development and initial validation of the children participation questionnaire (cpq)

RESEARCH PAPER

Development and initial validation of the Children ParticipationQuestionnaire (CPQ)

LIMOR ROSENBERG1, TAL JARUS2 & ORIT BART3

1Department of Occupational Therapy, School of Health Professions, Sackler Faculty of medicine, Tel Aviv University,2Department of Occupational Science and Occupational Therapy, CanDo research center, Faculty of Medicine, University of

British Columbia, Vancouver, Canada, and 3Department of Occupational Therapy, School of Health Professions, Sackler

Faculty of medicine, Tel Aviv University

Accepted January 2010

AbstractPurpose. To develop and test the psychometric properties of a parent-reported questionnaire measuring participation ofpreschool children (Children Participation Questionnaire; CPQ) aged 4–6 years in their everyday activities.Methods. Reliability was tested by Cronbach’s a and by test–retest. Construct validity was computed by known groupdifferences analysis. Convergent and divergent validities were calculated by correlation with the Vineland AdaptiveBehaviour Scale (VABS). Two hundred thirty-one children with mild to moderate developmental disabilities (mean age5.16 + 0.66 years old) were compared to 249 children without disability (mean age 5.13 + 0.72 years old).Results. The CPQ has good internal reliability. Cronbach’s a for the participation measures ranged between 0.79 and 0.90,indicating good homogeneity. The temporal stability of the CPQ was supported with intra-class correlations ranging from0.71 to 1.00. Significant differences were found between children with and without disabilities in all the CPQ measures. TheCPQ could also differentiate between age groups and groups of varying socio-economic status. Convergent and divergentvalidity were supported.Conclusions. The CPQ has demonstrated good psychometric properties and can be used as a reliable and valid measure toassess children’s participation at the age of 4–6 years.

Keywords: Child participation, participation measurement, parent’s questionnaire

Introduction

Participation is defined by the World Health

Organization (WHO) [1] as involvement in life

situations and as engagement in occupations of

daily activities that are essential for development,

life experience and well-being [2]. Throughout

childhood, participation is the process and the

product of development [3–6]. Participation is a

multi-dimensional construct affected by many per-

sonal factors, such as gender, chronological or

developmental age, performance skills, and en-

vironmental factors, such as accessibility, supportive-

ness or socio-economic status [7–9]. Enhancing

children’s participation is an ultimate goal of rehabi-

litation in children with diverse health status and

disabilities.

Evaluating participation is essential for setting

goals, implementation of treatment programmes,

and evaluation of intervention efficacy [8,10].

Although the number of researchers investigating

participation in various paediatric populations has

increased [11–18], most focus on school age children

older than 6 years, with severe developmental

disabilities. A literature search [2,10,19,20] for the

assessment tools designed to measure child partici-

pation reveals a paucity of tools appropriate to

capture the full essence of the construct of parti-

cipation. Most of these tools, for example the

School Function Assessment (SFA) [21], Children’s

Correspondence: Limor Rosenberg, Department of Occupational Therapy, School of Health Professions, Sackler Faculty of medicine , Tel Aviv University,

Ramat Aviv, Tel Aviv, 69978, Israel. E-mail: [email protected]

Disability and Rehabilitation, 2010; 32(20): 1633–1644

ISSN 0963-8288 print/ISSN 1464-5165 online ª 2010 Informa UK, Ltd.

DOI: 10.3109/09638281003611086

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Assessment of Participation and Enjoyment (CAPE)

[22] and the Assessment of Life Habits (LIFE-H)

[23] are originally designed, as mentioned pre-

viously, for school-aged children with severe dis-

abilities. Little is known about participation patterns

of younger children with mild to moderate develop-

mental disabilities, although these children make up

the majority of referrals to developmental paediatrics

clinics [24]. It is especially important to assess

participation of young children as their function at

this age may predict their scholastic and social

adjustment in later years [25].

Several authors [8,10,20,26] discuss measurements

of participation according to the International Classi-

fication of Functioning, disability and health (ICF)

model, emphasising the importance of assessing the

actual doing of activity rather than capability [27]. It is

also suggested that participation measurement has to

reflect the child’s engagement in all areas of occupa-

tion that are common to children in their home,

educational setting and community [2,10,19,28]. In

addition participation should be measured by objective

dimensions, such as diversity (what one does),

intensity (how often one does it), and independence

(how much assistance one needs), alongside

with subjective dimensions such as how much enjoy-

ment and satisfaction one finds [2,8]. In constructing

participation evaluation methods for young children,

gathering information through their parents is recom-

mended in the literature [23,28]. Parents’ reports are

considered to be a sensitive, reliable and valid source

of information [29,30]. Moreover, the use of parents’

reports may be inexpensive and feasible [31].

Therefore, the purpose of the present study is to

develop and test the psychometric properties of a

parent-reported questionnaire measuring participation

of children (Children Participation Questionnaire;

CPQ) aged 4–6 years. We hypothesise that the CPQ

will be reliable and valid. In light of the ICF model and

previous findings that demonstrated personal factors

[7,9,32–35] and environmental factors [36–38] af-

fecting child participation, we predicted that the

CPQ participation measures will be able to differ-

entiate between age groups, between children with

and without developmental disabilities, and between

children from diverse socio-economic statuses. We

also hypothesise that construct validity will be

supported by significant correlations between the

CPQ and the Vineland Adaptive Behaviour Scale

(VABS) [39], which is an established functional

measure that is being used for validity studies

[30,20]. Specifically, we hypothesise that the objec-

tive measures of the CPQ will correlate with the

VABS to ascertain convergent validity, whereas

divergent validity will be supported by lower

correlations of the VABS to the CPQ subjective

measures, as this aspect is not included in the VABS.

Construction of the questionnaire

Children Participation Questionnaire description

The CPQ is a parent-completed questionnaire for

children aged 4–6 years. In order to avoid ambiguity

about the operational definition of participation, we

chose the Occupational Therapy Practice Frame-

work (OTPF) definition [40] to guide the CPQ

construction. The OTPF provides a classification

system (or taxonomy) of areas of occupations and

activities.

Based on the OTPF, the CPQ contains 44

activities in six areas of occupations: activities of

daily living (ADL; e.g. dressing), instrumental

activities of daily living (IADL; e.g. setting the

table), play (e.g. pretend play, computer games),

leisure (e.g. bicycle riding, listening to a story), social

participation (e.g. visiting a friend) and education

(e.g. drawing and graphic-motor exercises in a

preschool classroom). For each activity in which a

child participates, parents report on intensity, child’s

independence level, child enjoyment and their

satisfaction. Thus, the questionnaire yields five

participation measures: participation diversity (D)

is the number of activities in which a child

participates (maximum 44); participation Intensity

(I) is the child’s mean participation frequency

ranging from 0 (never) to 5 (everyday); indepen-

dence (Ind) is the mean assistance level of the child

ranging from 1 to 6, where 6 means fully indepen-

dent; child enjoyment (E) is the mean level of the

child’s enjoyment ranging from 1 to 6 and parent

satisfaction (PS) is the mean Parent Satisfaction with

the performance of their child, ranging from 1 to 6,

where 6 indicates highest enjoyment or satisfaction.

In addition, if needed, each total measure (diversity,

intensity, child enjoyment, and parent satisfaction)

can be split into six subtotal scores for each area of

occupation (i.e. ADL, IADL, play, leisure, social

participation, and education; see Appendix).

Children Participation Questionnaire content validity

In the first stage of the CPQ construction, we

phrased the questionnaire items based on all the

areas of occupation as outlined in the OTPF and

adjusted them to fit the activities and performances

of young children. We defined the measurement

indexes and selected the measurement scales. The

first version of the questionnaire was reviewed by a

group of six paediatric occupational therapists, and a

group of three occupational therapy academic

researchers to establish the questionnaire content

validity [41]. Based on their feedback, 4 items were

added and 3 were shifted from one category to

1634 L. Rosenberg et al.

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another. Measurement scales were enlarged from 1–4

to 1–6 in order to increase the variability of the scores

and prevent ceiling effect. The revised version of the

CPQ was introduced to three paediatric occupational

therapy teams who pilot tested the questionnaire with

10 parents of treated children and 10 of non-treated

children. All the parents affirmed that the 44 activities

of the CPQ covered the full range of their children’s

life. Parents’ questions, comments and feedback were

discussed by team members and the researchers.

Based on those discussions, a few items were

rephrased (e.g. ‘free play’ was rephrased to ‘pretend

play’), examples were added where necessary (e.g. to

the activity of ‘use of arts and crafts materials’ we

added a list of materials, such as glue, clay and finger

paints), and the instruction guide was rewritten.

Following those steps, a final version was designed

(see Appendix).

Methods

Participants

We performed a power analysis using the data from a

pilot study (N ¼ 100, 50 for each group of children

with and without disability). The Diversity measure

did not differ between the two groups, therefore we

did not consider it in the calculation of sample size.

Assuming a 5% level of significance, 80% power and

a moderate effect size (Cohen’s d ¼ 0.5) [42,43],

247 participants were required per group based on

the Participation Intensity measure (the other CPQ

measures required much smaller sample sizes ran-

ging from 31 to 35 per group).

Five hundred twenty-eight parents were recruited

through a convenience sampling method and com-

pleted the CPQ. Nine per cent of the questionnaires

were incomplete and therefore only 480 children and

their parents participated in the study. Two hundred

thirty-one children (45 girls, 186 boys, mean age

5.16 + 0.66 years old) were recruited from seven

paediatric occupational therapy clinics in central and

northern Israel. To be included in this group, parti-

cipants had to attend regular preschool and had to be

referred to occupational therapy evaluation because of

mild or moderate developmental difficulties, including

clumsiness, gross motor difficulties, fine motor delays,

visual motor difficulties, sensory sensitivity, attention

deficit disorder or learning disabilities. The second

group contained 249 children without developmental

disabilities (45 girls, 204 boys, mean age 5.13 + 0.72

years old). There were no significant differences

between the two groups in age, gender and family

income. Sixty participants (23 children with disabil-

ities, 37 children without disabilities) were from

families with below average income, 222 participants

(115 children with disabilities, 107 children without

disabilities) were from families with average income

and 195 participants (91 children with disabilities, 104

children without disabilities) were from families with

above average income.

Measurements

Vineland Adaptive Behaviour Scale [39]. The VABS is

a semi-structured interview addressed to parents or

caregivers to assess children’s adaptive behaviour

from birth to 18 years of age. Originally the VABS

was developed for children with intellectual disabil-

ities to assess child adaptive behaviour in four

dimensions: ADL, communication, motor skills

and socialisation. The VABS was chosen to establish

criterion validity of the CPQ as it is the only

instrument that assesses similar constructs to those

of the CPQ, and is commonly used in validity studies

of developing new tools [20,30]. The VABS has

sound psychometric properties [44].

Procedure

Ethical approval was provided by the Behavioural

Research Ethics Board of Tel-Aviv University. Parents,

who agreed to participate in the study, received

information about the procedure and purpose of the

study, signed a consent form and completed the CPQ

independently at their own convenience. The ques-

tionnaires were collected a few days later. To assess

test–retest reliability, a randomly selected sub-sample

of 40 parents, 20 from each group (with and without

disabilities), completed the questionnaire twice in a 2-

week interval. To assess convergent and divergent

validity, another sub-sample of 108 parents of children

without disabilities was also interviewed for the

completion of the VABS [39].

Data analyses

For establishing the CPQ homogeneity (internal

consistency), we used Cronbach’s a coefficient and

Spearman correlations to calculate inter-item corre-

lations. For establishing temporal stability (test–retest

reliability), we used k test and intra-class correlations

(ICC). k 5 0.40 was considered poor to fair, and

0.41–0.60 indicated moderate agreement. k 4 0.61

is considered as a good level of agreement, and when

it exceeds 0.80 the agreement is very good [45]. The

ICC as the parametric equivalent test of the k can be

interpreted the same. The construct validity of the

CPQ was tested using two-way analysis of variance

(ANOVA) tests to establish group differences

The Child Participation Questionnaire 1635

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between age groups and diagnostic groups. Two

hundred six participants were assigned to the young

preschoolers’ group (M ¼ 4.48, SD ¼ 0.32, range

4.00–5.00) and 274 were assigned to the older

preschoolers’ group (M ¼ 5.65, SD ¼ 0.42, range

5.01–6.99). In addition, two-way ANOVA was

computed with group (with and without disability)

and family income (below average, average, above

average) as ‘between-group’ factors and participation

measures (Diversity, Intensity, Independence, child

enjoyment, Parent Satisfaction) as a ‘within-subject’

factor. We used the Eta square (Zp2) results to assess

effect size. Zp2 5 0.06 is considered to be poor, and

above 0.14 is considered to be high [46]. Convergent

and divergent validities were calculated using Spear-

man correlation between the CPQ measures and the

VABS subscales. To support convergent validity,

based on similar validity studies [47,48], we expected

significant, small to moderate correlations (around

0.4) between the objective measures of the CPQ and

the VABS subscales. To support divergent validity we

expected no significant or lower correlations (around

0.2) between the subjective measures of the CPQ and

the VABS subscales.

Results

Reliability of the Children Participation Questionnaire

Internal consistency reliability. Cronbach’s coefficient awas calculated to examine how well all items

measured the same construct and contributed to

the total assessment score, with 0.70 specified as an

acceptable level [49]. The a coefficients for the CPQ

total measures (Participation Intensity, Indepen-

dence Level, child enjoyment, and Parent Satisfac-

tion) and for each area of occupation (ADL, IADL

etc.) are presented in Table I. We did not calculate

an a coefficient for participation diversity as it is a

categorical measure. Of note, the reliability of all the

total measures is above acceptable level and

much higher than the reliability of each area of

occupation.

Test–retest

Temporal stability of each of the 44 activities on all

the CPQ total measures (i.e. participation diversity,

Participation Intensity, Independence Level, child

enjoyment, and Parent Satisfaction) was calculated

using k. When k could not be analysed we calculated

the agreement percentage. The temporal stability of

the CPQ was supported with a k ranging from 0.28

to 1.00 (96% of the calculated items scored between

moderate to very good), and an agreement percen-

tage ranging from 41 to 100% for all 44 activities6 4

measures.

Test–retest for the mean scores of the 5 CPQ total

measures (average scores across all 44 activities) were

calculated using ICC. The ICC results ranged from

0.84 to 0.90, exhibiting very good agreement (see

Table II).

Construct validity

Homogeneity. Estimating correlations between subt-

ests with the total score is a known procedure to anal-

yse homogeneity. Homogeneity of subtests indicates a

single construct [50]. Table III presents correlations

between the six areas of occupation with the CPQ total

measures. All associations were moderate to high,

significantly correlated, except for two significant low

correlations in the ADL area of occupation. Results

support the homogeneity of the CPQ.

Group and age differences

Two-way ANOVA was computed with group (with

and without disability) and age (young pre-schoolers,

old pre-schoolers) as ‘between-group’ factors for

each of the participation measures (diversity, inten-

sity, independence, child enjoyment, parent satisfac-

tion) as ‘within-subject’ factors. Table IV presents

means and standard deviations of CPQ participation

measures by group and age. No significant interac-

tion effect was found for group and age.

Table I. The Cronbach’s a coefficients for the CPQ total measures and sub-total measures for each area of occupation (N¼ 480).

Area of occupation Intensity Independence

Child

enjoyment

Parent

satisfaction

CPQ total measures 0.79 0.89 0.88 0.90

CPQ sub-total measures

ADL 0.57 0.68 0.68 0.66

IADL 0.45 0.65 0.63 0.62

Play 0.49 0.64 0.70 0.78

Leisure 0.62 0.70 0.70 0.76

Social participation 0.70 0.79 0.71 0.78

Education 0.52 0.78 0.78 0.77


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A significant main effect for age was found for

the total participation diversity measure [F(1,

479) ¼ 6.14, p 5 0.05, Zp2 ¼ 0.01]; and for the

total independence level measure [F(1,

479) ¼ 21.72, p 5 0.01, Zp2 ¼ 0.04] although the

clinical significance is low. In both groups, younger

children participated in fewer tasks compared to their

older peers (M ¼ 38.33 + 2.69, M ¼ 38.91 +2.86, respectively) and were less independent

(M ¼ 4.98 + 0.54, M ¼ 5.18 + 0.51, respectively)

while performing the activities included in the CPQ.

In the other three total CPQ participation measures

(Intensity, child enjoyment, and Parent Satisfaction),

no main effects were found.

A significant main effect for group was found in all

CPQ total measures. It was found that children with

disabilities participated in fewer activities (F(1,

479) ¼ 10.27, p 5 0.001, Zp2 ¼ 0.02) in lower

frequencies (F(1, 479) ¼ 13.00, p 5 0.001, Zp2 ¼

0.03), and were less independent (F(1,

479) ¼ 37.86, p 5 0.001, Zp2 ¼ 0.07). Their

enjoyment was decreased (F(1, 479) ¼ 44.97,

p 5 0.001, Zp2 ¼ 0.09), and their parents were less

satisfied with their children’s participation (F(1,

479) ¼ 64.59, p 5 0.001, Zp2 ¼ 0.12) (see Table

IV for means and SD).

Group and income differences

Two-way ANOVA was computed with group (with

and without disability) and family income (below

average, average, above average) as ‘between-group’

factors for each of the participation measures

separately (diversity, intensity, independence, enjoy-

ment, parent satisfaction). Table V presents means

and standard deviations of the CPQ total participa-

tion measures by group and family income.

Table II. ICC of the CPQ total measures, and for each area of occupation (N¼ 40).

Diversity Intensity Independence Child enjoyment Parent satisfaction

CPQ total measures 0.84 0.89 0.88 0.85 0.87

ADL – – 0.91 0.84 0.88

IADL 0.90 0.83 0.72 0.78 0.75

Play 1.00 0.87 0.87 0.85 0.83

Leisure 0.71 0.89 0.80 0.88 0.85

Social Participation 0.87 0.78 0.89 0.90 0.89

Education 0.96 0.90 0.95 0.89 0.96

ADL, Activity of Daily Living; IADL, Instrumental Activity of Daily Living.

Table III. Spearman Correlations between the areas of occupation with the CPQ total participation measure (N¼480).

Diversity Intensity total Independence total Child Enjoyment total Parent Satisfaction total

ADL .16** .18** .62** .68** .67**

IADL .67** .53** .64** .62** .65**

Play .40** .57** .67** .62** .73**

Leisure .51** .75** .82** .77** .82**

Social Participation .71** .63** .72** .63** .73**

Education .68** .50** .70** .75** .74**

**p5.0001.

Table IV. Means and standard deviations of CPQ total participation measures (diversity, intensity, independence, child enjoyment, parent

satisfaction) by group and age (N¼480).

Children with disabilities

(mean+SD)

Children without disabilities

(mean+SD) Total (mean+SD)

Young

(N¼ 94)

Old

(N¼137)

Young

(N¼ 112)

Old

(N¼137)

Children with

disabilities

(N¼ 231)

Children without

disabilities

(N¼ 249)

Participation diversity 37.70+ 2.82 38.67+ 2.90 38.86+2.46 39.15+ 2.81 38.28+2.90 39.02+ 2.66

Participation intensity 3.85+ 0.25 3.87+ 0.30 3.95+0.32 3.97+ 0.28 3.86+0.28 3.96+ 0.30

Independence level 4.86+ 0.59 5.01+ 0.56 5.07+0.47 5.36+ 0.39 4.95+0.57 5.23+ 0.45

Child enjoyment 5.28+ 0.42 5.27+ 0.46 5.49+0.39 5.56+ 0.32 5.27+0.44 5.53+ 0.36

Parent satisfaction 5.12+ 0.55 5.12+ 0.61 5.43+0.47 5.57+ 0.37 5.12+0.58 5.57+ 0.37


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A significant interaction effect was found for

group and family income in the participation

diversity measure (F(2, 476) ¼ 4.24, p 5 0.05,

Zp2 ¼ 0.02). Children with disabilities with a family

income below average participated in fewer activities

as compared to the other two groups (see Figure 1).

A significant main effect for family income was

found for the participation intensity measure (F(2,

476) ¼ 10.31, p 5 0.001, Zp2 ¼ 0.04). Participation

Intensity of children from families with below

average income was higher than that of children

from families with average and above average

income. A significant main effect for Income was

also found for the Independence measure (F(2,

476) ¼ 4.59, p 5 0.05, Zp2 ¼ 0.02) and for the

child enjoyment measure (F(2, 476) ¼ 6.08, p 50.05, Zp

2 ¼ 0.03). Children from families with above

average income were less independent and enjoyed

less everyday activities compared to their peers from

families with average and below average income. No

significant differences were found between the three

income levels in parent satisfaction.

Convergent and divergent validities

Convergent and divergent validities were computed

using Spearman correlations between the CPQ total

measures (diversity, intensity, independence, child

enjoyment, and parent satisfaction) and the VABS

subscales (ADL, Communication, Socialisation, and

Motor skills; see Table VI). Convergent validity was

partially supported by the significant, low to moder-

ate correlations between the objective CPQ total

participation measures (i.e. participation diversity,

participation intensity, and independence level) and

all the VABS subscales (except VABS Communica-

tion with Participation Intensity). In particular,

substantial correlations were found with the ADL

subscale of the VABS.

No significant correlations or low correlations

were found between the subjective CPQ total

participation measures (i.e. child enjoyment and

Parent Satisfaction) and the VABS Communication,

Socialisation, and Motor subscales (except VABS

ADL with child enjoyment), thus partially support-

ing the divergent validity of the CPQ.

Discussion

This study offers a new tool, the CPQ, for measuring

preschool child participation. The CPQ is grounded

in a family-centred approach, and assesses child

participation according to the parent’s perspective.

To capture all dimensions of the multi-dimensional

Table V. Means and standard deviations of CPQ participation measures (diversity, intensity, independence, enjoyment, parent satisfaction)

by group and family income (N¼477).

Children with disabilities (mean+SD) Children without disabilities (mean+SD)

Below

average

(N¼ 23)

Average

(N¼ 115)

Above

average

(N¼ 91)

Below

average

(N¼ 37)

Average

(N¼107)

Above

average

(N¼ 104)

Participation diversity 35.26+4.30 38.16+2.72 39.21+2.06 37.38+ 3.95 39.33+ 2.12 39.27+ 2.41

Participation intensity 4.01+0.36 3.86+0.30 3.82+0.22 4.11+ 0.36 3.96+ 0.31 3.90+ 0.26

Independence level 5.15+0.54 4.97+0.61 4.85+0.53 5.23+ 0.41 5.30+ 0.42 5.16+ 0.48

Child enjoyment 5.47+0.38 5.30+0.48 5.19+0.39 5.56+ 0.35 5.57+ 0.32 5.47+ 0.39

Parent satisfaction 5.25+0.67 5.13+0.62 5.06+0.51 5.54+ 0.43 5.54+ 0.38 5.45+ 0.46

Figure 1. Children’s participation diversity by family income level.


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and complex concept of participation, we used five

participation measures: participation diversity (the

number of activities a child takes part in), participa-

tion intensity (how often participation occurs),

independence level (how much assistance is re-

quired), child enjoyment and parent satisfaction.

Our findings suggest adequate initial psychometric

support for the CPQ as a promising new measure for

assessing pre-schooler’s participation in everyday

activities.

The internal consistency of the CPQ total mea-

sures is found to be good based on Cronbach’s acoefficient values which range from 0.79 to 0.90 in all

four participation measures. These results substanti-

ate the evidence that for each total measure (intensity,

independence, child enjoyment, and parent satisfac-

tion) all items measure the same underlying construct

and each are internally consistent. However, the

internal consistency of each area of occupation (i.e.

subtotal scores) is lower. These differences may be

due to the different length of the various scales. The

temporal reliability of the CPQ is adequately sup-

ported, although the test-retest sample size is small.

Similarly to the a results, the reliability coefficients of

the CPQ total measures are higher than that of the

individual items. Therefore, we suggest using the

CPQ total participation measures, which have higher

reliability, as the CPQ scores. Those scores reflect the

essence of participation as a complex construct.

However, it may be possible to cautiously use the

subtest scores for more detailed information if

needed, especially for clinical practice.

In order to examine the construct validity of the

CPQ, we used a group comparison method to

determine whether the CPQ can distinguish between

groups that are believed to score differently based on

theory. Our findings indicate that the CPQ has

satisfactory construct validity and the questionnaire

is sensitive enough to significantly differentiate

between participation patterns of children with and

without mild or moderate disabilities. In addition,

the CPQ can significantly differentiate between age

groups, and between children in families of different

socio-economic statuses.

Specifically, two CPQ participation measures can

significantly discriminate between the two assessed

age groups despite the narrow target age range of the

questionnaire (4–6.11 years old). The two

distinguishing measures are participation diversity

and independence level. Older children are usually

more independent and engaged in more diverse

activities than younger children, as would typically

occur in normal development. The participation

intensity measure does not discriminate between age

groups, as the timetable of children in these two age

groups are stable and mainly structured by their

parents [26, 33]. No differences are found between

age groups in child enjoyment and parent satisfaction

measures as these measures are not thought to

change across preschool years. As a whole, subjective

measures of participation that reflect well-being do

not appear to be strongly related to demographic

variables such as age or gender, at least not before

adolescence [51,52].

All the five CPQ total participation measures

significantly discriminate between children with and

without mild or moderate developmental disabilities.

These results are in accordance with the literature

describing decreased participation of children with

developmental disabilities in comparison to children

without developmental disabilities [7,16], and thus

support the CPQ construct validity. Although all

CPQ total participation measures can discriminate

between groups, their magnitude differs. Based on

the effect size, independence level, child enjoyment,

and parent satisfaction are the best discriminant

measures. Thus the unique format of the CPQ can

deepen our understanding about the implications of

even mild or moderate developmental disabilities on

well-being of children and their parents.

As it is documented that family income is one of the

fundamental contextual factors affecting child devel-

opment and participation [9,37], we compared the

participation of children from three family income

groups (below average, average, and above average).

All the CPQ total participation measures discriminate

between family income groups except for the parent

satisfaction measure. Children from families with

below average family income participate in fewer

activities. However, they were more independent than

children from the other two income groups. For the

diversity measure, an interaction effect is found

Table VI. Spearman correlations between the CPQ measures (Diversity, Intensity, Independence, Child Enjoyment, Parent Satisfaction)

and the VABS subscales (ADL, Communication, Socialisation, and Motor skills) of children without developmental disabilities (N¼108).

VABS Communication VABS ADL VABS Socialisation VABS Motor

Participation Diversity .42** .40** .36** .38**

Participation Intensity .18 .47** .36** .41**

Independence Level .29** .55** .36** .46**

Child Enjoyment .16 .41** .21* .24*

Parent Satisfaction .10 .33** .20* .22*

*p5.05; **p5.001.


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between income and group. This indicates that the

diversity participation measure of children who are

referred to occupational therapy services, and who are

from above average families, do not differ from

children without disabilities from the same socio-

economic status. Differently, children with disability

from below average income families exhibit the lowest

participation diversity scores. Taking together these

results, we may assume that high family income may

serve as a protective factor for participation diversity of

children with mild and moderate developmental

disabilities. These findings enrich our understanding

of how participation is affected by contexts. While

comparing the groups of children with and without

disabilities, the differences between the groups in the

child independence and parent satisfaction measures

are the highest, based on the Zp2 analysis. However,

while comparing family income groups, the most

significant measure is participation diversity. Family

income, as an environmental factor, contributes

differently to the variation in children’s participation.

These findings illuminate the unique contribution

of each one of the five CPQ total participation mea-

sures to the multidimensional construct of participa-

tion, and thus enhance the CPQ construct validity.

Although the effect of group, age and income are

significant, their effect sizes are small to moderate.

We assume that these results are due to the sample

characteristics. Our study consists of children with

mild or moderate developmental disabilities (chil-

dren with severe developmental disabilities were

excluded). We used a narrow age range, and all the

children have similar backgrounds. On the other

hand, the relatively small effect size between group,

age and income may reflect some traits of participa-

tion that should be further studied.

Convergent and divergent validities of the CPQ

are partially demonstrated by comparison with the

VABS. Although the correlations between the two

questionnaires were only calculated for children

without disabilities, meaningful results were ob-

tained. Higher levels of convergent validity (ex-

pressed by higher correlations) are found between

the three objective CPQ total measures, diversity,

intensity, and independence, and VABS subscales

which address similar theoretical constructs. Not

surprisingly, the highest correlations are found

between the ADL subscale of the VABS and all

the CPQ total measures, which reflect the similar-

ity in content addressed by these measures (i.e.

dressing oneself, helping setting the table). Yet,

lower correlations are found between the CPQ

total measures and the VABS-communication

subscale which reflects the dissimilarities in the

content addressed by these subscales.

Divergent validity is partially supported by the

absence of significant correlations or low correlations

between the subjective CPQ total measures, child

enjoyment and parent satisfaction, and all the VABS

subscales (except VABS–ADL where stronger corre-

lations were found). This indicates that the child

enjoyment and parent satisfaction, which were not

part of existing and conventional functional assess-

ment tools, are new measures unique to the CPQ.

These measures are subjective measures that reflect

well-being and life satisfaction, which are considered

to be essential inherent aspects of participation and

health outcomes according to the ICF model. Our

findings accentuate the importance of these mea-

sures to the study of child participation and the

unique contribution of the CPQ to this evolving

body of knowledge.

Limitations and conclusions

The gender imbalance in our sample (more boys

than girls) is in accordance to the higher prevalence

of boys in many developmental disabilities groups.

Previous literature discusses gender differences in

activities and occupations throughout childhood [20,

46]; however in our study we could not find gender

differences in the CPQ total measures. Further study

is needed to clarify gender differences in participa-

tion patterns of children at younger ages.

The reliability of the CPQ temporal stability

should be further assessed as we used relatively small

sample size in the current test–retest study. In

addition, we studied children with mild or moderate

developmental disabilities from relatively similar

demographic backgrounds which may limit the

generalisability of the findings. The convergent and

divergent validity of the CPQ should be further

assessed with diverse populations.

In conclusion, the CPQ has demonstrated accep-

table psychometric properties. Therefore, the CPQ

can be used as a reliable and valid measure to assess

children’s participation at the age of 4–6 years. The

findings support that the CPQ can assess participation

in everyday activities through multidimensional mea-

sures. Thus the CPQ enables us to derive important

information about participation. Further studies

should focus on the suitability of the questionnaire to

other populations, its feasibility for intervention plan-

ning and its responsiveness to treatment.

Acknowledgements

This work was performed in partial fulfillment of the

requirements for Ph.D. degree of Limor Rosenberg,

Sackler Faculty of medicine, Tel Aviv University,

Israel. We are grateful to the parents and children

who participated in this study.


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Appendix. Children Participation

Questionnaire (CPQ).

Child Participation Questionnaire

Dear parent,

This questionnaire is intended to learn the participa-

tion habits of your child in different day to day

occupations.

Thank you for your responsiveness, this information

will assist in determining the goals of the treatment,

and in determining the efficiency of the treatment in

the future.

Name of child: Date of birth:

Name of parent: Current date:

This questionnaire is intended to learn about your

child’s participation in the various activities typical

for children aged 4–6. Please answer in accordance

to what your child actually does, and not what your

child is capable of doing.

Regarding the last three months, mark the following

for every activity:

1- The number representing how frequently

your child participates in a certain activity,

according to the key at the top of the table (for

example: showers- everyday, visits a friend-

twice a week, etc). In the event that your child

does not participate in a certain activity at all

(frequency of-0) there is no need to answer the

rest of the questions regarding that activity.

2- The degree of help/assistance/ encourage-

ment/ escorting, your child requires in parti-

cipating in the activity at hand (for example:

help dressing, guidance in playing a game,

parental presence at a friend’s birthday party).

3- In your opinion, the degree of pleasure

your child obtains from the activity (pleasure,

motivation, will to carry out).

4- The degree of satisfaction you have as a

parent, from the frequency of participation

and from your child’s independence in the

activity in general.

- In the event that an activity your child

participates in is not mentioned in the

questionnaire you could add it to the

questionnaire in the designated spot.

- Refer to the activities your child per-

forms outside the preschool.

- Only in the article of ‘‘Education’’ will

you be asked to regard the participation in

preschool, in the event you do not know,

consult with the teacher and converse with

your child.

Remember this information will assist in identifying

the activities in which you would like to see a change.


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Ap

pen

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1

Fre

qu

ency

of

par

tici

pat

ion

Deg

ree

of

assi

stan

ce

Ch

ild

’sp

leas

ure

inp

arti

cip

atin

g

Par

enta

lsa

tisf

acti

on

fro

m

child

’sp

arti

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atio

n

Th

eac

tivi

ty

0-

nev

er1

-o

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inth

ree

mo

nth

s

2-

1,2

am

on

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-o

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-ev

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day

Nee

ds

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ch

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dep

end

ent

Do

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ot

take

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re

Tak

esm

uch

ple

asu

re

No

tat

all

sati

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Ver

y

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Ed

uca

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n

1.

Att

end

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me

01

23

45

12

34

56

12

34

56

12

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56

2.

Pla

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23

45

61

23

45

61

23

45

6

3.

Tak

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01

23

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12

34

56

12

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56

12

34

56

4.

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12

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51

23

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61

23

45

61

23

45

6

5.

Att

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kin

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gar

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01

23

45

12

34

56

12

34

56

12

34

56

6.

Do

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and

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ts

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gar

ten

01

23

45

12

34

56

12

34

56

12

34

56

7.

Usi

ng

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and

craf

ts

mat

eria

lsat

kin

der

gar

ten

01

23

45

12

34

56

12

34

56

12

34

56

8.

Att

end

ing

kin

der

gar

ten

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mo

nie

s/p

arti

es

01

23

45

12

34

56

12

34

56

12

34

56

9.

Tak

ing

sport

/d

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ng

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tern

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n

01

23

45

12

34

56

12

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56

12

34

56

10

.T

akin

gm

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c/ar

t

less

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tern

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01

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12

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12

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34

56

11

.T

akin

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gu

ages

)

01

23

45

12

34

56

12

34

56

12

34

56

12

.O

ther

acti

vity

:__________

01

23

45

12

34

56

12

34

56

12

34

56

(e.g

.m

ovi

e,th

eatr

e)

11

.O

ther

acti

vity

:__________

01

23

45

12

34

56

12

34

56

12

34

56

So

cia

lP

arti

cip

ati

on

1.

Pla

yin

gw

ith

afr

ien

d0

12

34

51

23

45

61

23

45

61

23

45

6

2.

Vis

itin

gat

afr

ien

ds

ho

use

01

23

45

12

34

56

12

34

56

12

34

56

3.

Invi

tin

gan

dh

ost

ing

afr

ien

d0

12

34

51

23

45

61

23

45

61

23

45

6

4.

Att

end

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frie

nd

’sb

irth

day

par

ties

01

23

45

12

34

56

12

34

56

12

34

56

5.

Go

ing

tofa

mily

even

ts0

12

34

51

23

45

61

23

45

61

23

45

6

6.

Sle

epin

go

ver

atfa

mily

ho

use

01

23

45

12

34

56

12

34

56

12

34

56

7.

Sle

epin

go

ver

ata

frie

nd

’sh

ou

se0

12

34

51

23

45

61

23

45

61

23

45

6

8.

Tal

kin

gon

the

ph

on

e0

12

34

51

23

45

61

23

45

61

23

45

6

9.

Oth

erac

tivi

ty:

____________

01

23

45

12

34

56

12

34

56

12

34

56

Pla

y

1.

Ch

oo

sin

ga

gam

e0

12

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51

23

45

61

23

45

61

23

45

6

2.

Pla

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ith

con

stru

ctio

nto

ys

(bu

ild

ing

blo

cks,

pu

zzle

s)

01

23

45

12

34

56

12

34

56

12

34

56

(con

tinued

)


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nly.

Ap

pen

dix

.(C

onti

nued

).

Fre

qu

ency

of

par

tici

pat

ion

Deg

ree

of

assi

stan

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Ch

ild

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ure

inp

arti

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g

Par

enta

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tisf

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m

child

’sp

arti

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n

Th

eac

tivi

ty

0-

nev

er1

-o

nce

inth

ree

mo

nth

s

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am

on

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-o

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aw

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4-

twic

ea

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k5

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ds

mu

ch

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end

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Do

esn

ot

take

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re

Tak

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re

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all

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Pla

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01

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4.

Pla

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61

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5.

Tak

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or

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01

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12

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Leis

ure

1.

Ch

oo

sin

ga

leis

ure

acti

vity

(occ

up

yo

nes

elf)

01

23

45

12

34

56

12

34

56

12

34

56

2.

Pla

yin

go

np

layg

rou

nd

equ

ipm

ent

01

23

45

12

34

56

12

34

56

12

34

56

3.

Rid

din

ga

bik

e0

12

34

51

23

45

61

23

45

61

23

45

6

4.

Pla

yin

gb

all

gam

es0

12

34

51

23

45

61

23

45

61

23

45

6

5.

Lis

ten

ing

toa

sto

ry0

12

34

51

23

45

61

23

45

61

23

45

6

6.

Wat

chin

gT

V0

12

34

51

23

45

61

23

45

61

23

45

6

7.

Do

ing

arts

and

craf

ts

ath

om

e

01

23

45

12

34

56

12

34

56

12

34

56

8.

Usi

ng

art

and

craf

tm

ater

ials

01

23

45

12

34

56

12

34

56

12

34

56

9.

Go

ing

for

ad

aytr

ip,

pic

nic

,ca

mp

ing

01

23

45

12

34

56

12

34

56

12

34

56

10

.G

oin

gto

alive

even

t0

12

34

51

23

45

61

23

45

61

23

45

6

AD

L

1.

Dre

ssin

g0

12

34

51

23

45

61

23

45

61

23

45

6

2.

Sh

ow

erin

g/

Bat

hin

g0

12

34

51

23

45

61

23

45

61

23

45

6

3.

Bru

shin

gT

eeth

01

23

45

12

34

56

12

34

56

12

34

56

4.

To

ilet

ing

01

23

45

12

34

56

12

34

56

12

34

56

5.

Eat

ing

wit

hcu

tler

y0

12

34

51

23

45

61

23

45

61

23

45

6

6.

Oth

erac

tivi

ty:

_________

01

23

45

12

34

56

12

34

56

12

34

56

IAD

L

1.

Tak

ing

par

tin

Org

aniz

ing

roo

m/

ho

use

01

23

45

12

34

56

12

34

56

12

34

56

2.

Tak

ing

par

tin

Mea

l

pre

par

atio

n/

sett

ing

the

tab

le

01

23

45

12

34

56

12

34

56

12

34

56

3.

Op

erat

ing

elec

tro

nic

dev

ice

(TV

,D

VD

,p

ho

ne)

01

23

45

12

34

56

12

34

56

12

34

56

4.

Sh

op

pin

gin

gro

cery

sto

re0

12

34

51

23

45

61

23

45

61

23

45

6

5.

Tak

ing

care

of

pet

01

23

45

12

34

56

12

34

56

12

34

56

6.

Oth

erac

tivi

ty:

__________

01

23

45

12

34

56

12

34

56

12

34

56


Dis

abil

Reh

abil

Dow

nloa

ded

from

info

rmah

ealth

care

.com

by

Nat

iona

l Sili

cosi

s L

ibra

ry o

n 10

/29/

14Fo

r pe

rson

al u

se o

nly.

development and initial validation of the children participation questionnaire (cpq)

Documents