Occupational Therapists Use of the School Playground to Address the Social Participation of Preschool and Elementary School Children with Disabilities

Objective: The purposes of this study were to: (a) learn if and how school based occupational therapists address the social participation needs of children with disabilities, (b) to learn if school based occupational therapists utilize the school playground to address the social participation of children with disabilities, (c) if so, to understand how occupational therapists utilize the school playground to address the social participation of children with disabilities; and (d) to learn what influences occupational therapists’ use of the school playground to address social participation of children with disabilities. Method: A questionnaire was mailed to 357 occupational therapists in the U.S. who were enrolled as primary members of the American Occupational Therapy Association’s Early Intervention and Schools special interest section. Results: Approximately 42% of the questionnaires mailed out were returned. Of these, 54.3% met the screening qualifications for participation. This yielded a usable response rate of 23%. Nearly 20% of school based respondents noted not addressing social participation needs of students on their caseload. Approximately 71% of occupational therapists noted utilizing the school playground to address the social participation of children with disabilities. Approximately 17% of occupational therapists reported utilizing the school playground at least once per week. Respondents noted the ability to provide treatment in a naturalistic environment and the presence of peers as factors that promoted providing intervention on the school playground. Therapists’ time, environmental distractions, mobility concerns, and safety concerns acted as potential barriers. Conclusions: The majority of respondents, who met the inclusion criteria for participation, utilized the school playground to address the social participation of children with disabilities; however, the potential barriers they encounter seem to interfere with doing so consistently. Occupational therapists’ unique skills and training should enable them to overcome these barriers and thus utilize the school playground more often. Since it is seems to be one of the most appropriate environments to address the social participation of children in preschool and elementary school. Running head: SOCIAL PARTICIPATION AND THE SCHOOL PLAYGROUND 1 Approximately 25% of children with disabilities are socially isolated at school (Frostad & Pijl, 2007; Koster, Pijl, Nakken, & Van Houten, 2010; Odom et al., 2006). This may occur, in part, as a result of the increased difficulty children with disabilities face when attempting to facilitate and engage in peer interactions (Koster et al., 2010; Frostad & Pijl, 2007; Richardson, 2002). Children, who do not participate socially may face negative outcomes as they age (Odom et al., 2006), including poor academic performance (Eisenman, 2007; Finn, 1993), increased depression, anxiety, antisocial behaviors, and interpersonal difficulties (Laursen, Bukowski, Aunola, & Nurmi, 2007). Participation in formal education is one of the primary occupations for children (AOTA, 2008). During the school day, one of the few opportunities for children to engage in social interactions is during recess (Jarrett, 2004; Pellegrini, 1995), which frequently occurs on the school playground (Bundy et al., 2008; Harper, Symon & Frea, 2008; Pellegrini, 1995). Pellegrini and Bjorklund (1997) define recess as “...a ‘break’ (either indoors or outdoors) from academic work in which children are free to choose and engage in an activity on their own terms ” (p. 35). This “break” from academic studies provides children an opportunity to engage in and facilitate social interactions with peers independently (Pellegrini, 1995). These social interactions seem to promote the development of social skills essential for positive social communication with peers (Pellegrini, Blatchford, Kato, & Baines, 2004). Since recess provides an opportunity for social interaction (Jarrett, 2004; Pellegrini et al., 2004), which may influence the pursuit of education and academic performance (Eisenman, 2007; Finn, 1993), then all children, including children with disabilities, should be provided the opportunity to participate in recess. Running head: SOCIAL PARTICIPATION AND THE SCHOOL PLAYGROUND 2 The importance of including children with disabilities in all aspects of education is outlined in the Individuals with Disabilities Education Improvement Act of 2004 (IDEA) and in the American Occupational Therapy Association’s (AOTA) Occupational Therapy Framework: Domain and Practice, 2 Edition (OTPF II; 2008). The IDEA (2004) guides the delivery of services that provide assistance to children with disabilities. Specifically, the IDEA (2004) assures these children the right to an education and seeks to promote, “equality of opportunity, full participation, independent living, and economic selfsufficiency for individuals with disabilities” (p. 118). As a means to achieve this, the U.S. Department of Education (2004) mandates the provision of services to approximately 6.5 million children with disabilities. Such services, including occupational therapy, are provided as a means to grant a “...free and [sic] appropriate public education...to meet their [children with disabilities] unique needs and prepare them for employment and independent living” (Silverstein, 2000, p. 33). The IDEA (2004) encourages these services be delivered in the least restrictive environment possible, meaning that children with disabilities should be allowed to participate, when appropriate, with non-disabled children during all activities of school, including extra-curricular activities like mealtimes and recess. In agreement with the intention of the IDEA (2004), the OTPF II states that the occupational rights for children, including children with disabilities, consist of participation in formal education and social participation (AOTA, 2008). Consequently, it is appropriate that occupational therapists utilize their unique skill set to provide interventions that support the participation of children with disabilities in these occupations. Running head: SOCIAL PARTICIPATION AND THE SCHOOL PLAYGROUND 3 The OTPF II clarifies the dual nature of participation in formal education as including engagement in both academic (e.g. math and reading) and non-academic (e.g. recess and lunch) components of education (AOTA, 2008). In order for occupational therapists to provide intervention that attempts to ensure equitable participation of children with disabilities in appropriate school environments, it is important to understand social participation, which often occurs during recess (Jarrett, 2004; Pellegrini et al., 2004) and on the school playground (Bundy et al., 2008; Harper et al., 2008; Pellegrini, 1995), as a component of school participation. Likewise, it is critical to understand how occupational therapists can best address the social participation needs of children with disabilities during school. Background Social Participation and the School Environment In a general sense, participation enables children to “...understand the expectations of society and gain the physical and social skills needed to flourish and function in their homes and communities” (Law & King, 2000, p. 10). To acknowledge this importance of participation, the World Health Organization (WHO) replaced “handicap” with “participation,” in the International Classification of Functioning, Disability and Health (Forsyth & Jarvis, 2002), defining participation as “the involvement of the person in life situations” (WHO, 2001). More specifically, AOTA adopted the definition of social participation as “organized patterns of behavior that are characteristic and expected of an individual in a given position within a social system” (Mosey, 1996, p. 340 as cited in AOTA, 2008). Since life situations have many components, it is reasonable to understand how participation could be shaped by physical, cognitive, Running head: SOCIAL PARTICIPATION AND THE SCHOOL PLAYGROUND 4 and/or communication skills of the individual (Law & King, 2000) as well as caregiver and environmental influences (Missiuna & Pollack, 1991; Richardson, 2002). These factors seem to influence the social participation of children with disabilities during school (Koster et al., 2010, Odom et al., 2006; & Richardson, 2002) and specifically during recess (Egilson & Coster, 2004; Ingram, Mayes, Troxell, & Calhoun, 2007; Koster et al., 2010; Prellwitz & Skar, 2007). First, Richardson (2002) described how communication skills of children with disabilities may influence their social participation, finding that school aged children with disabilities’ poor timing, inappropriately interpreted attempts at interaction, and lack of interest of the potential peer often result in failure to engage peers socially. Similarly, Odom et al. (2006) found that the absence of an effective communication system contributed to the social rejection of preschool aged children with disabilities. Second, Prellwitz and Skar (2007) noted that the design of a playground might not promote independent mobility for children with disabilities. This could possibly interfere with children with disabilities pursuit of social interaction. This rationale agreed with the findings of Egilson & Coster (2004), who utilized the School Function Assessment (SFA) and found that children with physical disabilities participate less during playground/recess than any of the other categories (Regular/Special ed. Classroom, Transportation, Bathroom/Toileting, Transitions, Mealtime) of the SFA. They reasoned that this possibly occurred as a result of the difficulty nature of attempting to adapt “...the playground environment, which is characterized by physical space, challenging terrain, and unpredictable movement of people and objects...” compared to other components of the school environment (Egilson & Coster, 2004, p. 166). Running head: SOCIAL PARTICIPATION AND THE SCHOOL PLAYGROUND 5 Finally, the social participation of children with disabilities during recess may be influenced by the fact that children with disabilities seem to require constant supervision and occasional assistance from adults during recess (Egilson & Coster, 2004; Richardson, 2002). This support is often provided by an assigned paraeducator (Werts, Harris, Young, & Tillery, 2004). Richardson (2002) noted that this type of adult support “...during recess and play times often served to remove them [the children] from the opportunity to be part of a peer interaction group and disrupted the flow of play activities” (p. 300). Consequently, children with disabilities frequently rely on adults to serve as alternate social partners while at school (Richardson, 2002); however, this adult presence tends to further promote peer rejection and social isolation of children with disabilities from their peers (Hemmingsson, Borrel & Gustavsson, 2003; Richardson, 2002; Tsao et al., 2008). The physical, cognitive, and/or communication skills of children with disabilities (Law & King, 2000) as well as caregiver and environmental influences (Missiuna & Pollack, 1991; Richardson, 2002) seem to result in specific differences of the social participation of children with disabilities compared to typically developing children during recess (Egilson & Coster, 2004; Ingram, Mayes, Troxell, & Calhoun, 2007; Koster et al., 2010; Prellwitz & Skar, 2007). Ingram et al. (2007) found that children with disabilities engage in social play with peers less than typically developing children during recess. When compared to typically developing children who engage in social play with peers all of the time, children with autism engage in social play with peers 10% of the time and children with mental retardation engage in social play with peers 88% of the time (Ingram et al., 2007). Furthermore, children with autism and mental retardation initiated Running head: SOCIAL PARTICIPATION AND THE SCHOOL PLAYGROUND 6 and sustained conversations with peers much less than typically developing peers (Ingram et al., 2007). Fewer peer engagements during recess likely lends to decreased opportunity for children with disabilities to develop their social skills (Pellegrini et al., 2004). This possibly may perpetuate the peer rejection and social isolation of children with disabilities. The peer rejection and subsequent social isolation children with disabilities sometimes face during recess, likely contributes to the fact that children with disabilities differ significantly from their peers on their ability to develop and maintain friendships (Koster et al., 2010). Specifically, Koster et al. (2010) found that students with disabilities have fewer friends than typically developing peers, have fewer interactions with peers, and are less accepted by peers. This lack of friendship could possibly affect the academic performance of children with disabilities in a negative way (Bailey, 1968; Finn, 1993; Flook, Repetti, & Ullman, 2005; Wentzel & Caldwell, 1997). Peer acceptance seems to correlate with academic performance (Bailey, 1968; Finn, 1993; Flook et al., 2005; Wentzel & Caldwell, 1997). Poor academic performance and disengagement from school place students at an increased risk for school dropout (Eisenmann, 2007). Bailey (1968) found that peer acceptance and intelligence correlated with academic achievement at an equal magnitude. These findings indicate that peer acceptance seems to be as influential as intelligence (measured by intelligence quotient) on the academic achievement (measured by grade point average) of fifth grade children (Bailey, 1968). Likewise, Wentzel and Caldwell (1997) found that reciprocated friendships, peer acceptance, and group membership (all components of peer relationships) are significantly correlated with academic achievement in a sample Running head: SOCIAL PARTICIPATION AND THE SCHOOL PLAYGROUND 7 of sixth grade children. Lastly, Flook et al. (2005) found that peer acceptance accounted for one fourth of the variance of academic performance, indicating that less socially accepted children tend to perform worse academically in school. Research indicates that social participation and peer acceptance affects the academic performance of children. Since children with disabilities seem to participate less socially during school, it seems reasonable, under the IDEA (2004), to provide intervention to address the social participation of children with disabilities in the school environment. Since the primary opportunity for children to engage in social interactions is during recess (Jarrett, 2004; Pellegrini, 1995), and often on the school playground (Bundy et al., 2008; Harper et al., 2008; Pellegrini, 1995), it seems logical that the best environment to address the social participation of children with disabilities would be the school playground; however, to accomplish this, it is first important to examine the construct of recess. Recess provides an opportunity for children to participate socially by engaging and facilitating social interactions with peers (Pellegrini, 1995). This occurs because recess is the time during the school day when children are able to take respite from their academic day and participate in activities of their choosing (Pellegrini & Bjorklund, 1997). Children oftentimes spend recess, which typically occurs on a school playground (Bundy et al., 2008; Harper et al., 2008; Pellegrini, 1995), participating in various games (Pellegrini et al., 2004). It has been noted that children seem to use engagement in games as a means to develop social familiarity (Pellegrini et al., 2004). Specifically, Pellegrini et al. (2004) described their findings that children’s recess games seemed to become progressively more complex in nature as children became more familiar with Running head: SOCIAL PARTICIPATION AND THE SCHOOL PLAYGROUND 8 one another over the duration of the school year. They believed that this phenomenon is indicative of the fact that it is during recess, when children can initiate and facilitate social interaction with minimal adult influence (Pellegrini, 1995), that children develop social skills through continued social participation in increasingly more complex interactions (Pellegrini et al., 2004). It seems that the challenges faced by children with disabilities when attempting to participate during recess, which typically occurs on the school playground (Bundy et al., 2008; Harper et al., 2008; Pellegrini, 1995), make interacting socially more difficult. This lack of interaction seems to promote the social isolation of children with disabilities, and, in turn, may contribute to poor academic performance (Bailey, 1968; Finn, 1993; Flook et al., 2005; Wentzel & Caldwell, 1997) and possibly result in an increased risk of school drop out (Eisenman, 2007). As a result, it seems reasonable that services be provided to address the social participation of children with disabilities in one of the most commonly occurring sites of social participation during the school day, the school playground, as the academic performance of children is ultimately affected. The Role of Occupational Therapists Occupational therapists are concerned with an individual’s ability to participate independently and optimally in all areas of occupation. Because the participation of children with disabilities in recess is considered to be a component of their daily occupation, which includes both formal school participation and social participation (AOTA, 2008), it seems logical that occupational therapists intervene to promote participation of children with disabilities in recess. It is reasonable that occupational therapists provide these interventions as they are skilled in their ability to adapt, modify, Running head: SOCIAL PARTICIPATION AND THE SCHOOL PLAYGROUND 9 and change tasks and activities to best match the capabilities of the client (AOTA, 2008). Specifically, occupational therapists are trained in identifying opportunities that promote children with disabilities mobility, use of senses, and cognition on the playground (Stout, 1988). The training and skills of occupational therapists enable them to design playground activities that match the developmental stage as well as the cognitive, physical, and social needs of the individual (Nabors, Willoughby, & Badawi, 1999). The inclusion of children with disabilities during playground activities is more likely to occur when the demands of the activity are appropriately matched to their abilities. Thus, occupational therapists can utilize their unique skill set to promote the social participation of children with disabilities. As a means to understand how occupational therapists utilize their unique skills in addressing the social participation needs of children with disabilities, John (2009) examined the roles and perspectives of pediatric occupational therapists addressing social participation. She found that 97.4% of respondents addressed social participation of children with disabilities. Furthermore, she found that 69.2% of respondents believed the school setting to be the best environment in which to address the social participation needs of children with disabilities (John, 2009). Since the playground is one of the most commonly occurring sites that children socially interact during the school day (Bundy et al., 2008; Harper et al., 2008; Pellegrini, 1995), Knight (2003) sought to understand how and if occupational therapists use playgrounds to provide intervention. She found that occupational therapists seem to not be utilizing playgrounds to specifically address the social participation of children but rather to work on goals that specifically address needs in the areas of “...behavior, gross motor, play skills, psychosocial, sensory Running head: SOCIAL PARTICIPATION AND THE SCHOOL PLAYGROUND 10 integration or processing, strengthening, and other goals” (Knight, 2003, p. 14). Although Knight’s (2003) findings did not indicate that occupational therapists utilize playgrounds to specifically address social participation goals, the goals listed above by respondents could be considered essential elements of improving the social participation of children with disabilities. For example, a child needs to be able to regulate their behavior and have sufficient strength and gross motor coordination to participate in many playground games, such as four square or kickball. As a result, as a means to better understand how to address the social participation of children with disabilities, it would be beneficial to more specifically understand school based occupational therapists’ use of the school playground to address the social participation of children with disabilities. Summary Children with disabilities often fail to interact socially during recess (Egilson & Coster, 2004; Ingram, Mayes, Troxell, & Calhoun, 2007; Koster et al., 2010; Prellwitz & Skar, 2007), which often occurs on the school playground (Bundy et al., 2008; Harper et al., 2008; Pellegrini, 1995). As a result, they may face the unfortunate consequences of social isolation (Laursen, Bukowski, Aunola, & Nurmi, 2007). Previous research supports the notion that the school environment is the most appropriate setting to address the social participation needs of children with disabilities (John Thilager, 2009). The IDEA (2004) asserts that services should be provided in the least restrictive environment possible; therefore, it seems most appropriate that social participation should be addressed on the school playground since social interaction for school-aged Running head: SOCIAL PARTICIPATION AND THE SCHOOL PLAYGROUND 11 children typically occurs during recess (Jarrett, 2004; Pellegrini, 1995) and on the school playground (Bundy et al., 2008; Harper et al., 2008; Pellegrini, 1995). As a means to best know how occupational therapists can utilize the school playground to address the social participation of children with disabilities, it seems essential to better understand how and if occupational therapists are utilizing the school playground to provide intervention relating to social participation. As a result, the purposes of this study are to build on the previous research of John (2007) and Knight (2003) and to: (a) learn if and how school based occupational therapists address the social participation needs of children with disabilities, (b) to learn if school based occupational therapists utilize the school playground to address the social participation of children with disabilities, (c) if so, to understand how occupational therapists utilize the school playground to address the social participation of children with disabilities; and (d) to learn what influences occupational therapists’ use of the school playground to address social participation of children with disabilities. Method Research Design A survey in the form of a descriptive questionnaire was distributed by mail throughout the U.S. to school based occupational therapists. The survey aimed to better understand their use of the school playground to provide intervention relating to the social participation of children with disabilities. The questionnaire had four objectives: (a) if and how school based occupational therapists address the social participation needs of children with disabilities, (b) if school based occupational therapists utilize the school playground to address the social participation of children with disabilities, (c) if Running head: SOCIAL PARTICIPATION AND THE SCHOOL PLAYGROUND 12 so, to learn how occupational therapists utilize the school playground to address the social participation of children with disabilities; (d) and what influences occupational therapists’ use of the school playground to address social participation of children with