While the history of sports for the DA can be traced back a century, the development of junior-level activities and competition can be measured only in a few short decades. The NWAA created a junior division in the early 1980s that encompassed children and adolescents from 6 to 18 years of age. It has since established the annual Junior Wheelchair Nationals. Junior-level participation and programming have been adopted by many other organizations, including the National Wheelchair Basketball Association (NWBA), DS/USA, and American Athletic Association of the Deaf (AAAD). Sports for youth with disabilities are increasingly available in many communities through Adapted Physical Education (APE) programs in schools, inclusion programs in Scouting, Little League baseball, and others.

EXERCISE IN PEDIATRICS: PHYSIOLOGIC IMPACT

It is widely accepted that exercise and physical activity (PA) have many physical and psychological benefits. Much research has been done to support this in adults. More recently, data has been presented to describe the benefits of exercise in both healthy children and those with chronic disease.

Exercise programs in healthy children have resulted in quantifiable improvements in aerobic endurance, static strength, flexibility, and equilibrium (2). Regular PA in adolescence is associated with lower mean adult diastolic blood pressures (3). However, a survey of middle school children showed that the majority are not involved in regular PA or physical education (PE) classes in school (4). Despite this, school days are associated with a greater level of PA in children at all grade levels than free days (5). Requiring PE classes in school improves the level of PA in children, but does not lower the risk for development of overweight or obesity (6) without dietary education and modification (7). Children attending after-school programs participate in greater amounts of moderate and vigorous PA than their peers (8).

Obesity is increasing in epidemic proportions among children in developed countries. It has been linked to development of the metabolic syndrome (defined as having three or more of the following conditions: waist circumference ≥ 90th percentile for age/sex, hyperglycemia, elevated triglycerides, low- and high-density lipoprotein [HDL] cholesterol, and hypertension) (9); both obesity and metabolic syndrome are more common in adolescents with lower levels of PA (10). Insulin resistance is reduced in youth who are physically active, reducing the risk of developing type 2 diabetes (11). Exercise in obese children can improve oxygen consumption and may improve cardiopulmonary decrements, including resting heart rate (12). An 8-week cycling program has been shown to improve HDL levels and endothelial function (13), though in the absence of weight loss, had little effect on adipokine levels (14).

Exercise has positive effects on bone mineralization and formation. Jumping programs in healthy prepubescent children can increase bone area in the tibia (15) and femoral neck, and bone mineralization in the lumbar spine (16). The effects of exercise and weight-bearing may be further enhanced by calcium supplementation (17). The effects on postpubertal teens are less clear.

In children with chronic physical disease and disability, the beneficial effects of exercise are beginning to be studied more systematically. Historically, it was believed that children with cerebral palsy (CP) could be negatively impacted by strengthening exercises, which would exacerbate weakness and spasticity. Recent studies show this to be untrue. Ambulatory children with CP who participate in circuit training show improved aerobic and anaerobic capacity, muscle strength, and health-related quality-of-life scores (18). In ambulatory adolescents with CP, circuit training can reduce the degree of crouched gait and improve perception of body image (19). Performing loaded sit-to-stand exercises results in improved leg strength and walking efficiency (20,21).

Supervised physical training can safely improve aerobic capacity and muscle force in children with osteogenesis imperfecta (24). Patients with cystic fibrosis who participate in stationary cycling for aerobic conditioning dislike the tedium of the exercise, but improve their muscle strength, oxygen consumption, and perceived appearance and self-worth (25). Pediatric severe-burn survivors have lower lean body mass and muscle strength compared with nonburned peers; however, both are significantly improved following exercise training (26).

Children with polyarticular juvenile idiopathic arthritis have safely participated in aerobic conditioning programs, with improvements noted in strength and conditioning. Those with hip pain may be negatively impacted, having increased pain and disability (27). The exercise prescription in children experiencing hip pain should be modified to reduce joint forces and torques.

Joint hypermobility and hypomobility syndromes commonly result in pain. These patients demonstrate lower levels of physical fitness and higher body mass indexes, likely secondary to deconditioning (28). These and other children with pain syndromes benefit from increased exercise and PA.

EXERCISE IN PEDIATRICS: PSYCHOSOCIAL IMPACT

The U.S. Department of Health and Human Services published in 2010 that 31% of children (ages 4–11) were reported to be sad, unhappy, or depressed compared with 17% of children without disabilities (29). Regular PA in early childhood through adolescence fosters not only improvements in physical health, but also psychosocial health and development (30,31). The amount and quality of PA have significantly declined over the past several decades and even able-bodied (AB) children are no longer meeting the recommended guideline of 1 hour or more of moderate-intensity PA on 5 or more days a week (32). In disabled children, the amount of PA is even more restricted due to a variety of factors, including the underlying disability, physical barriers, and availability of resources (33). Sit et al. noted that the amount of time spent by children in moderate PA at school during PE and recess was lowest for children with a physical disability, at 8.9%, and highest for children with a hearing loss, at 16.6% of recommended weekly minutes (34). Studies involving AB children have demonstrated that providing game equipment and encouragement from teachers can significantly increase moderate activity levels during recess (35). Deviterne et al. reported that providing participant-specific written and illustrated instruction concerning sporting activities such as archery to adolescents with motor handicaps improves their skill performance to a level similar to an AB adolescent at the end of the learning session that can foster increased self-esteem (36).

Many studies have demonstrated increased social isolation with fewer friendships among disabled children and adolescents. The Ontario Child Health Study revealed that children with a chronic disability had 5.4 times greater risk of being socially isolated and 3.4 times greater risk of psychiatric problems (37). Mainstreaming seems to have a positive impact, although concerns regarding AB peer rejection are still pervasive (38). Children in integrated PE programs were more likely to view their disabled peers as “fun” and “interesting” compared to children who were not integrated (39). One study of teacher expectations in mainstreamed PE classes revealed significantly lower expectations for the disabled student’s social relations with peers (40). The attitude toward mainstreamed PE among high school students was significantly more positive in the AB group as opposed to the disabled population (41). Disabled children often view their lack of physical competence and, second, the status among their peers as the major barriers in social competence (42).

In addition to regular PA, play is a major component of childhood and important in psychosocial development of children. In preschool children with developmental delay or mental retardation, they were more likely to play on their own or not participate in play compared to the typically developing peers. Placing them in an integrated playgroup increased peer interactions compared to a nonintegrated playgroup, but did not correct the discrepancy in sociometric measures (43). There have also been discrepancies noted in the type of play for children with developmental delays. These children are less likely to participate in imaginative or constructive play (ie, creating something using play materials) and more likely to participate in functional (ie, simple repetitive tasks) and exploratory play (44). It has been suggested that play should be taught, and one study by DiCarlo demonstrated that a program that taught pretend play increased independent pretend toy play in 2-year-old children with disabilities (45).

In another study, children with motor disabilities were surveyed regarding how they perceived their technical aids in play situations. Younger children viewed their braces, crutches, walkers, or wheelchairs as an extension of themselves and helpful in play situations. Older children also saw the equipment as helpful, but a hindrance in their social life, as it made them different from their peers. Both older and younger children saw the environment as a significant barrier to play. Playgrounds often had fencing surrounding the area, sand, and equipment such as swings or slides that were not accessible without the assistance of an adult. The weather impacted accessibility due to difficulty maneuvering on ice or through snow. Children often took on an observational role on the playground or stayed inside. It was noted that the lack of accessibility sent the message that children with DA were not welcome and further isolated the DA group. As far as adult assistance, the younger children often incorporated the adult as a playmate. As children became older, they viewed their adult assistants as intrusive and a hindrance in social situations. Older children often chose to stay at home and be alone rather than going somewhere with an adult (46).

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.

PARTICIPATION IN PHYSICAL ACTIVITY

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 nonvocational 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).

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.

The purpose of classification is to minimize the impact of impairments on the activity (sport discipline). Thus having the impairment is not sufficient. The impact on the sport must be proved, and in each Paralympic sport, the criteria of grouping athletes by the degree of activity limitation resulting from the impairment are named “Sport Classes.” Through classification, it is determined which athletes are eligible to compete in a sport and how athletes are grouped together for competition. This, to a certain extent, is similar to grouping athletes by age, gender, or weight. Classification is sport-specific because an impairment affects the ability to perform in different sports to a different extent. As a consequence, an athlete may meet the criteria in one sport, but may not meet the criteria in another sport (IPC, 2007).

ADAPTING RECREATION OPPORTUNITIES

Camping

Both land and sea fishing opportunities are accessible to the disabled. Piers are usually ramped and may have lowered or removable rails for shorter or seated individuals. Boats with barrier-free designs offer fishing and sightseeing tours at many larger docks. These offer variable access to one or all decks, toilet facilities, and shade (85).

Hunting

Adaptations to crossbows and rifles have made hunting accessible for many. The crossbow handle and trigger can be modified for those with poor hand function. Stands for rifles and crossbows are also available for support. Many hunting ranges have incorporated wheelchair-accessible blinds.

Dance

Dancing has become more popular in the AB and disabled populations over the past 15 years. The wheelchair is considered an artistic extension of the body, and many dances have been adapted for the movement of the wheels to follow the foot patterns of classical ballroom dancing. Wheelchair dancing was first begun in 1972 and pairs DA and AB individuals in a variety of dances. Recreational opportunities and competition are available in many states, with classes including duo dance featuring two wheelchair dancers together, group dancing of AB and wheelchair competitors in a synchronized routine, and solo performances. Wheelchair dance sport has been a recognized sport within the Paralympics since 1998, although it is not currently included in the program. International competition in wheelchair dance has been around since 1977. In addition, ballet, jazz, and modern dance companies offer inclusion for children with disabilities.

Martial Arts

Martial arts classes include children with a variety of disabilities. The classes can be modified to allow skills at the wheelchair level in forms, fighting, weapons, and breaking. Children are taught self-respect, control, and can advance through the belt system. They are also taught basic self-defense in some settings. There are many different styles of martial arts, and parents should check within their communities for available resources. Equipment adaptations are not needed for this activity.

Scuba and Snorkeling

Freedom from gravity makes underwater adventure appealing to individuals with mobility impairments. Little adaptation to equipment is needed to allow older children and adolescents with disabilities to experience the underwater world. Lower-limb-deficient children may dive with specially designed prostheses or with adapted fins, or may choose to wear nothing on the residual limb. Similar to those with lower limb weakness or paralysis, they may use paddles or mitts on the hands to enhance efficiency of the arm stroke. Of particular importance is the maintenance of body temperature, especially in individuals with neurologic disability, such as spinal cord injury or CP. Wet or dry suits provide insulation for cool or cold water immersion. They also provide protection for insensate skin, which can be easily injured on nonslip pool surfaces, coral, and water entry surfaces.