Chapter 5 The Effects of Aquatic Intervention on Perceived Physical Competence and Social Acceptance in Children with Cerebral Palsy

Transcription

1 The Effects of Aquatic Intervention on Perceived Physical Competence and Social Acceptance in Children with Cerebral Palsy Getz, M., Hutzler, Y., & Vermeer, A. (2006). Manuscript submitted for publication.

2 Abstract Purpose: The aim of this study was to compare the effects of aquatic intervention with those of land-based intervention on social function, perceived competence, and social acceptance in children with cerebral palsy (CP). Twenty two children (F=17; M=5) with spastic diplegia CP participated in the study: 12 in the aquatic intervention group (5:4 yr +.95) and 10 in the exercise intervention group (4:9 yr +.99). Social function was measured by the Pediatric Evaluation of Disability Inventory (PEDI) social function domain. Perceived competence and social acceptance was measured by the Pictorial Scale of Perceived Competence and Social Acceptance for Children with CP. Results: Paired t-tests were used to evaluate differences between groups across all measures, and Pearson correlations were carried out to reveal relationships. Because of small group sizes, effect sizes were calculated across measures for each dependent variable. Results were calculated for each dependent variable before and after a four-month intervention period. No significant changes were found between groups in perceived physical competence. Significant differences (t=2.26, p<.035) were found between groups in social acceptance in favor of the aquatic group. No significant differences were found between groups in the PEDI social function. Significant differences were found between pre-test to post-test scores in the PEDI caregivers social function domain (t=- 3.78, p<.003) in the aquatic intervention group but not in the exercise group (t= -2.11, p<.065). Conclusion: Aquatic intervention appears to have a positive effect on perceived social acceptance and social function as reported by caregivers. 94

3 Perceived Physical Competence and Social Acceptance Introduction Most research concerning therapeutic interventions in children with cerebral palsy (CP) focuses on the physical outcomes of function. According to the International Classification of Functioning, Disability and Health (ICF, 2001) a person s functioning is a result of dynamic interactions of three dimensions of the individual with the environment. The three dimensions are (1) impairments of body structures or body functions; (2) activity limitations such as difficulties in performing a specific task or lacking the skills required for everyday living; and (3) participation restrictions with respect to social roles. According to the ICF, improvement of function and activity levels should facilitate participation. Therefore, the effectiveness of a therapeutic intervention program for children with CP should include evaluation of the children s ability in daily life activities (Scholtes, Vermeer, & Meek, 2002). One of the major motivational factors in initiating and maintaining participation is perceived competence (Harter, 1978). Competent motor behavior can have a positive influence on the development of other behavioral aspects, which in turn can affect overall development (Vermeer, Lanen, Hendriksen, Speth, & Mulderij, 1994). Thus, to encourage their participation children must be made to believe in their competence. White (1959) introduced a one-dimensional theory of competence. He assumed competence to be the main attribute of motivation and that the main attribute to skill mastering was the effect it had on the environment. In other words, the motivation to master a skill is driven by the ability to produce an effect on the environment and it is labeled effectance motivation. If the effect is positive the person is motivated to persist in skill repetition, further enhancing development of the mastered skill; the resulting feeling of joy in turn strengthens motivation. Expanding on White s theory, Harter (1978) described competence motivation as a multi-dimensional concept affected by several constructs, with perceived competence assuming a central role. Harter maintained that the competence experienced by a child can differ across various aspects of competences such as physical, academic, and social. Furthermore, the level of competence can differ between one domain to the other. Thus, a child can have a high competence in the cognitive domain and low competence in the physical domain. Perceived competence is defined as the personal impression of one s own ability in each domain. Harter (1978) also introduced the social environment as an influencing factor 95

4 on competence. Positive or negative feedback from the social environment concerning a specific action can influence perceived competence. Therefore when evaluating the efficacy of functional performance in children, it is important to take into account the motivational factors that may impede or facilitate functional performance (Vermeer, Lijnse, & Lindhout, 2004). CP is defined as a non-progressive insult to a developing or immature central nervous system, particularly to those areas that affect motor function (Gage, 1991). Children with CP typically experience difficulty in developing normal movement patterns. The motor impairment affects the development of motor skills and causes inappropriate compensatory movement patterns that further impede development. Children with spastic CP have been shown to exhibit muscle weakness (Olney & Wright, 2000), coordination deficiencies, increased energy consumption during walking (Maltais, Bar-Or, Galea, & Pierrynowsky, 2000), and low levels of physical activity (Longmuir & Bar-Or, 2000). These impaired attributes may restrict the children s ability to develop positive interactions with the environment and thus affect their physical and social competence. Only a small number of studies have investigated the effects of physical intervention on perceived competence and social acceptance in children with special needs (Sherrill, 1997). Moreover, most research in this area focused on adolescents and not on children with CP According to the ICF, a variable that can enhance motor activity and participation is the environment in which the activity is implemented; this is the contextual factor. It may be argued that outcomes of similar activityoriented interventions can have different effects depending on the environment in which they were carried out. Furthermore, different environments can be beneficial in enhancing different body functions or activities. In a previous study, (Getz, Hutzler, Vermeer, & Yarom, submitted for publication) we have compared the effects of an aquatic intervention and a land-based intervention on energy expenditure and gross motor function in children with CP between the ages 3-6. Results suggested that aquatic interventions are more favorable in decreasing energy expenditure during walking, while exercise intervention is more favorable in affecting gross motor function. However, we did not address psycho-social influences in that particular study. Dodd, Taylor, Nichoals, Graham, and Kerr (2004) evaluated the effects of a six-week strength training program on self-concept in adolescents with CP. Results reported a decrease in the self-concept of adolescents participating 96

5 Perceived Physical Competence and Social Acceptance in the short-term home-based program compared with participants who undertook normal daily activities. The authors concluded that the contextual factor of the training program must be addressed. It has been suggested that swimming and aquatic activities are beneficial for children with motor deficiencies (Christie, 1985; Dumas & Francesco, 2001). The characteristics of the water, including buoyancy, hydrostatic pressure, viscosity, and turbulence can have such beneficial effects on body functions as muscle strengthening, increased vital capacity (Hutzler, Chacham, Bergman, & Szeinberg, 1998), and improved gross motor function (Mackinnon, 1997). From a psychosocial aspect, aquatic activities encourage social participation in group activities (Christie, 1985; Reid Campoin, 1997). In addition, pools are available both in therapeutic and community settings, offering an opportunity for participation and social interactions. We found only three studies investigating the effects of aquatic intervention on perceived competence and social acceptance in children with CP. Peganoff (1984) investigated the effects of an eight-week aquatic intervention on motor performance and self-perception on a 14-year old girl with CP. She reported improvement on daily living activities and active participation in pool sessions. In addition, an improvement was noted in the participant s selfesteem. Dorval, Tetreault, and Caron (1996) reported a significant relationship between self-esteem, functional independence, and aquatics activities in 20 adolescents with CP who participated once a week for 55 minutes in a 10- week program. Hutzler, Chacham, Bergman, and Reches (1998) reported no significant effects in the self-concept of 23 children with CP who participated in a six-month swimming program compared with children who participated in a land-based movement program. The purpose of the present study was to compare the effects of a fourmonth aquatic intervention program with those of a land-based exercise program on perceived physical competence, social acceptance, and social functioning in children with CP. Specifically, the research questions compare the effects of aquatic and land-based intervention programs on: (1) perceived physical competence; (2) social acceptance; and (3) social function. (4) We also investigated the effect of aquatic intervention on functional aquatic skill independence. 97

6 Method We used a controlled group design with an experimental group participating in an aquatic intervention program and a control group participating in a landbased exercise program. Participants Twenty two children (F= 17; M=5) with CP (spastic diplegia) aged 3:8-6 from four kindergartens participated in the study (Table 1). Twelve children were in the aquatic intervention group and ten in the control group. All children met the following criteria: (1) medical diagnosis of CP of the spastic diplegia type; (2) ability to comprehend instructions; (3) special education setting supervised by the Israeli Ministry of Education; (4) no medical procedures (such as casting, operations, or botulinum toxin injections) in the preceding six months; (5) written parental approval. The study was approved by the scientific committee of the Israeli Ministry of Education. Table 1. Distribution of Participants by Gender, Age, and Level of Activity Across Groups Characteristics Aquatic Intervention Exercise Intervention Age (y:m) Gender GMFCS Mean (SD) 5:4 (.95) 4:9 (.99) Male 4 1 Female 8 9 I 1 II 1 2 III

7 Perceived Physical Competence and Social Acceptance Instrumentation Perceived physical and social competence was evaluated by means of the Pictorial Scale of Perceived Competence and Social Acceptance for Children with Cerebral Palsy (Vermeer & Veenhof, 1997). This is a 40- item pictorial scale divided into two general construct areas that include perceived competence and social acceptance. Each construct area is divided into two sub-scales: perceived competence includes cognitive and physical competence, and perceived social acceptance includes acceptance by peers and acceptance by the mother. We administered the items of physical competence and acceptance by peers. Each sub-scale includes 10 items. The test was translated from Dutch into Hebrew and was found valid and reliable in children aged 4-7 with CP (Schnieder, 1998). Items were scored on a fourpoint scale (Figure 1) from 1=not very competent to 4=very competent. We did not administer the cognitive and parental sub-scales because the cognitive and parent-oriented effects were considered to be realistic aims of aquatic and physical interventions. The calculated score for each subscale was the average of the items. The test was administered individually in a secluded room by an adapted activity teacher. In some cases a speech therapist assisted in the administration procedure. The child was shown two pictures and was asked to choose which child he or she most resemble (Figure 1). After choosing a picture, children were asked whether they felt a lot or a little like the child in the picture. Scores were reported on a separate sheet. The time needed for administration of the test varied within a range of 10 to 15 minutes. One child in the experimental group was not able to complete the evaluation in one session, and the test was administered in two consecutive sessions. 99

8 Figure 1. Sample item of the perceived physical competence sub-scale Pediatric Evaluation of Disability Inventory (PEDI). The PEDI (Hayley, Coster, Ludlow, Haltiwanger, & Andrellos, 1992) is a standardized instrument for evaluating functional performance through a structured interview with caregivers and therapists. The PEDI is divided into three domains: (1) self care, (2) mobility, and (3) social function. We evaluated the social function domain, which consists of 65 items scored according to the child s ability to perform a certain item. Items were scored on a scale of 0=not capable to 1=capable. Scores were computed by summing the items. Scaled scores were assigned based on the sums. Speech therapists reported on the social function of the children under their care. The social function domain of the caregivers included five items and was scored according to two scales: (1) the child s degree of independence, scored on a scale of 0=total assistance to 5=independent; (2) a modification scale indicating the type of modifications needed to perform the skill. Kindergarten teachers reported on the care giver social function of the children in their group by means of a structured interview which was administered by an adapted physical activity teacher. Aquatic assessment. The Aquatic Independence Measure (AIM) was used to assess the children s level of skill acquisition in the aquatic environment. AIM was developed in Israel and designed specifically to assess aquatic performance in children with motor deficiencies. Recent evaluation found 100

9 Perceived Physical Competence and Social Acceptance high inter-rater and intra-rater reliability of the instrument (ICC>.99) (Chacham & Hutzler, 2001). The test consists of 22 items graded on a scale of 0=does not initiate to 4=completes the task independently with no assistance, according to the degree of assistance that the child requires to perform a given task. The test is designed to identify independent function rather than quality of movement. All assessments were administered under the same conditions regarding equipment and water temperature. The test was administered according to the following procedure: Each child was in the water with an instructor; the test administrator was outside the water. The test administrator communicated each test item to the aquatic instructor. The child was assessed on the performance of each skill by the test administrator. Procedure Children in the experimental group participated in an ongoing adapted aquatics program conducted in two kindergartens for children with physical disabilities. Children in the control groups were placed in a different kindergarten for children with physical disabilities who did not participate in adapted aquatic sessions as part of their educational curriculum. Pre-test measures were recorded after a minimum of three months attendance in the different programs to ensure habituation to the intervention settings and to the staff. Post-test measures were recorded after a four-month period during which 32 sessions were held in each group. Measures were recorded in a random order. All professionals administering the various measures were blinded to test scores acquired in other measures until all data were collected. Aquatic Intervention The adapted aquatics program consisted of two weekly individualized, 30- minute sessions. Each child was assigned to a trained instructor throughout the program. Goals were individually determined to meet the specific needs of each participant in cooperation with the attending physiotherapist. The 10-point program of the Halliwick method (Lambeck & Stanat, 2001a; 2001b), which includes water adjustment skills, longitudinal rotations, sagittal rotations, and swimming skills was used. Flotation devices were not used. Sessions were constructed of three parts: (1) the first five minutes of each session were devoted to a structured group activity with six children and their instructors. This part encouraged mental adaptation to the aquatic environment and was 101

10 accompanied by rhythmic children s songs that were repeated throughout the program. (2) The second part consisted of a 20-minute period during which children practiced individually or in pairs according to treatment goals. (3) The last five minutes of each session were devoted to group activities and children s songs, and were aimed at ending the session and disengaging the children from the aquatic environment. Exercise Intervention Children in the exercise group were placed in a different kindergarten and administered two weekly, individualized, 30-minute land-based activities as part of their educational curriculum. Activities consisted of (1) an additional physiotherapy session once a week, and (b) an adapted activity program once a week. A certified instructor conducted the adapted activity program. Program objectives were to improve fundamental motor skills such as walking, stepping over obstacles, climbing, catching, and throwing objects. Statistical Analysis Outcome data totals were distributed normally based on the Kolmogorov- Smirnov test. Therefore, parametrical tests were performed as follows: (1) paired t-tests were performed to evaluate differences between groups by using mean individual differences on each measure between the groups; (2) paired sample tests were performed between pre- to post-test scores in each group; (3) because of the small number of participants in each group effect sizes were calculated; (4) relations between measures were obtained by Pearson correlations; (5) multiple regressions analysis was performed on the dependent variables (perceived physical competence, social acceptance, PEDI social function domain, PEDI caregivers social function domain) to identify significant predictors. Results Descriptive statistics and differences between pre- and post-test scores across measures are presented in Table 2. The first analysis was designed to determine whether differences were present between the groups after the intervention period. Significant differences were found between pre- and post-test scores on AIM (t= -3.8, p<.003). 102

11 Perceived Physical Competence and Social Acceptance Perceived Physical Competence and Social Acceptance No significant changes were found in perceived physical competence (PPC) between the aquatic intervention group and the exercise group. Significant differences were found between the groups in social acceptance (SA) (t=2.26, p<.035). The exercise intervention group showed a small decrease on SA while the aquatic intervention group showed an increase (Figure 2). PEDI Social Function Domain No significant differences were found in the PEDI social function domain. No significant differences were found between groups in the PEDI caregivers social domain (t= 1.407, p<.17). An additional analysis was performed to determine whether differences existed within each group before and after the intervention period. Significant differences were found in the PEDI caregivers social domain between the pre- and post-test (t=-3.78, p<.003) in the aquatic group, and non-significant differences in the exercise group (t=- 2.11, p<.065). Regarding correlations in each group: The aquatic intervention group showed the strongest correlation between caregivers pre- and post-test scores (r=.936, p<001) and pre- and post-test scores in the PEDI social function domain (r=.910, p<001). Within the exercise group, the strongest correlation was found between pre- and post-test caregivers scores (r=.96, p<.001). Correlations were also examined between pre- and post-test scores of the PEDI social function domain (r=.639, p<.047) and between caregivers pretest scores and the PEDI social function domain (r=.66, p<.035). 103

12 Table 2. Descriptive and Statistical Data of Group Scores Across Measures Measure Aquatic Intervention (n=12) Exercise Intervention (n=10) Pre-test Post-test ES Pre-test Post-test ES Mean SD Mean SD Mean SD Mean SD PPC PSC PEDI SD PEDI CG AIM PPC = Perceived Physical Competence; PSC = Perceived Social Competence; PEDI SD = Social Domain; PEDI CG = PEDI Caregivers (Social function domain) 104

13 Perceived Physical Competence and Social Acceptance % Figure 2. Mean differences and standard deviations between groups across measures Discussion Despite the literature emphasizing perceived competence as a crucial factor in the developmental process (Sherrill, 2004), evidence-based program recommendations to enhance these aspects in children with CP are extremely limited. The objective of this study was to compare the effects of an aquatic intervention program with those of a land-based exercise program on perceived physical competence and social acceptance in kindergarten children with CP. 105

14 Perceived Physical Competence No significant differences were found between the groups in perceived physical competence following a four-month intervention period. Although, the aquatic intervention group improved significantly on the AIM post-test scores relative to the pre-test (t= -3.8, p<.003), no similar results were obtained between preand post-test scores on PPC, possibly because the majority of the items in the physical competence sub-scale are associated with skills accomplished on land, and only one item refers to an aquatic skill. This may suggest that PPC is context specific. Therefore, when evaluating an aquatic intervention program inclusion of items related to aquatic function is warranted. Perceived Social Acceptance A major finding of this study is the effect of aquatic intervention on social acceptance in children with CP. A significant difference was found between the aquatic intervention group and the exercise group (t=2.26, p<.035). The aquatic intervention group showed an increase in social acceptance, whereas the exercise group reported a decrease. The aquatic environment, specifically buoyancy, enables children to be more active and to initiate multiple social interactions with their instructors and other children. These opportunities are limited on land because of gravitational constraints. White (1959) suggested that movement had a positive effect on motivation, specifically because of interactions affecting the environment. Every movement of the child produces an environmental output (Newell & Valvano, 1998). Furthermore, the aquatic intervention group showed a significant improvement in mastering aquatic skills (t=-3.8, p<.003). It appears that children became more independent in the aquatic environment and therefore able to initiate more social interactions with fewer physical limitations. This may further suggest that physical limitations can be viewed as a barrier in achieving social acceptance. Social Function A significant difference was found in the PEDI caregivers social function domain between pre- and post-test scores: (t=-3.78, p<.003) for the aquatic group, compared with (t=-3.8, p<.065) for the exercise group. Two explanations are proposed for this outcome: (1) Exposure of the kindergarten teachers to the aquatic intervention. Kindergarten teachers and teaching assistants brought the children to the pool area, assisted with removing 106

15 Perceived Physical Competence and Social Acceptance the clothing and with dressing, and watched the activities. Exposure of the educational staff to possibilities for movement demonstrated by children in the aquatic environment, and specifically the social interactions observed in the group activities might have influenced their perceptions on the children s abilities. In contrast, caregivers in the exercise group were used to seeing the children in land-based activities. Therefore, the contextual factor may have influenced these results. (2) The aquatic group showed a significant increase in social acceptance resulting in an improvement in social function in daily situations as measured by PEDI. In summary, our findings indicate that aquatic interventions appear to have a positive effect on social acceptance and social function as reported by caregivers by means of PEDI. The aquatic environment and treatment seem to lead to positive social interactions that carry over to daily life situations. As the main barrier before children with CP is freedom of movement, placing them in a movement enabling environment such as the water can lead to positive experiences that can affect development in other domains. These preliminary results should be viewed with caution because of several limitations. First, we were unable to assess scores on outcome measures before the beginning of the program because of program constraints. Second, there was a seven-months difference between the average age in the two groups, which can account for some of our results. Third, there was a small number of participants in each group, which limits the generalizability of the results. Finally, we were unable to randomize the placement of children in the intervention groups because the programs were part of the children s educational curriculum. 107

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