Relationships that children form early in life help contribute to their quality of life and provide them with opportunities for social, emotional, and intellectual growth as well as companionship.1 Children with disabilities often do not have opportunities to participate in age-appropriate activities alongside their peers without disabilities. As a result, they tend to be more isolated from their peers and lack social skills, thereby making it difficult for them to form personal relationships and friendships.2
Solish et al1 compared activity participation and friendship in children without disabilities, children with autism spectrum disorders, and children with intellectual disabilities through parent questionnaires about their child's participation in social, recreational, and leisure activities. Results indicated that children without disabilities participated in significantly more social and recreational activities and also had more friends than both groups of children with disabilities. Children with intellectual disabilities have also been found to engage in fewer leisure activities than their peers without disabilities. These children report that they do not try to find alternative activities or initiate finding friends during leisure time to combat loneliness.3
Inclusive programs integrate children with disabilities and children without disabilities into the same leisure, community, and school activities.4 These programs promote the development of friendships and relationships through social interaction and play. Benefits of inclusive programs include improvements in social skills, play skills, social acceptance, behavior, cognition, and independence for children with and without disabilities.4,5 Children without disabilities do not appear to be negatively affected by participation in inclusive programming, and in fact may improve in areas such as language skills.6
Downing and Peckham-Hardin7 examined the benefits of inclusion in children with and without disabilities in a school setting and reported that children with severe disabilities were happier, more independent, and motivated when given the chance to interact with their peers without disabilities. The children without disabilities were more aware of differences, demonstrated improved compassion for others, and were more willing to help their peers. Similar results were found by Seymour et al8 and Gun Han and Chadsey,9 who investigated inclusive activities in physical education classes. These studies suggest that the development of friendships between children with and without disabilities are possible and may be promoted through inclusion. Furthermore, these studies suggest that children without disabilities are willing to make friends with peers with disabilities and also learned to become more accepting of children that are different than them.
Inclusive programs also provide opportunities for social acceptance for children with disabilities.10 Social acceptance is important in developing positive quality of life11 and self-perception12 in children with disabilities. Low peer acceptance in children without disabilities has been found to correlate with truancy, juvenile delinquency, suicide, decreased academic performance, loneliness, increased high school dropout rates, adult crimes, and decreased job performance.13 In comparison, high peer acceptance rates during childhood have been positively associated with friendly and spontaneous play, increased frequency of giving positive reinforcement,14 perceived social acceptance,15 positive self-perceptions,16 and increased friendship.17 Vogler et al18 found that inclusion of a child with severe cerebral palsy in physical education led to widespread social acceptance among peers. Interventions that foster exposure and interaction of children with and without disabilities have been successful in developing acceptance in children with disabilities and are the most important predictors of peer acceptance.19,20
Social acceptance, along with achievement and self-esteem, are important factors related to self-concept in children. Self-concept comprises various components, such as: intellectual/academic, body image, social acceptance, and behavioral conduct21,22; physical achievement, reading, writing, spelling, and mathematics21; and anxiety and happiness.22 Whereas it was previously reported that the self-concept of children with disabilities is generally lower than children without disabilities, especially when related to academics,23,24 more recent studies have shown that although children with disabilities may have a negative self-concept of their academic, social, and behavioral function, they generally have a global self-concept comparable with children without disabilities.25,26
Friendships, social acceptance, and ultimately self-concept all have a potential effect on quality of life in children. Understanding and appreciating children's point of view regarding their health-related quality of life (HRQOL) is of great value in generating and predicting future heath care needs.27 Health-related quality of life is also imperative in identifying the dimensions of a child's health most at risk or in need of support at an early stage. Because children with disabilities have fewer opportunities for participation in social and physical activities, they may exhibit lower scores in their HRQOL.28
Although the benefits of inclusive programming have been supported in the educational setting, the effect of inclusive after-school programs has not been explored. The purpose of this study was to examine the psychosocial effect of an inclusive community-based aquatics program on children with and without disabilities participating in the program. The psychosocial dimensions examined included HRQOL, self-concept, acceptance, and friendship.
Children of all abilities were recruited for participation in this study through letters sent to local schools and related service providers. Inclusion criteria were as follows: (1) able to ambulate independently (with or without an assistive device) and (2) willing to participate in aquatic activities. This sample of convenience included 26 children aged 4 to 18 years of age. Of the 26 children initially recruited, 10 had a disability and 16 did not. Twenty-three children completed all parts of the study. Table 1 describes the participant demographics.
Among the children with disabilities, primary diagnoses included spina bifida (n = 5), attention-deficit hyperactivity disorder (n = 2), cerebral palsy (n = 1), autism spectrum disorder (n = 1), and Noonan syndrome (n = 1). Secondary diagnoses included attention-deficit hyperactivity disorder (n = 1), autism spectrum disorder (n = 1), and epilepsy (n = 1). Seven of the children with disabilities ambulated independently without an assistive device, whereas 3 ambulated independently with Lofstrand crutches and molded ankle foot orthoses. All of the participants ambulated into the pool (via ramp) willfully without any apparent fear of the water.
The swimming abilities among participants varied. Four of the children with disabilities were able to swim independently without a flotation device, whereas 6 required a flotation device (4 with minimal physical assistance; 2 with no physical assistance). Ten of the children without disabilities were able to swim independently without a flotation device, whereas 3 required a flotation device and minimal physical assistance. All of the children who used a flotation device were able to participate in activities at the deep and shallow ends of the pool with or without physical assistance.
This study was approved by the Institutional Review Board at Lebanon Valley College. Before testing, parents provided consent for their children to participate in the study. This prospective quasi-experimental study was 8 weeks in length. Outcome measures were obtained during pretesting before the intervention was initiated and at the end of the 8-week intervention. The outcome measures included PedsQL version 4.0,29 Piers-Harris 2 Self-Concept Scale,30 and Peer Sociometric Nomination Assessment (Friendship Questionnaire).31 The measures were carried out with each child individually in a sequential order during pre- and posttesting by the same researcher. The PedsQL 4.0 and the Piers-Harris 2 Self-Concept Scale were read individually to participants by the researchers.
The PedsQL 4.0 was used to assess HRQOL. The PedsQL 4.0, a 23-item questionnaire used to measure HRQOL in children and adolescents who are healthy, and those with acute and chronic health conditions, has been found to be valid and reliable.32–34 The PedsQL 4.0 comprises several subscales, including: Physical Functioning (8 items), Emotional Functioning (5 items), Social Functioning (5 items), and School Functioning (5 items). The young child self-report was used, which includes a 3-item Likert scale (0 = not a problem, 2 = sometimes a problem, 4 = a lot of a problem). Items are transformed using a 0 to 100 scale (0 = 100, 2 = 50, 4 = 0), then totaled and divided by the total number of items. A higher score is indicative of a better HRQOL.32 The lowest possible score is zero, whereas the highest possible total score (indicating a higher HRQOL) is 100.
Piers-Harris 2 Children's Self-Concept Scale
The Piers-Harris 2 Children's Self-Concept Scale was used to assess self-concept. The Piers-Harris Children's Self-Concept Scale is a norm-referenced 60-item self-report questionnaire designed to assess self-concept in children between the ages of 7 and 18 years. This valid and reliable questionnaire provides a general measure of self-concept, based on the total score. The Piers-Harris 2 has the following subscales: Behavioral, Intellectual, Physical, Friendship, Popularity, and Happiness. Scoring of the Piers-Harris 2 first accounts for validity issues of exaggeration, response bias, and random responding. A higher score on this outcome measure is indicative of a more positive self-concept, in comparison with a lower score indicating a more negative self-concept. In each domain, T scores can be used to place individuals or groups into categories defined by the following ranges: above average (≥56), average (55 to 40), and low (≤39). For the total score, T score categories are defined by the following ranges: high (≥60), average (59 to 40), and low (≤39).30
This scale has been used to measure self-concept in children with emotional disturbance, mental retardation, and specific learning disabilities.35–37 It is recommended that administrators of the Piers-Harris 2 answer any questions that arise regarding individual test items.30
Peer Sociometric Nomination Assessment
The Peer Sociometric Nomination Assessment was used to assess peer acceptance. It has been used in the literature as a peer nomination of sociometric status,38,39 although reliability and validity have not been established. Studies to date using this tool include only children without physical and cognitive disabilities. The participants were asked to select 3 of their peers who were present at time of testing with whom they would most and least like to play.31 The participants all had a name card placed in front of them during testing and were assisted as needed by the researchers.
The participants attended the 1-hour aquatics program at Lebanon Valley College once a week for 8 weeks. The goal of the community-based intervention was to provide a fun, safe, nonthreatening environment where children with and without disabilities could participate together in a physical activity. The aquatic activities including a 5-minute warm-up, 20 minutes of aerobic exercises, 20 minutes of strengthening exercises, a 10-minute free swim, and a 5-minute cool down. The warm-up included forming a circle and walking in a clockwise and counterclockwise direction. The aerobic component of the session included games such as keep away, red light/green light, and age-based swims from one side of the pool to the other. The strengthening exercises included activities such as jumping jacks, arm circles, marching, punching, squatting, kicking beside the pool, and jumping. Free swim allowed the children an opportunity to interact with all children in the program. The cool down included activities similar to those in the warm-up.
Adaptations were required in some cases for participants who were unable to swim, and were accomplished using devices such as pool noodles, kick boards, and flotation belts. The aquatic intervention was designed and implemented by 2 pediatric physical therapists who were experienced in aquatic programming, along with 6 physical therapist students. In addition, physical therapist student volunteers participated providing an adult to child ratio of 1:2.
As the program was designed to give children with and without disabilities an opportunity to participate with their peers in a community-based setting, the researchers paired children of different abilities for some activities, such as strengthening. Pairs were not kept the same each week. The children were not paired for all activities, however, to provide an opportunity for children to choose with whom they interacted. This was most common during the free swim, although interaction was consistently promoted during all activities by the researchers.
Statistical analyses were performed using SPSS statistical software, version 17.0. Descriptive statistics were calculated for all variables. The demographic variables were compared between groups by use of t tests and χ2 tests. A 2-way analysis of variance (ANOVA), 2 × 2 (group × time), with repeated measures on the second factor time, was used to measure the effect of the inclusive aquatic fitness program for PedsQL 4.0 Total, Physical Functioning, Emotional Functioning, Social Functioning, and School Functioning scores and Piers-Harris 2 total, Behavioral, Intellectual, Physical, Friendship, Popularity, and Happiness, using the pretest scores as covariates to control for pretreatment differences. Independent t tests were performed to examine whether there were differences for PedsQL 4.0 (total and subscales) and Piers-Harris 2 (total and subscales) scores for the children with and without disabilities at pretest. Paired t tests were performed to examine whether PedsQL 4.0 (total and subscales) and Piers-Harris 2 (total and subscales) scores differed from pre- to posttest for the children with and without disabilities. Data from the Peer Sociometric Nomination Assessment (Friendship Questionnaire) were analyzed using response frequencies and corresponding percentages.
Among the 26 children who were recruited and met the inclusion criteria, 2 children without disabilities were unable to complete the study because of other after-school obligations, and 1 child with a disability was only able to complete the Friendship Questionnaire as a result of being too young to understand the questions. The mean age of the 23 children who completed all tests was 9.17 (SD = 4.04) years. The children with disabilities were significantly older than the children without disabilities (P = < .001), but there was not a significant difference in gender (P = 0.53). Means and standard deviations for all variables are presented in Table 2.
A significant pretest difference was found between groups for the School Functioning subsection of the PedsQL 4.0 (P = .029). There were no statistically significant differences between groups at posttest for the PedsQL 4.0 Total, Physical Functioning, Emotional Functioning, Social Functioning, and School Functioning scores. There was, however, a significant difference between children without disabilities from pre- to posttest on the School Functioning subsection of the PedsQL 4.0 (P = .001).
Piers-Harris 2 Children's Self-Concept Scale
No statistically significant differences were found between groups at pretest on the total score or any subsections of the Piers-Harris 2. There was a statistically significant difference between groups at posttest for the Piers-Harris 2 Intellectual subsection (f = 5.12, P = .03). The children with disabilities showed a statistically significant decrease on the Piers-Harris 2 Happiness subsection from pre- to posttest (P = .006). Although 6 of 23 participants were younger than 7 years, their responses were found to valid and therefore were used in the analysis.
Peer Sociometric Nomination Assessment
Examination of the mean percentages of the Peer Sociometric Nomination Assessment (typical = 13, atypical = 11) revealed that at pretest 55% of children with disabilities received a negative peer nomination whereas only 38% of the children without disabilities received a negative peer nomination (Figure 1). At pretest, 9% of children with disabilities received a positive peer nomination and 46% of children without disabilities received a positive peer nomination. At posttest, 45% of children with disabilities received a negative peer nomination, and 45% of children with disabilities received positive peer nominations. For the children with disabilities, this demonstrates an increase of 36% in positive nominations from pre- to posttest and a decrease of 10% in negative nominations from pre- to posttest. From pretest to posttest, the number of children with disabilities that wanted to play with the children without disabilities decreased from 66.7% to 33.3%.
Forming relationships early in life provides children with opportunities for social, emotional, and intellectual growth and it also contributes to their overall HRQOL.1 Children with disabilities have fewer opportunities to participate in activities after school, and have fewer opportunities to interact with their peers. Pediatric physical therapists have a unique role in the development and implementation of such activities for children with disabilities, given their expertise in health promotion. Our study examined changes in HRQOL, self-concept, friendship, and social acceptance in 23 children aged 4 to 18 years after participating in an 8-week inclusive aquatic fitness program that was developed and implemented by pediatric physical therapists and physical therapist students.
The PedsQL 4.0 was used to assess HRQOL in this study. The results demonstrated a significant difference between groups at pretesting for the School subsection of the PedsQL 4.0. Children with disabilities exhibited a higher score indicating that they had more difficulty with School Functioning compared with the children without disabilities. Many of the questions on the PedsQL 4.0 pertain to a child's ability to participate in school and how participation is disrupted by events such as doctor appointments and hospital stays. Children with disabilities are more likely to miss school because of illness, appointments, and visits to the hospital. As a result, when asked questions such as, “Do you miss school because of not feeling good?” and “Do you miss school because you have to go the doctor's or hospital?” children with disabilities are likely to score higher than their peers with fewer medical needs.
There was also a significant difference within the children without disabilities group from pretest to posttest for the PedsQL 4.0 School subsection. From pre- to posttest the scores for the children without disabilities increased indicating decreased ability to function in school. Although this perceived decrease in School Functioning may have been due to their interactions over the 8-week period with the children with disabilities, the finding was largely unexpected and unexplained.
Overall, the PedsQL 4.0 mean scores were consistently lower in both the children with and without disabilities groups than the means reported by Varni et al32 for children who were healthy and chronically ill (except for Emotional Functioning in the children with disabilities group and pretest School Functioning in the children without disabilities group). It is possible that the parents of the participants in this study enrolled their child because they had concerns about their quality of life and participation with peers in community-based settings. The improvements in mean scores for the children with disabilities group brought their scores closer to those described by Varni et al,32 and represented a minimal clinically significant difference for PedsQL Total Score (difference of >4.36), the PedsQL 4.0 Physical Functioning subsection (difference of >6.66), and the PedsQL 4.0 Social Functioning subsection (difference of >8.36).40
This study also examined self-concept using the Piers-Harris 2. A significant difference was found in the intellectual subsection between groups at posttest. Children without disabilities scored significantly higher in this subsection than the children with disabilities; however, both groups demonstrated global self-concept that was not significantly different. Gans et al25 and Smith and Nagle26 found similar results between children with and without disabilities in self-concept as measured by the Piers-Harris 2 and the Self-Perception Profile for Learning Disabled Students, respectively. Both studies revealed that children with disabilities perceive themselves lower on intellectual subscales of self-concept than children without disabilities; however, no difference was found between groups in global self-concept.
An unexpected finding was that children with disabilities scored significantly lower on the subsection of Happiness in the Piers-Harris 2 at posttest than pretest. This finding could be the result of self-reflection and becoming more aware of functional limitations and overall participation restrictions when compared with their peers without disabilities. It was our hope that the children with disabilities would improve in this domain at the completion of the study. This may be a potential negative implication of inclusive programming, and should be explored further in future studies.
Although statistically significant differences were observed on 2 subsections of the Piers-Harris 2, it is unclear whether these changes were clinically significant, given that the majority of scores fell within the average range. The means of the children without disabilities on friendship subsection did change from average to high average and the children with disabilities group changed from low average to average.30 These findings were not statistically significant, but may be clinically meaningful.
Results of the peer sociometric nominations suggested that the children with disabilities were less accepted by their peers at pretest as evidenced by the greater number of negative peer nominations. This finding is consistent with other studies examining acceptance in children with and without disabilities. Odom et al41 found that as a group, children with disabilities experience a higher rate of social rejection than children without disabilities as measured by the Code for Active Student Participation and Engagement (CASPER II), peer sociometric nominations, Teacher and Parent Friendship Questionnaire, and interviews with family members, other service providers, and teachers. Cambra and Silvestre42 also found that children with disabilities are less socially preferred than their peers without disabilities.
At posttest, the children with disabilities were more accepted by both groups of peers as evidenced by the decreased number of negative peer nominations and the increased number of positive peer nominations. This change in acceptance occurred after a limited duration of direct inclusive exposure totaling 8 hours. These results are consistent with previous studies. Fox43 found that when children with and without disabilities were paired for various academic activities for 8 weeks, children with disabilities received higher social acceptance ratings by their peers without disabilities when compared with the control group. Similarly, Favazza et al19 suggested that inclusive programs can lead to lasting increased acceptance of children with disabilities.
Gun Han and Chadsey9 reported that the most frequently cited reason that children without disabilities did not have friends with disabilities was because of the limited opportunity to interact with their peers who have disabilities, and that children without disabilities were willing to become friends with children with disabilities if they had the opportunity to do so.9 The aquatic fitness program described in this study gave children of all abilities an opportunity to participate together, and led to an increase in positive peer nominations for children with disabilities. The children with and without disabilities were given the opportunity to interact at their own free will. This helped to provide an open atmosphere and made for a less intimidating environment.
Surprisingly, the results of the peer sociometric nominations indicated that at pretest, the majority of children with disabilities chose children without disabilities to “play with” instead of other children with disabilities. However, at posttest, it was found that the majority of children with disabilities chose other children with disabilities as the most desirable to “play with.” One possibility for this finding is that the majority of children with disabilities were unable to swim independently and spent more time in the shallow end of the pool with each other (even though they had flotation devices and adult assistance if needed) as opposed to swimming without restriction like the children without disabilities. This could also be because of the older age and level of maturity of the children with disabilities. It is possible that they did not want to play with the younger children during the program. Some studies indicate that direct exposure to children with disabilities alone may not foster optimal acceptance and self-concept in the children with disabilities.19,42
Whereas these findings support the notion that children with disabilities may be more accepted by their peers without disabilities after participation in an 8-week inclusive program, these findings also suggest that such an experience may lead to children with disabilities preferring to “play with” other children with disabilities. Further research is necessary to explore this phenomenon.
Although the results of this study are encouraging, several limitations exist that reduce the generalizability of the results. Limitations to this study include a small sample size and the use of a sample of convenience from a small geographical area. The ages of the children in this study also varied widely from 4 to 18 years, with the average age of the children with disabilities significantly higher than the average age of the children without disabilities. The physical and cognitive abilities of the participants in this study were also not controlled, nor was participation in other community activities that may have accounted for changes observed over time.
Prior relationships between participants were also not controlled and may have affected “friend” choices. The inclusive aquatic activity program was conducted over an 8-week period, which makes it difficult to examine the long-term effects of inclusion.
Results of this study suggest that participation in an inclusive after-school program may lead to improved acceptance for children with disabilities by their peers without disabilities. Although the children with disabilities seemed to be more accepted by their peers at the completion of this study and improved their overall HRQOL, this did not appear to have a positive effect on overall self-concept. Further research needs to be done to examine community-based inclusive programs as opposed to inclusion in the school setting. A qualitative evaluation of children's perceptions of inclusive community-based programs would assist in determining the effectiveness of such programs. Long-term effects also need to be examined to determine if the friendships formed in these programs are long lasting.
The goal of many pediatric physical therapists is to transition children with disabilities from direct intervention to community-based activities with their peers. Unfortunately, in many communities few activities exist for children with disabilities. Pediatric physical therapists have a role in the design and implementation of such activities. This research suggests that inclusive community-based programming should be considered and may lead to improved acceptance of children with disabilities by their peers without disabilities.
The authors thank Steven Chapman, PT, DPT, and Holly Sallade, PT, DPT, for their contributions to data collection and the writing of the article.
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children with disabilities; psychosocial support system; quality of life; self-concept; social environment; swimming