DEVELOPMENTAL MEDICINE & CHILD NEUROLOGY ORIGINAL ARTICLE

Assessing patterns of participation and enjoyment in children with

spinal cord injury
SARA J KLAAS 1 | ERIN H KELLY 1 | JULIE GORZKOWSKI 1 | ERICA HOMKO 2 | LAWRENCE C VOGEL 1

1 Shriners Hospitals for Children, Chicago, Illinois, USA. 2 Shriners Hospitals for Children, Philadelphia, Pennsylvania, USA.
Correspondence to Sara J Klaas at the Shriners Hospitals for Children, 2211 North Oak Park Avenue, Chicago, IL 60707, USA. E-mail: sklaas@shrinenet.org

PUBLICATION DATA AIM To determine patterns of participation and levels of enjoyment in young people with spinal
Accepted for publication 24th August 2009. cord injuries (SCI) and to assess how informal and formal participation varies across child, injury-
Published online 23rd December 2009. related, household, and community variables.
METHOD One hundred and ninety-four participants (106 males, 88 females; mean age 13y 2mo,
SD 3y 8mo, range 6–18y) with SCI and their primary caregivers completed a demographics ques-
tionnaire and a standardized measure of participation (the Children’s Assessment of Participation
and Enjoyment, [CAPE]) at three pediatric SCI centers in a single hospital system in the United
States. Their mean age at injury was 7 years 2 months (SD 5y 8mo, range 0–17y); 71% had para-
plegia, and 58% had complete injuries.
RESULTS Young people participated more often in informal activities (t(174)=29.84, p<0.001) and
reported higher enjoyment with these (t(174)=2.01, p=0.046). However, when engaging in formal
activities, they participated with a more diverse group (t(174)=)16.26, p<0.001) and further from
home (t(174)=)16.08, p<0.001). Aspects of informal participation were related to the child’s age,
sex, and injury level, and formal participation to the child’s age and caregiver education. Caregiver
education was more critical to formal participation among young people with tetraplegia than
among those with paraplegia (F(4,151)=2.67, p=0.034).
INTERPRETATION Points of intervention include providing more participation opportunities
for young people with tetraplegia and giving caregivers the resources necessary to enhance their
children’s formal participation.

A spinal cord injury (SCI) is a life-changing event and is par- ability to play and interact with their environment.7 This dis-
ticularly devastating when it occurs during childhood. Many ruption may adversely affect the developmental process, as lack
unique challenges exist for children with SCI as a result of of socialization and participation affect crucial physical and
both the injury and the dynamic growth and development psychosocial milestones. In addition, children with disabilities
issues that occur during childhood.1 One area of particular often experience exclusion by able-bodied peers, which may
concern is that of participation. The World Health Organiza- limit their involvement in typical childhood activities.5,8
tion2 defines participation as ‘involvement in a life situation’ Past research indicates that children with disabilities often
and the result of peer interaction within an individual’s social participate in fewer types of activities overall, participate in
and physical environment. Researchers have found that fewer social activities, and spend more time in quiet, sedentary
involvement, particularly in physical recreation and sports, is activities.5,9,10 Longmuir and Bar-Or11 found that children
highly related to overall health, disease prevention, mainte- with physical disabilities or visual impairments undertook
nance of functional independence,3 and life satisfaction.4 more sedentary activity than those with chronic illness.
Despite this, rates of participation tend to be lower among Simeonsson et al.12 observed significantly lower participation
young people with disabilities.5 In the present study, we among children with physical or neurological impairment.
explored participation among young people with SCI. Imms et al.13 found that severity of disability affected partici-
Participation is essential to the development of children. It pation, but only among the most severely impaired young
is often through participation that children learn about societal people.
expectations, develop communication skills, build friendships, In a study of participation in 427 children with physical dis-
and conquer important milestones while gaining skills and abilities, using the Children’s Assessment of Participation and
knowledge imperative to success at home and in the commu- Enjoyment (CAPE), investigators found that young people
nity.6 Children with disabilities are at risk of decreased partici- engaged more often in informal than in formal activities.6
pation.5 A disability creates a major disruption in children’s More recently, King et al.14 found that children with

468 DOI: 10.1111/j.1469-8749.2009.03552.x ª The Authors. Journal compilation ª Mac Keith Press 2009
 14698749, 2010, 5, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/j.1469-8749.2009.03552.x, Wiley Online Library on [08/01/2025]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
disabilities participate in fewer formal and informal activities assent, participants completed the survey instruments
and with less intensity than their able-bodied peers. Further, themselves or received help from a research assistant. Young
children without disabilities reported greater enjoyment of people who had been hospitalized for longer than 4 months
formal activities than those with disabilities. These results are were either excluded or were asked to answer questions about
consistent with other research5,15 that found that children with life before their most recent hospitalization. Survey adminis-
disabilities have low levels of participation in community- tration took between 45 and 75 minutes depending on the
based formal activities and in spontaneous social activities.14 child’s reading level and the amount of information that the
Literature specific to participation in children with SCI is child shared about participation. The project secured approval
limited. In one study of 66 young people with SCI, the partici- from the institutional review boards at all three hospitals, and
pants reported involvement in a preponderance of sedentary the Ethical Treatment of Human Subjects protocol was fol-
homebound activities that involved minimal social interaction, lowed throughout the process.
and they reported little participation in more strenuous or
physical activities.16 In another study of participation in orga- Data analysis
nized community activities, 62% of young people reported no Descriptive statistics were used to summarize sample charac-
participation in sports, clubs, or youth centers after injury.10 teristics and rates of participation. Means are presented to
Results from this research suggest that participation rates are describe averages. Differences between informal and formal
low among the pediatric SCI population. participation scores by dimension (how often, with whom,
In an era of increased sedentary lifestyles, participation has where, and enjoyment) were assessed using paired-samples
become more important for all children, yet research con- t-tests (diversity was not assessed because the number of items
ducted into young people with physical disabilities suggests in the informal and formal domains differed).
that rates of participation are not at optimal levels. As a first Differences in informal and formal participation between
step towards improving interventions aimed at enhancing par- subgroups of young people were assessed using multivariate
ticipation, we describe the participation of young people with analysis of variance (MANOVA). MANOVA allows for
SCI and explore how informal and formal participation relate examination of interaction effects between independent vari-
to key demographic, injury-related, household, and commu- ables and control over type I error.19 Two two-way MA-
nity variables. NOVA tests were used to assess differences in informal and
formal participation related to the age (6–12y or 13–18y)
METHOD and sex of the child. Two three-way MANOVA tests were
Participant recruitment used to assess differences in informal and formal participa-
The 194 study participants were recruited as part of a larger tion related to child injury level (paraplegia or tetraplegia),
project to examine relationships between psychosocial out- caregiver education (college or no college), and community
comes in children with SCI and their primary caregivers. We type (urban or rural). Four dependent variables were
recruited children with SCI aged between 6 and 18 years who included in each equation: with whom, where, enjoyment of
had been injured at least 1 year previously and who had informal or formal participation, and a composite that com-
received services between March 2007 and December 2008 bined diversity and intensity into an overall frequency vari-
from one of the three Shriners Hospitals for Children SCI able. This composite was created because the diversity and
programs in Chicago, Philadelphia, and Northern California. intensity scores were highly correlated (0.873 for informal
Thirty-seven young people refused to participate in the study participation, 0.917 for formal participation), indicating that
for reasons such as not being interested and participating in including both as dependent measures would be problem-
too many other studies. atic. In addition, the authors of CAPE suggest examining
diversity and intensity scores together to provide a more
Instruments complete description of participation.17 For each MANO-
A study-specific demographics questionnaire was completed VA, the reported results include the F statistic and p value
by the child’s primary caregiver. Injury level was deter- for all main effects and significant interactions (using Wilks’
mined from a review of medical records. The CAPE17,18 criterion), and partial g2 to assess effect size for each signifi-
was administered to the young people. This CAPE assess- cant finding. Univariate analysis of variance tests were con-
ment includes 55 items to measure participation for chil- ducted to follow up on significant main effects and
dren with disabilities. Items are categorized into two interactions. Sample sizes for the MANOVA analyses are
domains: formal and informal. If a child answers that they presented below; these changed for each analysis because 19
participate in an activity, they then answer questions about young people did not participate in any formal activities,
how often, with whom, where, and how much they enjoy and data on demographic variables were incomplete, as
that activity. All activities endorsed by participants are reported below. Normality was assessed, and the natural log
therefore scored on five dimensions (Table I). transformation of the new formal frequency composite was
used because of a non-normal distribution.
Procedure Two multivariate analyses of covariance were also con-
Data were collected during in-patient hospitalizations or out- ducted to test the impact of injury level, caregiver education,
patient visits. After providing written informed consent and and community type on informal and formal participation

Participation in Children with Spinal Cord Injury Sara Klaas et al. 469
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Table I: The Children's Assessment of Participation and Enjoyment (CAPE)a: dimensions, response options, and interpretation

Dimension Response options Interpretation

Diversity 0 Does not participate in activity Higher score indicates more

1 Does participate in activity variety of activities
(total possible is 55, i.e. a score of
1 for each of 55 activities)
Intensity 1 1 time in past 4mo Higher score indicates greater
2 2 times in past 4mo extent of time spent participating
3 1 time a month
4 2–3 times a month
5 1 time a week
6 2–3 times a week
7 1 time a day or more
With whom 1 Alone Higher score indicates more social
2 With family (parents, siblings) engagement
3 With other relatives
(grandparents, aunts,
uncles, cousins)
4 With friends
5 With others (instructors,
other individuals, or different
types of people)
Where 1 At home Higher score indicates more
2 At a relative’s home community-based participation
3 In your neighborhood
4 At school (but not during classes)
5 In your community
6 Beyond your community
Enjoyment 1 Not at all Higher score indicates more
2 Somewhat; sort of enjoyment from participation
3 Pretty much
4 Very much
5 Love it

a
Children’s Assessment of Participation and Enjoyment (CAPE). Copyright ª 2004 NCS Pearson, Inc. Adapted and reproduced with permission of
publisher, NCS Pearson, Inc. All rights reserved. ‘Children’s Assessment of Participation and Enjoyment’ and ‘CAPE’ are trademarks, in the US
and ⁄ or other countries of Pearson Education, Inc. or its affiliates.

while adjusting for child age and sex. These results were not Participation of young people with SCI
different from the MANOVA results and therefore will not be Table II includes mean participation scores in all five dimen-
discussed. sions for overall participation and for the informal and formal
domains. Overall, young people participated in a mean of
RESULTS 23.83 (43%) of the 55 activities included in CAPE, with a
A total of 194 young people were enrolled (106 males, 88 range of 9 to 44 activities. Table SI (supporting information
females). Most were Caucasian (n=128, 66%), with 28 (14%) published online) lists participation rates for all activities, and
Hispanic, 11 (6%) African-American, and 18 (9%) of other shows that young people with SCI participate mostly in seden-
races (data on race were missing for nine participants, 5%). tary, informal activities.
The mean age at interview was 13 years 2 months (SD 3y Young people participated more often in informal activities
8mo, range 6–18y), and the mean age at injury was 7 years (t174=29.84, p<0.001) and reported higher levels of enjoyment
2 months (SD 5y 8mo, range 0–17y); 137 participants (71%) with these (t174=2.01, p=0.046). When participating in formal
had paraplegia, and 57 (29%) had tetraplegia. The injuries activities young people were more socially engaged
were due to vehicular or pedestrian accidents (n=97, 50%), (t174=)16.26, p<0.001). Further, formal activities were more
medical or surgical interventions (n=58, 3 ⁄ 10), violence (n=17, community-based than activities in the informal domain
9%), sports activities (n=15, 8%), falls (n=5, 2%), or other or (t174=)16.08, p<0.001).
unknown causes (n=2, 1 ⁄ 100). Primary caregivers interviewed
were predominantly mothers (n=150, 77%); 21 (11%) were How participation relates to sex and age
fathers, 10 (5%) were grandmothers, three (2%) were other Two two-way MANOVAs were conducted to evaluate the
family members, and no data on relationship were available for relationship between a child’s sex and age and informal and
10 caregivers (5%). Of the 180 caregivers for whom informa- formal participation (see Table III for mean participation
tion on education was available, 116 (64%) had some college scores by subgroup).
experience. One hundred families (51%) reported living in a For informal participation (n=194), the combined depen-
small town or rural area, and 87 (45%) lived in a city, urban, or dent variables were significantly related to child sex
suburban area (data were not available for seven families, 4%). (F4,187=4.11, p=0.003, partial g2=0.08) and age (F4,187=13.76,

470 Developmental Medicine & Child Neurology 2010, 52: 468–474

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Table II: Mean (SD) scores for the Children's Assessment of Participation and Enjoyment (CAPE) dimensions

Domain

Dimension Overall (55 items) Informal (40 items) Formal (15 items)

Items endorsed on average, n (%) 24 (43) 21 (53) 3 (18)

Participants endorsing at least one activity, n (%) 194 (100) 194 (100) 175 (90)
Diversity 23.83 (6.50) 21.09 (5.32) 2.74 (2.05)
Intensity (possible score range 1–7) 2.08 (0.61) 2.56 (0.69) 0.90 (0.69)a
With whom (possible score range 1–5) 2.65 (0.52) 2.52 (0.53) 3.71 (1.00)a
Where (possible score range 1–6) 2.81 (0.62) 2.64 (0.65) 4.17 (1.17)a
Enjoyment (possible score range 1–5) 3.97 (0.52) 3.97 (0.53) 3.85 (0.99)b

a
p<0.001; bp<0.05.

p<0.001, partial g2=0.23), but not to their interaction quent analyses revealed that young people aged 13 to 18 years
(F4,187=0.60, p=0.664). Subsequent analyses revealed that were more socially engaged when participating in formal activ-
females participated more often in and enjoyed informal activ- ities (F1,171=7.80, p=0.005).
ities more than males did (females: F1,190=7.57, p=0.007; males:
F1,190=8.45, p=0.004). Further, younger children (aged 6–12y) How participation relates to child, injury-related, household,
participated more often in informal activities (F1,190=26.33, and community variables
p<0.001), whereas young people aged 13 to 18 years were Two three-way MANOVAs were conducted to evaluate the
more socially engaged and community based when participat- relationship between injury level, caregiver education, and
ing in informal activities (F1,190=22.37, p<0.001; F1,190=13.39, community type and the dimensions of informal and formal
p<0.001 respectively). participation.
For formal participation (n=175), the combined dependent For informal participation (n=180), the combined dependent
variables were significantly related to child age (F4,168=3.41, variables were significantly affected by injury level (F4,169=3.17,
p=0.010, partial g2=0.08), but not sex (F4,168=1.59, p=0.179) or p=0.015, partial g2=0.07), but not by caregiver education
the interaction of age and sex (F4,168=0.726, p=0.575). Subse- (F4,169=2.40, p=0.052) or community type (F4,169=0.414,

Table III: Mean (SD) scores for the Children's Assessment of Participation and Enjoyment (CAPE) dimensions, by subgroup variable and domain (informal or
formal participation)

Dimension

Variable Domain Diversity Intensity With whom Where Enjoyment

Current age
6–12y Informal 23.45 (4.71) 2.82 (0.69) 2.31 (0.33) 2.43 (0.48) 4.04 (0.54)
13–18y 19.51 (5.13) 2.38 (0.63) 2.66 (0.58) 2.79 (0.72) 3.93 (0.52)
6–12y Formal 3.06 (2.08) 1.00 (0.63) 3.45 (1.08) 4.02 (1.19) 3.88 (0.91)
13–18y 2.52 (2.01) 0.83 (0.73) 3.90 (0.90) 4.28 (1.14) 3.84 (1.04)
Sex
Females Informal 22.36 (5.09) 2.70 (0.63) 2.49 (0.54) 2.56 (0.57) 4.10 (0.50)
Males 20.04 (5.29) 2.45 (0.71) 2.55 (0.52) 2.71 (0.71) 3.88 (0.53)
Females Formal 2.81 (1.89) 0.89 (0.61) 3.89 (0.90) 4.14 (1.15) 3.78 (1.14)
Males 2.68 (2.18) 0.92 (0.76) 3.55 (1.07) 4.20 (1.19) 3.91 (0.83)
Injury level
Tetraplegia Informal 18.91 (4.82) 2.31 (0.60) 2.58 (0.48) 2.66 (0.68) 4.02 (0.56)
Paraplegia 22.00 (5.27) 2.66 (0.70) 2.50 (0.55) 2.64 (0.65) 3.96 (0.52)
Tetraplegia Formal 2.14 (1.80) 0.73 (0.58) 3.62 (1.14) 4.12 (1.36) 3.78 (1.19)
Paraplegia 2.99 (2.10) 0.97 (0.72) 3.75 (0.95) 4.19 (1.08) 3.88 (0.90)
Caregiver education
College Informal 21.85 (5.35) 2.63 (0.69) 2.47 (0.48) 2.60 (0.63) 3.95 (0.51)
No college 19.72 (4.80) 2.44 (0.62) 2.63 (0.60) 2.71 (0.71) 4.02 (0.56)
College Formal 3.03 (2.10) 0.97 (0.66) 3.67 (0.96) 4.25 (1.10) 3.94 (0.82)
No college 2.19 (1.73) 0.76 (0.60) 3.88 (1.04) 4.10 (1.32) 3.61 (1.24)
Type of community
Urban Informal 21.91 (5.92) 2.66 (0.79) 2.50 (0.53) 2.61 (0.70) 3.94 (0.54)
Rural 20.42 (4.71) 2.48 (0.59) 2.54 (0.53) 2.65 (0.62) 4.02 (0.51)
Urban Formal 2.80 (2.31) 0.92 (0.79) 3.79 (1.05) 4.11 (1.18) 3.84 (1.04)
Rural 2.74 (1.85) 0.91 (0.62) 3.67 (0.96) 4.23 (1.16) 3.85 (0.95)

Participation in Children with Spinal Cord Injury Sara Klaas et al. 471
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Table IV: Mean (SD) scores on `where' and `enjoyment' dimensions of formal participation of the Children's Assessment of Participation and Enjoyment
(CAPE) as a function of caregiver education and child level of injury

Caregiver education

Participation dimension Child level of injury College No college F statistic p value

Wherea Paraplegia 4.16 (1.10) 4.30 (1.06) F1,154=4.75 0.031

Tetraplegia 4.50 (1.07) 3.70 (1.69)
b
Enjoyment Paraplegia 3.89 (0.82) 3.81 (1.06) F1,154=5.01 0.027
Tetraplegia 4.11 (0.82) 3.22 (1.49)

a
Higher score=more community-based participation; bhigher score=more enjoyment in participation.

p=0.799), nor by the interaction of these factors. Subsequent socially engaged with their participation, and their informal
analyses revealed that young people with paraplegia partici- participation is more community-based than that of younger
pated more in informal activities (F1,172=10.12, p=0.002). children. This appears to be developmentally appropriate as
For formal participation (n=162), the combined dependent teenagers enter the phase of identity versus role confusion
variables were significantly affected by caregiver education where peer relationships take center stage. This finding is con-
(F4,151=4.01, p=0.004, partial g2=0.10), but not level of injury sistent with trends in the general population for the transition
(F4,151=1.92, p=0.110) or community type (F4,151=1.75, through adolescence,20 perhaps indicating a normal develop-
p=0.142). Subsequent analyses revealed that young people with mental milestone being reached as young people with disabili-
parents with college experience participated more in formal ties move away from their primary caregivers.
activities (F1,154=6.99, p=0.009) and reported greater enjoy- In terms of injury-related, household, and community char-
ment in formal activities (F1,154=8.70, p=0.004) There was also acteristics, injury level affected participation frequency, with
a significant interaction of caregiver education by injury level young people with paraplegia undertaking increased informal
(F4,151=2.67, p=0.034, partial g2=0.07). Subsequent analyses participation, possibly indicating that they have a more diverse
revealed significant interactions related to where young people set of participation opportunities available to them. Caregiver
participate in formal activities and how much they enjoy for- education affected formal participation in that young people
mal participation (Table IV). with caregivers with college experience participated more fre-
quently in formal activities and experienced increased enjoy-
DISCUSSION ment in such activities. The interaction of caregiver education
In this research, we explored patterns of participation and lev- by injury level suggests that caregiver education plays a more
els of enjoyment in children with SCI and assessed how partic- important role among young people with tetraplegia in terms
ipation changes across child, injury-related, household, and of where they participate and how much they enjoy participa-
community variables. This study adds to the current body of tion. Parents with college experience may have more ideas
knowledge on children with physical disabilities by providing about participation options for their children, have additional
the most comprehensive information to date about participa- financial resources, know how to access additional support,
tion patterns for a sample of young people with SCI. and have jobs that allow flexibility for parents to ensure that
Results indicate that young people with SCI participate their children are connected to activities. Particularly for par-
more often in informal activities. This is consistent with other ents without college exposure, it is imperative that education
studies in which young people with disabilities have been on participation be provided during rehabilitation to ensure
found to participate less often in structured and more often in that young people have access to opportunities and develop a
quiet, sedentary activities.5,6,9,10,14 When young people with well-balanced leisure lifestyle.
disabilities do participate in formal activities, they are more These findings indicate the importance of understanding
socially engaged and community based than with informal participation among young people with SCI and of educating
activities. This highlights the importance of formal activities as young people and family members about opportunities for
a potential bridge to expanding networks and experiences, and participation. Rehabilitation staff should conduct thorough
demonstrates the importance of providing such opportunities. leisure evaluations of patients with SCI, including their pre-
In terms of demographic characteristics, our results indicate injury activities and preferences. Identifying activities that a
that informal participation is related to both age and sex of the child wants to participate in after the injury and addressing
child, and formal participation is related to age. Females and any obstacles that may limit participation are essential.
younger children reported participating in more informal Addressing unique personal issues (such as injury level, age,
activities, and females reported enjoying informal participation sex, motivation, and fears) as well as environmental issues
more than males did. This is consistent with previous (such as physical accessibility, knowledge of adaptive pro-
research6 showing that as children with physical disabilities grams, and transportation) must both be priorities if the goal
get older their overall participation decreases, particularly in is to enhance interest in participation and minimize obstacles.
informal activities. Older adolescents are, however, more Frequently identified barriers to participation, such as

472 Developmental Medicine & Child Neurology 2010, 52: 468–474

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functional ability, cost of adaptive programs or equipment, by looking at capacity, opportunity, and choice.21 Specific to
and geographic location of opportunities, can be discussed and the CAPE, participation can also be explored at the activity
planned for, and barriers minimized. level, as young people are likely to participate in activities at
One additional area of concern that should be addressed differing rates, and activities are likely to have varying levels of
with families is the low level of formal participation for chil- importance. Finally, this study offered a new way of analyzing
dren with disabilities. Formal activities, those that are orga- the CAPE dimensions by creating a frequency composite that
nized, structured, and often led by an adult leader, are essential is a product of diversity and intensity scores. Future research
for development. These activities enhance skills, competence, should evaluate the utility and importance of the various
social relationships, and overall physical and mental health. dimensions of participation.
Our findings are consistent with a recent study showing lower
levels of formal than informal participation in children with Conclusion
disabilities and lower levels of formal participation and enjoy- Participation of children with disabilities promotes physical,
ment than in children without disabilities.14 Understanding emotional, and social well-being.22 Current societal trends
the significant role that formal participation plays for all chil- toward homebound, sedentary activities have negatively
dren, and particularly for those with disabilities, is vital. affected children and adolescents. Having a solid understand-
The present study has a number of limitations. This study ing of the patterns of participation and enjoyment of young
is limited to children and adolescents with SCI from a single people with SCI can positively affect the children, their fami-
hospital system, which may not be representative of the overall lies, and their rehabilitation providers. Participation patterns
pediatric SCI population. This study did not include a mea- for those with SCI often start during the rehabilitation pro-
sure of socio-economic status, a construct that is likely to be cess, which makes the rehabilitation setting an ideal place for
critical to determining opportunities for participation. Fur- intervention.
ther, this study lacked age- and sex-matched controls of young This research enhances our understanding of participa-
people without disabilities; without this comparison group it is tion patterns in children with SCI and adds to the grow-
hard to make definitive statements about the participation of ing knowledge base related to children with physical
young people with SCI. We also experienced limitations in disabilities. It is essential that these patterns are understood
terms of our measurement of participation. Although the in order to provide children and adolescents with physical
CAPE measures participants’ enjoyment of each activity disabilities a wide variety of appropriate opportunities for
assessed, there is no subjective measure of satisfaction with participation.
overall participation. Such subjective ratings should be taken
into account in future research, as two children with the same ACKNOWLEDGEMENTS
amount of objective participation may experience varying We thank the young people and their caregivers who graciously par-
degrees of satisfaction. ticipated in this research, as well as the anonymous reviewers for their
Researchers should also continue to work towards a more helpful comments on an earlier draft.
comprehensive understanding of the context of participation,
and examine how participation among young people with SCI SUPPORTING INFORMATION
relates to variables such as pre-injury participation, family par- Additional supporting information may be found in the online version
ticipation, quality of life, and child and caregiver mental of this article:
health. Further, in order to facilitate successful intervention Table SI: Frequency of participation in activities assessed in the
efforts, researchers should continue to investigate the relation- Children’s Assessment of Participation and Enjoyment (CAPE)
ship between modifiable variables at various levels that may Please note: Wiley-Blackwell are not responsible for the content or
affect the patterns of participation and enjoyment. Future functionality of any supporting materials supplied by the authors. Any
work can build on the recently articulated capability model queries (other than missing material) should be directed to the corre-
which combines the person, their resources, and the context sponding author for the article.

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