to test follow-on
booster programs that enable supportive relationships established at camp (during
the social inoculation experience) to continue to benefit clients once they return to
geographically separated home communities (continuous support within established
camp relationships). Until this is accomplished, the current widely utilized medical
camp model will continue to receive both praise and criticism for significant but short-
lived psychosocial outcomes. Social network analysis may be an ideal approach moving
forward to further investigate and improve the medical camp model.

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