A variety of fields provide training and expertise in adapted sports, recreation, and leisure. They include APE teachers, child life specialists, and therapeutic recreation (TR) specialists. Physical and occupational therapists often incorporate sports and recreation into their treatment plans as well. However, their involvement remains primarily within a medical framework and will not be discussed here.

APE developed in response to the Individuals with Disabilities Education Act (IDEA), which states that children with disabling conditions have the right to free, appropriate public education in the least restrictive environment. Included in the law is "instruction in physical education," which must be adapted and provided in accordance with the Individualized Education Program (IEP). APE teachers receive training in identification of children with special needs, assessment of needs, curriculum theory and development, instructional design, and planning, as well as direct teaching (49,50). The APE National Standards (51) were developed to outline and certify minimum competency for the field in response to only 14 states developing standards for APE following the passage of the IDEA. APE teachers provide some of the earliest exposure to sports and recreation for children with special needs, and introduce the skills and equipment needed for future participation.

TR has its roots in recreation and leisure. It provides recreation services to people with illness or disabling conditions. Stated in the American Therapeutic Recreation

Playground equipment can be adapted to include children of all abilities, including pathways for wheelchair and walker access.

FIGURE 9.1 Playground equipment can be adapted to include children of all abilities, including pathways for wheelchair and walker access.

Association Code of Ethics, the primary purposes of treatment services are "to improve functioning and independence as well as reduce or eliminate the effects of illness or disability" (52). Clinical interventions used by TR specialists run the gamut, from art, music, dance, and aquatic therapies to animal, poetry, humor, and play therapy. They may include yoga, tai chi chuan, aerobic activity, and adventure training in their interventions. While some training in pediatrics is standard in a TR training program, those who have minored in child life or who have done internships in pediatric settings are best suited for community program development. TR specialists are often involved in community-based sports for those with DA, serving as referral sources, consultants, and support staff.

Child life is quite different from TR. Its roots are in child development and in the study of the impact of hospitalization on children. Its focus remains primarily within the medical/hospital model, utilizing health care play and teaching in the management of pain and anxiety and in support. Leisure and recreation activities are some of the tools utilized by child life specialists. Unlike TR specialists, child life workers focus exclusively on the needs and interventions of children and adolescents. There is often overlap in the training programs of child life and TR specialists. The role of the child life specialist does not typically extend to community sports and recreation programs.


A number of scales have been developed to measure participation in activities. One example is the World Health Organization Health Behavior in School-Aged Children (WHO HBSC) survey. It is a self-reported measure of participation in vigorous activity that correlates well with aerobic fitness and has been shown to be reliable and valid (53). The Previous Day PA Recall (PDPAR) survey has been shown to correlate well with footsteps and heart rate monitoring, and may be useful in assessing moderate-to-vigorous activity of a short time span (54).

The PA Scale for Individuals with Physical Disabilities (PASIPD) records the number of days a week and hours daily of participation in recreational, household, and occupational activities over the past 7 days. Total scores can be calculated as the average hours daily times a metabolic equivalent value and summed over items (55).

The Craig Hospital Inventory of Environmental Factors (CHIEF) is a 25-item survey that identifies presence, severity, and frequency of barriers to participation, and is applicable to respondents of all ages and abilities. A 12-item short form, CHIEF-SF is also available. When applied to a population with diverse disabilities, the CHIEF measure revealed the most commonly identified barriers to participation are weather and family support (56).

Pediatric measures include CAPE, which stands for Children's Assessment of Participation and Enjoyment. This tool has been validated in AB and DA children aged 6 to 21 years. It is used in combination with the PAC, the Preferences for Activities of Children. Together, they measure six dimensions of participation (ie, diversity, intensity, where, with whom, enjoyment, and preference) in formal and informal activities and five types of activities (recreational, active physical, social, skill-based, and self-improvement) without regard to the level of assistance needed. The scales can be used to identify areas of interest and help develop collaborative goal setting between children and caregivers. Identification of interests and barriers can facilitate problem solving and substitution of activities fulfilling a similar need (57). The European Child Environment Questionnaire (ECEQ) has been used to show that intrinsic and extrinsic barriers are equally important in limiting PA among DA youth (58).

Using these and other measures, one finds that participation in PA varies widely, even among nondisabled populations. The Third National Health and Nutrition Examination survey found that the prevalence of little to no leisure-time PA in adults was between 24% and 30% (59). The groups with higher levels of inactivity included women, older persons, Mexican Americans, and non-Hispanic Blacks. A number of factors have been positively associated with participation in healthy adults, including availability and accessibility of facilities, availability of culture-specific programs, cost factors, and education regarding the importance of PA. Likewise, in healthy adolescents, PA is less prevalent among certain minorities, especially Mexican Americans and non-Hispanic Blacks. Participation in school-based PE or community recreation centers is positively correlated with PA, as are parental education level and family income (60). Paternal PA, time spent outdoors, and attendance at non vocational schools are more common among children with higher levels of PA (61). Access to parks increases participation, especially in boys. Lower levels of moderate or vigorous PA are seen in those who reside in high-crime areas (62).

When followed over time, adolescents tend to decrease their participation in PA from elementary to high school. Boys who are active have a tendency to pursue more team sports, whereas girls are more likely to participate in individual pursuits (63). Coaching problems, lack of time, lack of interest, and limited awareness have been cited as other barriers to PA (64). Overall, however, informal activities account for more participation in children and teens than formalized activities (65).

Ready access to technology is associated with a decline in healthy children's participation in PA. Television viewing is inversely related to activity levels and positively correlates with obesity, particularly in girls (66). Increased computer time is also related to obesity in teenage girls (67). Interestingly, playing digital games has not been linked with obesity, and active video games have, in fact, increased levels of PA among children and adolescents (68-70).

It is not surprising to learn that many of the barriers to PA identified by AB are the same as those experienced by children with DA. The most commonly cited are lack of local facilities, limited physical access, transportation problems, attitudinal barriers by public and staff, and financial concerns. Lack of sufficiently trained personnel and of appropriate equipment have also been identified (33,71,72). Among those children with severe motor impairments, the presence of single-parent household, lower family income, and lower parent education are significant barriers (65). Pain is more frequently reported in children with CP and interferes with participation in both activities of daily living (ADLs) and PA (73). The presence of seizures, intellectual impairment, impaired walking ability, and communication difficulties predicts lower levels of PA among children with CP (74). Many children are involved in formal physical and occupational therapy.

Therapists as a whole have been limited in their promotion of recreation and leisure pursuits for their pediatric clientele (75). Therapy sessions and school-based programs provide excellent opportunities for increasing awareness of the need and resources available for PA. Policy and law changes related to the Americans with Disabilities Act are resulting in improved access to public facilities and transportation. Many localities are providing adapted programs and facilities that are funded through local taxation (Figure 9.2). Impairment-specific sports have grown from grassroots efforts, often with the assistance or guidance of rehabilitation professionals. Organizations such as BlazeSports (blazesports .org) have developed programs throughout the United States. The bedrock of BlazeSports America is made up of the community-based, year-round programs delivered through local recreation providers. It is open to youth with all types of physical disabilities. Winners on Wheels "empowers kids in wheelchairs by encouraging personal achievement through creative learning and expanded life experiences that lead to independent living skills." Chapters exist in many cities across the United States and incorporate PA into many of the activities they sponsor.

The American Association of Adapted Sports Programs (AAASP) employs athletics through a system called the adaptedSPORTS model. "This award-winning model is an interscholastic structure of multiple sports seasons that parallels the traditional interscholastic athletic system and supports the concept that school-based sports are a vital part of the education process and the educational goals of students" (adaptedsports. org). The sports featured in the adaptedSPORTS model have their origin in Paralympic and adult disability sports. The program provides standardized rules for competition, facilitating widespread implementation.

Many public facilities have wheelchairs available for rent or use that are designed for use on the beach.

FIGURE 9.2 Many public facilities have wheelchairs available for rent or use that are designed for use on the beach.

Application in the primary and high school levels can help students develop skills that can lead to collegiate-, community-, and elite-level competition.

In some communities, AB teams or athletes have partnered with groups to develop activity-specific opportunities. Fore Hope is a nationally recognized, nonprofit organization that uses golf as an instrument to help in the rehabilitation of persons with disabilities or an inactive lifestyle. The program is facilitated by certified recreational therapists and golf professionals (forehope. org). A similar program known as KidSwing is available to DA children in Europe and South Africa (www Several National Football League (NFL) players have sponsored programs targeting disabled and disadvantaged youth. European soccer team players have paired with local organizations to promote the sport to DA children.

Financial resources are also becoming more available. The Challenged Athletes Foundation (CAF) supports athletic endeavors by providing grants for training, competition, and equipment needs for people with physical challenges. Athletes Helping Athletes (www is a nonprofit group that provides handcycles to children with disabilities at no cost. The Golden Opportunities fund ( provides support and encouragement to DA youth in skiing. More resources can be found at the Disaboom website (

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