Can I Play?

A Concept Analysis of Participation in Children with Disabilities

Lindsey Hoogsteen Roberta L. Woodgate

ABSTRACT. Participation is essential to childrens development. Children with disabilities are at risk for restricted participation. Despite wide use of the word participation, the denition remains vague. The eight steps of analysis by Walker and Avant (2005) were used to guide the concept analysis. The uses and dening attributes of participation were identied 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 denition 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-dened denition 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 Researchs 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

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In 1980, the World Health Organization (WHO) introduced the International Classication 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 dimensions, went from the negative terms of impairment, disability, and handicap, to un, 1999). In the more neutral terms of impairment, activity, and participation (Ust 2001, WHO made yet another major revision to the ICIDH-2. The International Classication of Functioning, Disability and Health (ICF) became the newest and current framework. The domains are now classied 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 specic to the unique and growing characteristics of children (Simeonsson et al., 2006). Although the ICF and ICF-CY address many shortcomings of the previous frameworks, there is still much debate over the concept of participation with respect to its denition 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. Disability has the ability to impact childrens 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 identied as factors affecting the participation 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 personenvironmentoccupationperformance model (Law et al., 1996), the model of human occupation (Kielhofner, 2002), and the personenvironmentoccupation model (Baum & Christiansen, 2005) have been developed to emphasize the complex interaction between person, occupation, and environment. Participation is imperative to children with disabilities, and health care professions play a vital role in increasing participation. By dening the nature of participation, health care professionals are able to conceptualize and measure this concept. Concept analysis is a formal, rigorous process that identies, explores, claries, validates, and denes 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 dening 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) identied 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 Avants choice of steps because of the lack of rigor and in-depth processing (Hupcey, Morse, Lenz, & Tas on, 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 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 dening attributes 5. Identify a model case 6. Identify borderline, related, contrary, invented, and illegitimate cases 7. Identify antecedents and consequences 8. Dene empirical referents

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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 denition 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 rst 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 denition 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 identied 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 denition 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 specied, but most papers found were from the past two decades dating from 1983 to 2008 and limited to the English language. Additionally, denitions 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 disciplines including nance, media, social, political, and health care incorporating nursing, occupational and physical therapy. Although consideration of all uses and denitions by as many elds and disciplines are recommended by Walker and Avant (2005), this

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process may become impractical and unreasonable. Denitions that are outside of the health care profession, therefore, will be discussed in a limited manner. According to Websters Third International Dictionary of the English Language (2002), participation is the action or state of participating. This is further dened by the association with others in a relationship, taking part in with others in an activity, and social interaction within a group. Rogets International Thesaurus (1977) gives a variety 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 nancial realm, The World Bank Group, a source of nancial and technical assistance to developing countries around the world denes participation as control over developmental program initiatives, decisions, and resources (The World Bank, 2008). This is similar to Cardno Acils denition 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 Assessment (Rietbergen-McCracken, Narayan-Parker, & Narayan, 1998) participation is acknowledged as information sharing and consulting to collaboration and empowerment that give stakeholders further inuence 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 beneting 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 dened 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 childs right to participate in all play and recreational activities appropriate to the childs age (Convention on the Rights of the Child, 1990). Hart (1992) argues that participation begins the moment that a child realizes that they can inuence 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 denes participation as the process of sharing decisions which affect ones life in the community in which one lives (Hart, 1992, p. 5). This is similar to the denition 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 dened 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 individuals engagement in activities

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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 denes participation as an individuals involvement in life situations. Perenboom and Chorus (2003) echo this denition 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) dene 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 denes the nature and extent of participation (p. 49). The disability creation process (DCP) denes 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 benecial 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 persons 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 denition of participation (Leyin, 2008; Simeonsson et al., 2001). Determine the Dening Attributes of Participation Dening the attributes is what Walker and Avant (2005) consider as the heart of concept analysis (p. 68). It is here that the attributes are identied 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 identied, only those relevant to this analysis will be utilized in dening the attributes. The dening 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 Websters Dictionary denition 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).

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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 dening 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 dening 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 Devons spastic movements have declined and he seems to have more muscle strength in all limbs. The activity of swimming lessons fullls the rst 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 tness are Devons 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 dening characteristics (Walker & Avant, 2005). The Borderline Case According to Walker and Avant (2005) a borderline case contains most of the dening attributes but not all of them.

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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 difculty with getting out of the house. After several attempts to get Kevin motivated to be out with his friends, Kevins mother registers him for sledge hockey. Although Kevin repeatedly tells his mother that he does not want to go, he attends his rst 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) nd 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 schools 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 Dened 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 dening attributes of participation. The Invented Case Invented cases are cases that contain ideas outside our own experiences (Walker & Avant, 2005, p. 72). It helps dene the attributes by taking the concept out of its normal context and putting it into an invented or science ction 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 fullling 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.

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TABLE 2. Key Findings of Concept Analysis of Participation

Antecedents The child needs to have an interest in something and a willingness to take part. Attributes 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. Consequences 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 renes 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 consequences. According to Walker and Avant (2005), antecedents are events or incidents that must occur before the occurrence of the concept, while consequences are dened 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 children acquire skills and competencies, connect with others and communities, and nd 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, emotional, and social well-being (Kirkcaldy, Shephard, & Seifen, 2002; Murphy, Carbone, & the Council on Children with Disabilities, 2008; Steptoe & Butler, 1996). Additionally, 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 childs 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 maximizing educational outcomes (Evans & Spicer, 2008). At school, full integration and participation of children with disabilities promotes independence and aids in the development of social relationships (Simeonsson et al., 2001). Children nourish skills of citizenship and formulate goals and values by participating (Brown & Gordon, 1987).

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Dene 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 illdened 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 childs 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, determine appropriate normative standards, nd 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 dene participation in the context of children with disabilities, there is the possibility that not all sources were found. The dening 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 commitment to achieve conceptual clarication, the concepts 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 specic 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 identies 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 identies roles the family and community can play in order to enhance the childs 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 dened 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

Description Originally developed to assess the quality of social participation DCP and satisfaction among disabled adults Childrens version is a modied adult version for children ages 513 years Short (64 items) and long (197 items) form available (McConachie et al. 2006) Describes how children with or without disabilities participate in everyday activities outside of mandated school activities Children ages 621years (King et al., 2004) Standardized pediatric functional assessment commonly used in Nagi Disablement hospital settings, evaluates functional change Scheme Six months to 7.5 years (and older children who have disabilities) Three constructs (functional skills scale, caregiver assistance and modications) Highly used in children with brain injuries (Kothari, Haley, Gill-Body, & Dumas, 2003) Designed to assess participation and functional activity performance in elementary school Three sections with six different settings to measure participation Brief instrument Developed to assess participation relevant to home, school, and 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 disabilities Child perspective Children ages 515 years Two versions: ASKc (what the child could do) and ASKp (what the child does) (McConachie et al. 2006) Unknown Davies, Soon, Young, and Clausen-Yamaki (2004) and Gates, Otsuka, Sanders, and McGee-Brown (2008). ICF Imms, Reilly, Carlin, and Dodd (2008), King et al. (2006), Law et al. (2004, 2006). Dumas, Haley, Fragala, and Steva (2001), Dumas, Haley, and Rabin (2001), and Kothari, Haley, Gill-Body, and Dumas (2003). Framework Examples of Studies Lepage, Noreau, and Bernard (1998), Lepage, Noreau, Bernard, and Fougeyrollas (1998), and Noreau et al. (2007).

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ICF Bedell (2004). Unknown Morris, Kurinczuk, Fitspatrick, and Rosenbaum (2006), Wai, Owen, Fehlings, Darcy, and Wright (2000), and Young, Williams, Yoshida, and Wright (2000).

Measure

Assessment of Life Habits (LIFE-H) for Children

Childrens 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)

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Through the accomplishment of these goals and the dening 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 fulll the identied 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 denition and known attributes of participation. CONCLUSION Although the concept of participation has been used widely in the literature, dening participation takes more consideration and analysis. While participation is dened as an individuals involvement in life situations by the ICF, the denition 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 identied 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 denition of participation that emerged from concept analysis provides a common language for consumers and health care providers. The denition 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 specic 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 conict of interest. The authors alone are responsible for the content and writing of this paper. REFERENCES
Babcock, P. (Ed.). (2002). Websters third international dictionary of the English language unabridged. Springeld, MA: Merriam-Webster. Badham, B. (2004). Participationfor a change: Disabled young people lead the way. Children and Society, 18, 143154. Baum, C.M., & Christiansen, C.H. (2005). Personenvironmentoccupationperformance: An occupation-based framework for practice in Christiansen. In C.H. Baum & J.B. Bass-Haugen (Eds.), Occupational therapy: Performance, participation, and well-being. (3rd ed., pp. 243266). Thorofare, NJ: SLACK.

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