Can I Play?

A Concept Analysis of Participation in

Children with Disabilities
Lindsey Hoogsteen
Roberta L. Woodgate

ABSTRACT. Participation is essential to children’s development. Children with dis-

abilities are at risk for restricted participation. Despite wide use of the word partici-
pation, the definition remains vague. The eight steps of analysis by Walker and Avant
(2005) were used to guide the concept analysis. The uses and defining attributes of
participation were identified and cases formulated within the context of children with
disabilities and health care professions. In order to participate, a child with disabilities
must take part in something or with someone, they must have a sense of inclusion,
control over what they are taking part in, and be working toward obtaining a goal
or enhanced quality of life. Through participation children acquire new skills, have
increased physical, emotional and social well-being and enhanced quality of life. It is
hoped that health care professionals can use this definition to address the shortcomings
of existing programs and develop measures to assess the attributes of participation.

KEYWORDS. Concept analysis, children, disability, participation, quality of life

Participation in everyday life is recognized as critical to achieving competence,

establishing meaningful relationships, and attaining life satisfaction (Rosenbaum
et al., 2005). Despite the importance of participation for people with disabilities and
the term being researched over the past decade, the concept of participation is not fully
understood within the health care sector. Although there are some measurement tools
currently used, critics argue that without a clear and well-defined definition of successful
participation in children with disabilities, one cannot accurately measure participation
(Coster & Khetani, 2008; Forsyth & Jarvis, 2002; McConachie et al., 2006).

Lindsey Hoogsteen, RN, is a graduate student, and Roberta L. Woodgate, RN, PhD, is Professor,
Faculty of Nursing, University of Manitoba, Winnipeg, Manitoba, Canada.
Address correspondence to: Lindsey Hoogsteen, RN, Faculty of Nursing, University of Manitoba,
Winnipeg, Manitoba R3T 2N2, Canada (E-mail: umhoogsl@cc.umanitoba.ca).
Lindsey Hoogsteen was supported by the Foundation for Registered Nurses of Manitoba Inc.
Graduate Scholarship. Dr. Woodgate was supported by a Dorothy J. Lamont Scientist Award. The
Dorothy J. Lamont Scientist Award is funded by the National Cancer Institute of Canada and Canadian
Institute of Health Research’s Institute of Cancer Research.
Physical & Occupational Therapy in Pediatrics, Vol. 30(4), 2010
Available online at http://informahealthcare.com/potp

C 2010 by Informa Healthcare USA, Inc. All rights reserved.
doi: 10.3109/01942638.2010.481661 325
326 PHYSICAL & OCCUPATIONAL THERAPY IN PEDIATRICS

In 1980, the World Health Organization (WHO) introduced the International Classi-
fication of Impairments, Disabilities and Handicaps (ICIDH), a conceptual framework
for disability that consisted of three dimensions: impairment, disability and handicap.
After receiving criticism regarding the term “handicap,” the ICIDH-2 was published
in 1999. The word diseases was replaced with “health conditions” and the three di-
mensions, went from the negative terms of impairment, disability, and handicap, to
the more neutral terms of impairment, activity, and participation (Üstün, 1999). In
2001, WHO made yet another major revision to the ICIDH-2. The International Clas-
sification of Functioning, Disability and Health (ICF) became the newest and current
framework. The domains are now classified as “body functions and structures” and
“activities and participation” (ICF, 2001). The latest addition to the ICF is the ICF
for Children and Youth (ICF-CY). Published in 2004, the ICF-CY is designed to be
specific to the unique and growing characteristics of children (Simeonsson et al., 2006).
Although the ICF and ICF-CY address many shortcomings of the previous frame-
works, there is still much debate over the concept of participation with respect to
its definition and critical attributes (Coster & Khetani, 2008; Dahl, 2002; Forsyth &
Jarvis, 2002; McConachie, Colver, Forsyth, Jarvis, & Parkinson, 2006; Ueda & Okawa,
2003).
Although there is debate as to what constitutes participation, it is nonetheless viewed
as essential to quality of life for children, including those with disabilities. Disabil-
ity has the ability to impact children’s participation. Children with disabilities are
more restricted with the type and amount of participation (Brown & Gordon, 1987).
They spend more time in informal activities such as reading and quiet recreation and
less time in formal activities and active recreation (Brown & Gordon, 1987; Harding
et al., 2009; Imms, Reilly, Carlin, & Dodd, 2008; Law et al., 2006). Environmental,
family and child characteristics have been identified as factors affecting the participa-
tion of these children (Chan, Lau, Fong, Poon, & Lam, 2005; King et al., 2003; Law,
Petrenchik, King, & Hurley, 2007). In addition, several ecological models such as the
person–environment–occupation–performance model (Law et al., 1996), the model of
human occupation (Kielhofner, 2002), and the person–environment–occupation model
(Baum & Christiansen, 2005) have been developed to emphasize the complex inter-
action between person, occupation, and environment. Participation is imperative to
children with disabilities, and health care professions play a vital role in increasing
participation. By defining the nature of participation, health care professionals are able
to conceptualize and measure this concept.
Concept analysis is a formal, rigorous process that identifies, explores, clarifies,
validates, and defines a concept. Concept analysis is used to clarify overused terms
with ambiguous meanings within the health care professions. Authors such as Rodgers
(1989), Morse (1995), Chin and Kramer (1991), and Meleis (1997) have developed
approaches for defining a concept. The method described by Walker and Avant (2005)
is commonly used because of its clear and systematic steps (Weaver & Mitcham, 2008).
Walker and Avant (2005) identified eight steps that are used to guide the examination
of the function and structure of a concept (Table 1). Although some critiques refute
Walker and Avant’s choice of steps because of the lack of rigor and in-depth processing
(Hupcey, Morse, Lenz, & Tasón, 1996; Morse, Hupcey, Mitcham, & Lenz, 1996), many
authors have successfully used this process in clarifying concepts such as quality of life
(Mandzuk & McMillian, 2005), teamwork (Xyrichis & Ream, 2007), and interactive
teaching (Ridley, 2007). In addition, to achieve full intellectual rigor and an in-depth
understanding of the underlying key attributes to the concept, many of the steps outlined
 Hoogsteen and Woodgate 327

TABLE 1. The Eight Steps of Concept Analysis by Walker and Avant (2005)

1. Select a concept
2. Determine the aim of the analysis
3. Identify all uses of the concept
4. Determine the defining attributes
5. Identify a model case
6. Identify borderline, related, contrary, invented, and illegitimate cases
7. Identify antecedents and consequences
8. Define empirical referents

by Walker and Avant occur simultaneously, encouraging internal dialog and reanalysis
throughout the entire procedure.
Although participation has been researched in health care settings over the past two
decades, there still remains an array of interpretations. The aim of this concept analysis
is to identify and explore the attributes of the concept participation and provide a
definition that will contribute to understanding its use within the context of children
with disabilities and health care. In accordance with the process of Walker and Avant
(2005), the first two steps, select a concept and determine the aim of the analysis
(Table 1), are the foundation for the concept analysis. We believe that a comprehensive
definition has implications for health care providers and inclusion of children with
disabilities in community programs that they enjoy and enhance quality of life.

METHOD

Identify All Uses of the Concept Participation

According to Walker and Avant (2005), all uses of the concept should be thoroughly
identified and should not be limited to those within the health care setting as this could
bias the understanding of the concept. A researcher is to employ all available literature
including dictionaries, thesauruses, and literature databases. Both explicit and implicit
uses should be considered and an extensive reading at this stage is warranted. Failing
to include a definition or use may severely impede the intellectual rigor that is required
for the concept analysis. Consequently, various bibliographic databases were searched.
Child Development and Adolescent Studies, ProQuest, CINAHL, Urban Studies and
Planning, Academic Search Elite, The Cochrane Library, Medline, and lay literature
were selected and explored for paper relevant to the concept of participation. Search
terms such as “participation,” “disability,” and “children” were used. No time frame was
specified, but most papers found were from the past two decades dating from 1983 to
2008 and limited to the English language. Additionally, definitions published in English
dictionaries and thesauruses were sought and included. The resulting literature was
originally reviewed by title and abstract and if relevant, the material was retrieved and
a full in-depth review was taken.
The literature search revealed a considerable amount of data from a variety of disci-
plines including finance, media, social, political, and health care incorporating nursing,
occupational and physical therapy. Although consideration of all uses and definitions
by as many fields and disciplines are recommended by Walker and Avant (2005), this
328 PHYSICAL & OCCUPATIONAL THERAPY IN PEDIATRICS

process may become impractical and unreasonable. Definitions that are outside of the
health care profession, therefore, will be discussed in a limited manner.
According to Webster’s Third International Dictionary of the English Language
(2002), participation is the action or state of participating. This is further defined by the
association with others in a relationship, taking part in with others in an activity, and
social interaction within a group. Roget’s International Thesaurus (1977) gives a vari-
ety of synonyms including partaking, sharing, contribution, association, involvement,
engagement, and partnership.
Participation has been used in different contexts. In advertising, participation is a
television program sponsorship, in which advertisements are played throughout a show
in the form of commercials (Motto, 2002), while in the financial realm, The World
Bank Group, a source of financial and technical assistance to developing countries
around the world defines participation as control over developmental program initia-
tives, decisions, and resources (The World Bank, 2008). This is similar to Cardno Acil’s
definition of participation, which is the empowerment of people to mobilize their own
capacities, manage their own resources, make decisions, and control their own lives
(Cardno Investments, 2007). Additionally, in the book Participation and Social As-
sessment (Rietbergen-McCracken, Narayan-Parker, & Narayan, 1998) participation is
acknowledged as information sharing and consulting to collaboration and empowerment
that give stakeholders further influence and control. Financial institutions give meaning
to participation as a large loan in which two or more lenders share in providing loan
funds to a borrower to bypass a legal lending limit (Farm Credit Administration, 2008).
Active participation in regard to pension plans is “whether a participant is ‘benefiting’
under a plan in a given year” (Turner, Muller, & Verma, 2003, p. 36).
In the political realm, Castro, Camacho, Balanon, Ong, and Yacat (2007) and Evans
and Spicer (2008) view participation as a meaningful involvement of children throughout
decision-making processes. Civic participation is defined by Cahill and Hart (2007) as
an engagement of young people working together with adults to evaluate and make
proposals to change. Participation is also mentioned in the Convention of the Rights
of the Child (1990). Article 23 states that all disabled children have a right to full
and active participation within the community and Article 29 recognizes the child’s
right to participate in all play and recreational activities appropriate to the child’s age
(Convention on the Rights of the Child, 1990). Hart (1992) argues that participation
begins the moment that a child realizes that they can influence the world. This is
echoed in Children as Citizens (Holden & Clough, 1998), in which children are seen
as “active participants in making sense, constructing meaning, and in the creation
of their self-identity” (p. 33). Hart further defines participation as “the process of
sharing decisions which affect one’s life in the community in which one lives” (Hart,
1992, p. 5). This is similar to the definition proposed by Richardson (1983) in which she
states that participation is the idea of sharing activities with others. Hart summarizes that
participation is a complex issue that varies with age and individual family and cultural
factors.
In a social context, participation has been defined as a “social and political process
that has a bearing on all relationships between people and institutions in society”
(Vedeld, 2001, p. 8). Project managers may refer to participation as any and all types
of consultation between stakeholders (Vedeld, 2001). Participation has been referred to
as an end to itself, a process, or a means of obtaining a goal (Brownlea, 1987; Charles
& DeMaio, 1993; Vedeld, 2001). Participation is “supposed to make a difference”
(Brownlea, 1987). Community participation is an individual’s engagement in activities
 Hoogsteen and Woodgate 329

within the community (Leyin, 2008) and according to Muller, Lyer, Keita, Sacko, and
Traore (2002), it is “a way of strengthening the capacities of neighborhood residents
and their social organizations by providing opportunities for informed decision making
and carrying out civic responsibilities” (p. 242).
Within the context of health care, the ICF defines participation as an individual’s
involvement in life situations. Perenboom and Chorus (2003) echo this definition but
supplement that participation also includes “being autonomous to some extent or being
able to control your own life, even if one is not actually doing things themselves”
(p. 578). King et al. (2003) define participation “as involvement in the formal and
informal everyday activities of childhood in all types of non-school environments,
including learning environments for play, sport, entertainment, learning, and religious
expression” (p. 65). Heah, Case, McGuire, and Law (2007) performed a qualitative
study and found that children with disabilities view participation as a means of having
fun, feeling successful, doing things by themselves, and doing and being with others.
According to Simeonsson et al. (2001), the “interaction of the person with dimensions
of the environment defines the nature and extent of participation” (p. 49). The disability
creation process (DCP) defines participation as a result of the interactions between
individual characteristics and capabilities and the various environmental factors that can
act as a facilitator or an obstacle (DCP, 2006). Participation is the goal of occupational
therapy. Law, Dunn, and Baum (2005) view it as “taking part in the occupations of
everyday life” (p. 107) and central to participation is the involvement or sharing in an
activity (Law, 2002). According to Brooke (2008), participation is a right for all.
When determining what exactly participation means, it is beneficial to consider
what participation is not. Participation is not the same as activities, and the lack of
clarity between the two concepts poses a challenge for measurement (Jette, Haley, &
Kooyoomijian, 2003). Participation is also not the environment around the person, nor
is it a person’s quality of life (Forsyth & Jarvis, 2002; McConachie et al., 2006). Some
researchers state that participation is the opposite of social exclusion (Evans & Spicer,
2008); however, although social inclusion may aid in participation it is not the definition
of participation (Leyin, 2008; Simeonsson et al., 2001).

Determine the Defining Attributes of Participation

Defining the attributes is what Walker and Avant (2005) consider as the “heart of
concept analysis” (p. 68). It is here that the attributes are identified that are most
frequently occurring and associated with the concept. It is important to remember that
attributes are not set in stone and may change throughout time as the understanding
of a concept evolves. Although multiple meanings of the concept of participation were
identified, only those relevant to this analysis will be utilized in defining the attributes.
The defining attributes of the concept of participation within the context of disabled
children are the following:

1. The child must take part in something or with someone. This was the most distinctive
attribute that emerged from the literature search. From the Webster’s Dictionary
definition to the ICF framework to the social context and the political scene, being
involved was fundamental to participation (Badham, 2004; Brownlea, 1987; Castro
et al., 2007; Coster & Khetani, 2008; Garth, Murphy, & Reddihough, 2009; Heah
et al., 2007; ICF, 2001).
330 PHYSICAL & OCCUPATIONAL THERAPY IN PEDIATRICS

2. The child must feel included or have a sense of inclusion in what they are partaking
in (Badham, 2004; Evans & Spicer, 2008; Garth et al., 2009; Heah et al., 2007). Ueda
and Okawa (2003) stress the importance of a subjective experience of participation
and the sense of acceptance. While participating, children must feel like they are
engaged by either doing or being.
3. The child must have a choice or control over what they are taking part in. Children
must want to be involved with the activity and hold a degree of autonomy. They
should have a feeling of choice, be given a sense of control, and take part in what
matters to them (Cardol, de Jong, & Ward, 2002; Coster & Khetani, 2008; Harding
et al., 2009; Heah et al., 2007; Law, 2002).
4. The child must work toward obtaining a personal or socially-meaningful goal or
enhancing quality of life (Coster & Khetani, 2008; Law, 2002; Perenboom & Chorus,
2003). Children must participate in something that is meaningful to them either
personally or socially. Through participation children are able to develop skills,
maintain or improve physical health, and achieve enjoyment, emotional and social
well-being (Brown & Gordon, 1987; King et al., 2003; Law, 2002; Murphy et al.,
2008; Steptoe & Butler, 1996).

Identify a Model Case

In order to truly understand the meaning of the concept, Walker and Avant (2005)
recommend developing a model case that demonstrates all defining attributes of the
term. The case provides a “real-life” example of the concept, synthesizing all of the
critical attributes. This model case has been developed to provide evidence of the four
defining attributes of the concept of participation.
After verbally expressing a keen interest in swimming, Carol, the mother of Devon,
a child with cerebral palsy, registers himself for weekly swimming lessons. Every week
Devon is thrilled to be able to get into the pool to laugh, splash, and play with the
other children of his class. Over time, Carol notices that Devon’s spastic movements
have declined and he seems to have more muscle strength in all limbs. The activity of
swimming lessons fulfills the first attribute about being involved in something. The idea
that Devon asked to take part in the swimming lessons and the laughs, smiles, and good
times he has while swimming enables the reader to believe that the child wants to be
involved and that he feels that he is actively engaging. The social aspects of making new
friends and increasing physical fitness are Devon’s ways of obtaining a goal through
participating.

Identify Additional Cases

Additional cases are developed to further understand the concept and to determine
what attributes “counts” from those that do not. By examining cases that are similar or
contrary to the concept of interest, one will be able to make a more concrete case for
determining the defining characteristics (Walker & Avant, 2005).

The Borderline Case

According to Walker and Avant (2005) a borderline case contains most of the defining
attributes but not all of them.
 Hoogsteen and Woodgate 331

Kevin, an 11-year-old boy, had a spinal cord injury three years ago that left him a
paraplegic. After months of therapy, Kevin now gets around well in his wheelchair
but still has difficulty with getting out of the house. After several attempts to get
Kevin motivated to be out with his friends, Kevin’s mother registers him for sledge
hockey. Although Kevin repeatedly tells his mother that he does not want to go, he
attends his first sledge hockey game. Kevin gives it a few weeks but yet still does
not enjoy himself. Although his mom notices an increase in upper body strength
and that Kevin is learning the rules of the game, Kevin is not fully participating.
Kevin fails to meet the third attribute of wanting to be involved and having a choice
over his participation.
The Related Case

Related cases are very similar to the main case but when examined more closely they
are actually different. Walker and Avant (2005) find that related cases help one clarify
what attributes count and what do not, as they are connected to the main concept but are
different.
Alexis, a 14-year-old who uses wheeled mobility, decided to join the Student
Council. She had heard that the school was thinking about installing an elevator
which would enable her to get to the upper levels of her school. Knowing that
she could make good use of the elevator, Alexis thought it would be nice to voice
her opinion in promoting the school’s acceptance. Once at the meeting, no one
asked for her opinion nor was she asked to speak. A week later the installation for
the elevator was approved. Alexis engaged in an activity by joining the Student
Counsel. Although she was happy about the approval of the elevator and achieving
her goal, Alexis did not participate because she was never given the opportunity
to speak, nor did she feel included.
The Contrary Case

Defined by Walker and Avant (2005), contrary cases are clear examples of what the
concept is not.
While playing in a soccer game with his brother, Christopher, a child diagnosed
with autism, is found standing on the sidelines uninterested and playing with the
dandelions. This example clearly shows that Christopher is not engaged in any of
the defining attributes of participation.
The Invented Case
Invented cases are “cases that contain ideas outside our own experiences” (Walker &
Avant, 2005, p. 72). It helps define the attributes by taking the concept out of its normal
context and putting it into an invented or science fiction one.
Barkley, golden retriever puppy runs to the door and grabs his leash when wanting
to go for a run. By doing this, he knows that his owner will take him outside for a
run. Barkley runs and jumps around all excitedly while outside. As the weeks go
he notices that he can run faster and longer; Barkley is participating by fulfilling
all attributes. Barkley takes part in daily runs, feels included by his owner, has
control by grabbing his leash, and in the end, is faster and stronger.
332 PHYSICAL & OCCUPATIONAL THERAPY IN PEDIATRICS

TABLE 2. Key Findings of Concept Analysis of Participation

Antecedents Attributes Consequences

The child needs to have an
interest in something and a
willingness to take part.
The child must take part in
something or with someone.
The child must feel included or
have a sense of inclusion.
The child must have a choice or
control over what they are
taking part in.
The child must work toward
obtaining a personal or socially
meaningful goal or enhancing
quality of life.
By participating a child with
disabilities:
Acquires new skills and
competencies
Finds meaning in life
Has an increased physical,
emotional, and social
well-being
Increases the development of
social relationships
Develops and refines skills
Promotes independence
A way of making new friends
Learns transferable skills
Formulates goals and values.

Identify Antecedents and Consequences

The penultimate step in the concept analysis is to identify the antecedent and con-
sequences. According to Walker and Avant (2005), antecedents are events or incidents
that must occur before the occurrence of the concept, while consequences are de-
fined as events or incidents that transpire as a result of the occurrence of the concept
(Table 2). The antecedents required are that the child needs to have an interest in
something and a willingness to take part.
Consequences are often seen as a result of participating. Through participation chil-
dren “acquire skills and competencies, connect with others and communities, and find
purpose and meaning in life” (Law, 2002, p. 640). For example, children with disabilities
who participated in sports and physical activity programs had increased physical, emo-
tional, and social well-being (Kirkcaldy, Shephard, & Seifen, 2002; Murphy, Carbone,
& the Council on Children with Disabilities, 2008; Steptoe & Butler, 1996). Addition-
ally, participation in sports increases cardiac and respiratory functions and enhances
muscle tone (Reynolds, 2006). Participation in everyday activities and extracurricular
activities is important for the development of a child’s social relationships and learning
skills (Reynolds, 2006; Simeonsson, Carlson, Huntington, McMillen, & Brent, 2001).
Participation is a way of making new friends, learning transferable skills, and maxi-
mizing educational outcomes (Evans & Spicer, 2008). At school, full integration and
participation of children with disabilities promotes independence and aids in the de-
velopment of social relationships (Simeonsson et al., 2001). Children nourish skills of
citizenship and formulate goals and values by participating (Brown & Gordon, 1987).
 Hoogsteen and Woodgate 333

Define Empirical Referents

Empirical referents are used to determine the existence of a concept (Walker &
Avant, 2005). Since the term handicap was introduced in the ICIDH in the 1980s,
several instruments have been developed to measure the now widely accepted but ill-
defined concept of participation in children (Table 3). Unfortunately, measures based on
the ICF have received criticism because of the lack of distinction between the activity
and participation domains (Coster & Khetani, 2008; Jette et al., 2003). Furthermore,
there has been criticism against determining what the normative criteria are in order
to evaluate participation in children with disabilities (Cardol, de Jong, & Ward, 2002).
In addition, some measures do not include the subjective experience, such as a child’s
satisfaction, choice, meaning, or importance when determining participation (Bedell &
Coster, 2008). Finally, criticism of existing measures has been related to the method of
administration and whether it should be by an external evaluator, proxy (parent) report,
or through the child (Coster & Khetani, 2008; Morris, 2007).
Although the ICF has been a valuable framework to the development of measures, the
challenge now is to continue to differentiate between activities and participation, deter-
mine appropriate normative standards, find ways to include the subjective experience,
and decide the appropriate method of administration. Accomplishment of these tasks
provides evidence of validity that the concept is being measured (Coster & Khetani,
2008; McConachie et al., 2006).

DISCUSSION

Although a variety of sources were used to define participation in the context of

children with disabilities, there is the possibility that not all sources were found. The
defining attributes were based on the information collected and therefore could be
different if other sources were found. Additionally, only papers in English were selected.
Recognizing that Paley (1996) strongly advocates the need for theoretical commit-
ment to achieve conceptual clarification, the concept’s relevance will be discussed within
an existing theory, the life needs model of pediatric service delivery (King et al., 2002).
The authors formulated the life needs model as a conceptual framework for identifying
services needed to support community participation and quality of life for children with
disabilities. The life needs model is a holistic need-based framework that describes
the major types of service delivery needs of children and youth with disabilities, their
families, and their communities to meet the long-term goals of community participation
and quality of life. This focuses on the strengths of children and families, the idea of
real-world function and participation through specific transition points, with the purpose
of creating nurturing environments to maximize community participation. Services are
provided by multiple systems that make it transdisciplinary. The model provides a list
of short-term goals and clearly identifies the ultimate long-term goals of community
participation and quality of life.
This model incorporates what is known about children with disabilities, includes
processes for determining needs, and identifies roles the family and community can play
in order to enhance the child’s participation and quality of life. Health care professionals
in both community and hospital settings play a pivotal role by becoming aware of the
unique needs of children with disabilities and their families. The attributes defined by the
concept analysis are similar to the short-term goals described by the life needs model.
 TABLE 3. Measures of Participation for Children with Disabilities
334
Measure
Assessment of Life Habits (LIFE-H) for Children
Children’s Assessment of Participation and Enjoyment
(CAPE) and Preferences for Activities of Children
Pediatric Evaluation of Disability Inventory (PEDI)
School Function Assessment (SFA)
Child and Adolescent Scale of Participation (CASP)
Activities Scale for Kids (ASK)
Description Framework Examples of Studies
Originally developed to assess the quality of social participation DCP Lepage, Noreau, and Bernard (1998), Lepage, Noreau,
and satisfaction among disabled adults Bernard, and Fougeyrollas (1998), and Noreau et al.
(2007).
Children’s version is a modified adult version for children ages
5–13 years
Short (64 items) and long (197 items) form available
(McConachie et al. 2006)
Describes how children with or without disabilities participate ICF Imms, Reilly, Carlin, and Dodd (2008), King et al.
in everyday activities outside of mandated school activities (2006), Law et al. (2004, 2006).
Children ages 6–21years (King et al., 2004)
Standardized pediatric functional assessment commonly used in Nagi Disablement Dumas, Haley, Fragala, and Steva (2001), Dumas, Haley,
hospital settings, evaluates functional change Scheme and Rabin (2001), and Kothari, Haley, Gill-Body, and
Dumas (2003).
Six months to 7.5 years (and older children who have
disabilities)
Three constructs (functional skills scale, caregiver assistance
and modifications)
Highly used in children with brain injuries (Kothari, Haley,
Gill-Body, & Dumas, 2003)
Designed to assess participation and functional activity Unknown Davies, Soon, Young, and Clausen-Yamaki (2004) and
performance in elementary school Gates, Otsuka, Sanders, and McGee-Brown (2008).
Three sections with six different settings to measure
participation
Brief instrument
Developed to assess participation relevant to home, school, and ICF Bedell (2004).
community life with children and young people with or
without acquired brain injuries
Brief instrument
Ages three years and up (McConachie et al. 2006)
Measures the frequency of participation of children with Unknown Morris, Kurinczuk, Fitspatrick, and Rosenbaum (2006),
disabilities Wai, Owen, Fehlings, Darcy, and Wright (2000), and
Young, Williams, Yoshida, and Wright (2000).
Child perspective
Children ages 5–15 years
Two versions: ASKc (what the child could do) and ASKp (what
the child does) (McConachie et al. 2006)
 Hoogsteen and Woodgate 335

Through the accomplishment of these goals and the defining attributes, children with
disabilities are given the opportunity to participate and therefore enhance their quality
of life.
The concept analysis of participation in combination with the life needs model can
serve as a useful framework for health care professionals including nurses, physical
therapists, and occupational therapists in the development of strategies that enable
children with disabilities to participate in daily life. Health care professionals can
facilitate in the development and implementation of programs that fulfill the identified
needs. The results of this concept analysis of participation in the context of children
with disabilities are applicable to the life needs model of King et al. (2002). Further
research documenting the participation and quality of life in children with disabilities
is required and will only strengthen the definition and known attributes of participation.

CONCLUSION

Although the concept of participation has been used widely in the literature, defining
participation takes more consideration and analysis. While participation is defined as an
individual’s involvement in life situations by the ICF, the definition is vague with many
unanswered questions. Through the concept analysis, we concluded that in order to
participate, children with disabilities must be involved in something or with someone,
they must feel a sense of inclusion, they must have a choice or control over what
they are taking part in, and they must be working toward a goal or enhancing their
quality of life. The consequences of participation identified are extremely meaningful to
children with disabilities. Occupational therapists, physical therapists, and other health
care professionals need to be aware of what could be lacking in the lives of children if
they are unable to participate.
The definition of participation that emerged from concept analysis provides a common
language for consumers and health care providers. The definition may prove useful for
appraisal of the content of existing measures and development of measures that assess
the multiple dimensions of participation. The content analysis also may guide health
care professionals in identifying gaps in existing service areas and determine priorities
in the development of services. Additionally, service providers may be able to identify
specific strategies to promote participation among children with disabilities, including
areas of access, adaptation of programs and facilities, and transportation which may be
lacking in existing program.

Declaration of interest: The authors report no conflict of interest. The authors alone
are responsible for the content and writing of this paper.

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