Children’s Assessment of Participation and Enjoyment

Abstract

The Children’s Assessment of Participation and Enjoyment (CAPE) and its companion tool, the Preferences for Activities of Children (PAC), are standardized, questionnaire-based psychometric instruments developed to evaluate day-to-day activity participation and subjective engagement among children and youth aged 6 to 21 years outside of their mandatory school curriculum. Developed by Gillian King, Mary Law, Susanne King, Patricia Hurley, Steven Hanna, Marilyn Kertoy, and Nancy Rosenbaum in 2004 through the CanChild Centre for Childhood Disability Research, the instrument operationalizes the “Participation” construct codified within the International Classification of Functioning, Disability and Health (ICF) framework established by the World Health Organization (WHO). The CAPE evaluates 55 distinct formal and informal activities spanning five categorical activity domains: Recreational, Active Physical, Social, Skill-Based, and Self-Improvement. For each activity performed within a four-month recall period, the CAPE captures five multidimensional parameters of participation: Diversity (whether the activity is performed; binary 0/1), Intensity (frequency of performance on an ordinal 7-point scale), With Whom (social contextualization on an ordinal 1-to-5 scale), Where (geographic-environmental setting on an ordinal 1-to-6 scale), and Enjoyment (affective appraisal on a 5-point Likert-type scale). The PAC assesses child preference across the identical 55 items using an authentic 3-point categorical rating scale. Psychometric validation studies demonstrate acceptable to high test-retest reliability (intraclass correlation coefficients [ICC] ranging from .64 to .86 for overall intensity and diversity across cohorts with and without physical disabilities), adequate internal consistency across activity domain subscales, and robust construct, discriminative, and convergent validity when compared against measures of functional independence, gross motor capability, and pediatric health-related quality of life.

Keywords

Children’s Assessment of Participation and Enjoyment, CAPE, Preferences for Activities of Children, PAC, pediatric participation, leisure activities, occupational therapy, International Classification of Functioning Disability and Health, pediatric rehabilitation, psychometrics, child enjoyment, activity diversity, activity intensity

Authors

The CAPE and PAC assessment battery was authored by a collaborative, interdisciplinary team of clinical researchers and methodologists based primarily at the CanChild Centre for Childhood Disability Research at McMaster University in Hamilton, Ontario, Canada:

• Gillian King, Ph.D. — Senior Scientist at Bloorview Research Institute, Holland Bloorview Kids Rehabilitation Hospital, and Professor in the Department of Occupational Science and Occupational Therapy at the University of Toronto. Formerly Research Associate at CanChild Centre for Childhood Disability Research, McMaster University.
• Mary Law, Ph.D., OT Reg. (Ont.) — Professor Emeritus in the School of Rehabilitation Science and Co-Founder of CanChild Centre for Childhood Disability Research, McMaster University. Globally recognized leader in occupational therapy theory, co-developer of the Person-Environment-Occupation (PEO) model and the Canadian Occupational Performance Measure (COPM).
• Susanne King, M.Sc. — Research Coordinator and Associate at CanChild Centre for Childhood Disability Research, McMaster University.
• Patricia Hurley, M.Sc. — Research Assistant and Project Coordinator at CanChild Centre for Childhood Disability Research, McMaster University.
• Steven D. Hanna, Ph.D. — Associate Professor in the Department of Health Research Methods, Evidence, and Impact (HEI) and CanChild Scientist, McMaster University; biostatistician specializing in longitudinal growth curves and pediatric outcome modeling.
• Marilyn Kertoy, Ph.D., CCC-SLP — Associate Professor in the School of Communication Sciences and Disorders, Faculty of Health Sciences, Western University (University of Western Ontario), London, Ontario.
• Nancy Rosenbaum, M.A. — Research Associate and Clinical Project Director at CanChild Centre for Childhood Disability Research, McMaster University.
• Dutch Adaptation Authors: Maurits K. Bult, M.Sc., Marian J. Jongmans, Ph.D., Marjolijn Ketelaar, Ph.D., and Paul J. M. Helders, Ph.D., PT (2010), representing University Medical Center Utrecht, Rehabilitation Center De Hoogstraat, and Utrecht University, the Netherlands.

Purpose

The foundational purpose of the Children’s Assessment of Participation and Enjoyment (CAPE) is to provide a standardized, child-centered, ecologically valid measure of everyday leisure, recreational, and life skill activities outside the mandatory school curriculum. Historically, pediatric clinical assessments predominantly focused on body structures, physiological impairments, and isolated motor or cognitive skills measured within artificial clinic settings. However, clinical advances during the late 1990s and early 2000s catalyzed by the World Health Organization shifted focus toward human functioning in real-life settings. This paradigm shift demanded psychometric instruments capable of quantifying dynamic, community-based life participation as experienced directly by the child.

The CAPE satisfies this need by answering fundamental developmental and clinical questions: What activities does the child engage in? How frequently do they do them? With whom do they interact during these occupations? Where do these activities take place physically and environmentally? And critically, how much affective pleasure and fulfillment does the child derive from their participation? Unlike observational checklists completed exclusively by proxy informants, the CAPE prioritizes the child’s subjective voice through self-administration or standardized clinician-assisted visual sorting protocols utilizing illustrated activity cards.

In pediatric clinical practice—spanning occupational therapy, physical therapy, speech-language pathology, developmental pediatrics, and pediatric physiatry—the CAPE serves as a baseline diagnostic mapping tool, an intervention planning guide, and a longitudinal outcome measure. By identifying patterns of low diversity or restricted social context (e.g., activities performed exclusively alone at home), therapists formulate individualized, family-centered therapy goals directed at overcoming physical, environmental, or attitudinal barriers to leisure. In research contexts, the CAPE provides empirical metrics to examine structural disparities in community engagement between typically developing youth and children navigating neurodevelopmental, sensory, or physical impairments, including cerebral palsy, autism spectrum disorder, developmental coordination disorder, and spina bifida.

Psychological Construct

The CAPE operationalizes participation not as a unidimensional count of behaviors, but as a complex, dynamic psychological and behavioral construct comprising multiple discrete dimensions:

1. The Five Evaluative Dimensions of Participation

• Diversity: The breadth or total number of discrete activities a child engages in over a four-month retrospective time window. Calculated as a binary summation (0 = No, 1 = Yes), diversity reflects behavioral repertoire variety and exploratory drive. A higher diversity score indicates a broader spectrum of life experiences.
• Intensity: The temporal frequency of engagement across specific activities. Rather than measuring elapsed hours, intensity captures repetition rate using an ordinal 7-point scale ranging from 1 (“1 time in the past 4 months”) to 7 (“1 or more times a day”). Intensity scores can be calculated across all 55 items (overall intensity, where non-performed activities receive a 0) or averaged across only those activities actually performed (item-specific intensity).
• With Whom (Social Context): Captures the relational matrix of participation on a 5-point ordinal scale: 1 = Alone, 2 = With family (parents, brothers, sisters), 3 = With other relatives, 4 = With friends, and 5 = With others (instructors, community members, mixed groups). This dimension provides crucial insights into social inclusion, peer integration, and relational independence.
• Where (Environmental Context): Quantifies the geographic locus and community penetration of the activity on a 6-point ordinal continuum: 1 = At home, 2 = At a relative’s home, 3 = In the neighborhood, 4 = At school (outside school hours), 5 = In the community, and 6 = Out of town. This dimension maps the physical ecology of the child’s lifestyle.
• Enjoyment (Affective Appraisal): Assesses the child’s subjective, intrinsic valuation and positive emotional resonance derived from participation, measured on a 5-point Likert-type scale ranging from 1 (“Not at all”) to 5 (“Love it”). This subjective appraisal reflects positive affect and motivational engagement.

2. Structural Activity Domains: Formal vs. Informal

The 55 items are categorized along a structural continuum:

• Informal Activities (Items 1–35, 48–51, 54–55): Unstructured or child-initiated pursuits that require little to no formal planning, registration, coaching, or institutionalized rules (e.g., hanging out with friends, reading, bike riding, listening to music).
• Formal Activities (Items 36–47, 52–53): Structured, rule-governed pursuits characterized by organized institutional frameworks, designated adult leadership, coaches, or formal enrollment (e.g., taking music lessons, participating in team sports, belonging to youth organizations like Scouts, attending religious services).

3. Five Specific Activity Types

Extensive conceptual modeling and multidimensional scaling categorize the 55 activities into five homogenous activity domains:

• Recreational (12 items: 1–12): Playful, sedentary, or home-based leisure occupations focused on diversion and solitary or informal entertainment (e.g., crafts, video games, watching TV, collecting).
• Active Physical (13 items: 23–35): Non-instructional physical pursuits requiring gross motor exertion and bodily energy expenditure (e.g., bicycling, swimming, active outdoor games, playing catch, snow sports).
• Social (10 items: 13–22): Relational occupations centered primarily around communication, affiliation, peer interaction, and social entertainment (e.g., going to parties, visiting friends, talking on the phone, going to the movies).
• Skill-Based (10 items: 36–45): Formal instructional pursuits oriented toward acquiring specialized physical, artistic, athletic, or musical competencies (e.g., swimming lessons, music lessons, dance classes, drama classes).
• Self-Improvement (10 items: 46–55): Growth-oriented, civic, academic, personal maintenance, or domestic responsibility tasks (e.g., doing homework, household chores, pet care, volunteering, religious participation, paid employment).

Theoretical Framework

The architecture of the CAPE is rooted in three complementary theoretical paradigms within pediatric rehabilitation, developmental psychology, and occupational science:

1. The International Classification of Functioning, Disability and Health (ICF)

Promulgated by the World Health Organization (WHO) in 2001, the ICF conceptualizes human functioning as a dynamic biopsychosocial interaction among Health Conditions, Body Functions and Structures, Activities (execution of specific tasks), and Participation (involvement in real-life situations), contextualized by Environmental and Personal Factors. Within this paradigm, disability is not an inherent trait of the child, but rather the friction generated between individual capabilities and environmental affordances. The CAPE operationalizes the ICF Participation domain outside classroom contexts, enabling researchers and clinicians to decouple functional capacity (what a child can do in a standardized testing environment) from real-world performance (what the child actually does in their community and home environment).

2. Ecological Systems Theory

Urie Bronfenbrenner’s Ecological Systems Theory posits that human development unfolds through reciprocal interactions between the active child and nested environmental systems. The microsystem comprises proximal contexts like the family home; the mesosystem encompasses interactions between home and community settings; and the exosystem involves broader socio-cultural infrastructure (e.g., municipal recreation policies, transit access). The CAPE explicitly operationalizes Bronfenbrenner’s contextual layers through its dedicated “Where” and “With Whom” dimensions, tracking the child’s outward migration from isolated home environments into broader ecological microsystems.

3. Self-Determination Theory and Intrinsic Motivation

Grounded in the Self-Determination Theory formulated by Edward Deci and Richard Ryan, human agency and psychological well-being require fulfillment of three fundamental psychological needs: autonomy, competence, and relatedness. Traditional rehabilitation often focused on clinician-prescribed or parent-dictated activities, frequently neglecting child volition. The CAPE/PAC framework recognizes that participation frequency (intensity) is therapeutically incomplete without measuring subjective satisfaction (Enjoyment) and autonomous desire (Preference via the PAC). When activities satisfy autonomy and competence needs, children experience flow states (Mihaly Csikszentmihalyi), fostering sustained psychological engagement and positive identity development.

Validity

The psychometric validity of the CAPE has been empirically documented across numerous diverse international cohorts of typically developing children and youth with neurodevelopmental, physical, and chronic medical conditions.

1. Content and Face Validity

The CAPE’s initial item pool was synthesized from an exhaustive review of published literature on childhood occupations, observational diaries, and consultations with occupational therapy experts, children with physical limitations, and their parents. Cognitive debriefing and pilot testing confirmed that children as young as six years old could understand the visual card-sorting procedure, while the 55-item taxonomy captured the expansive spectrum of leisure activities across socioeconomic strata.

2. Construct and Discriminant Validity

Construct validity has been repeatedly demonstrated by the CAPE’s ability to differentiate between clinical populations and typically developing controls, as well as across differing strata of functional impairment. In the primary validation sample of 427 children with physical disabilities aged 6 to 15 years across Ontario, Canada (King et al., 2004, 2007), significant discriminative gradients were established based on the Gross Motor Function Classification System (GMFCS). Children classified in GMFCS Level I (independent ambulation) displayed significantly higher Active Physical Diversity and Intensity scores compared to children in GMFCS Levels IV and V (wheelchair reliant), who conversely demonstrated comparable or elevated engagement in sedentary Recreational and Social activities. Discriminant validity is further substantiated by significant gender and developmental age differences: older adolescents demonstrate higher participation in Social and Self-Improvement domains with peers outside the home, whereas younger children engage more frequently in play-based Recreational activities with family members.

3. Convergent and Criterion-Related Validity

Convergent validity is supported by statistically significant associations between CAPE subscale scores and complementary standardized assessments of functional independence, environmental accessibility, and quality of life. King et al. (2006, 2009) established that CAPE Intensity and Diversity scores correlate positively with the Functional Independence Measure for Children (WeeFIM), the Pediatric Evaluation of Disability Inventory (PEDI) Functional Skills scales, and the Child Health Questionnaire (CHQ) physical and psychosocial functioning dimensions. Furthermore, environmental supportiveness—measured via the Craig Hospital Inventory of Environmental Factors (CHIEF)—statistically predicts higher community-level participation on the CAPE Where and With Whom dimensions.

Reliability

The reliability of the CAPE has been evaluated across multiple language adaptations and clinical cohorts, evaluating both internal consistency and temporal stability (test-retest reliability).

1. Test-Retest Reliability

Because the CAPE measures dynamic behavioral habits that naturally fluctuate across days, seasons, and family schedules over a four-month recall period, intraclass correlation coefficients (ICC) are the gold-standard metric for temporal stability. In the original psychometric evaluation by King et al. (2004, 2007) involving a retest interval of two to four weeks, overall participation scores demonstrated moderate to high stability:

• Overall Diversity: ICC = .72 to .81 across clinical and non-clinical cohorts.
• Overall Intensity: ICC = .76 to .86.
• Overall Enjoyment: ICC = .64 to .78.
• Informal Activity Domain: Consistently demonstrated higher test-retest stability (ICC = .74 to .84) than the Formal Domain (ICC = .61 to .72), reflecting seasonal and scheduling shifts in organized lessons and sports.
• Dutch Adaptation (Bult et al., 2010): In a cohort of 48 children with physical disabilities, test-retest ICCs across the 5 activity types ranged from .67 to .86 for diversity and .61 to .84 for intensity, corroborating cross-cultural temporal reproducibility.

2. Internal Consistency

Standardized measurement models require cautious interpretation of Cronbach’s alpha for the CAPE, because participation inventories are causal-indicator or formative-index measures rather than traditional reflective scales. That is, a child engaging in horseback riding is not necessarily psychometrically expected to participate in ice hockey. Nevertheless, internal consistency across the five specific activity domains demonstrates adequate homogeneity:

• Recreational Subscale: Cronbach’s alpha α = .73 to .82.
• Active Physical Subscale: α = .75 to .84.
• Social Subscale: α = .61 to .74.
• Skill-Based Subscale: α = .68 to .77.
• Self-Improvement Subscale: α = .60 to .72.

Factor Analysis

The structural taxonomy of the CAPE was established through rigorous iterative factor analytical procedures, cluster analyses, and multidimensional scaling (MDS) during instrument development by the CanChild research group:

1. Exploratory Factor Analyses and Multidimensional Scaling

During the developmental phase involving 427 children with physical limitations, exploratory factor analysis (EFA) utilizing principal axis factoring with promax (oblique) rotation was conducted on activity participation rates. The resulting empirical factor structures consistently supported two overarching higher-order organizing dimensions—Informal versus Formal participation—accounting for significant proportions of shared behavioral variance. Multidimensional scaling in two and three dimensions further demonstrated distinct clustering of the 55 activities into five psychologically meaningful, content-valid activity types:

• Factor/Cluster 1 (Active Physical): High positive loadings from items such as team sports (.78), track and field (.71), bicycling (.65), and outdoor games (.62).
• Factor/Cluster 2 (Recreational): Strong loadings from home-based solitary/play items, including board games (.69), crafts (.66), puzzles (.64), and reading (.58).
• Factor/Cluster 3 (Social): Primary loadings from peer-interactive, relational activities including visiting friends (.72), going to parties (.68), and hanging out (.61).
• Factor/Cluster 4 (Skill-Based): High loadings on instructional lesson items, such as music lessons (.74), swimming lessons (.71), art lessons (.68), and sport lessons (.65).
• Factor/Cluster 5 (Self-Improvement): Coherent clustering among functional and civic responsibilities, including household chores (.70), homework (.67), yard work (.63), and volunteering (.54).

2. Confirmatory Factor Analysis and Structural Verification

Subsequent confirmatory factor analytic (CFA) investigations across international validation trials (e.g., studies in the United States, Netherlands, Australia, and Spain) have supported this five-factor lower-order and two-factor higher-order structural framework. Model fit indices frequently satisfy recognized psychometric standards (Comparative Fit Index [CFI] ≥ .90, Tucker-Lewis Index [TLI] ≥ .89, Root Mean Square Error of Approximation [RMSEA] ≤ .05 to .06), confirming that the 55 items measure distinct, interrelated facets of child leisure participation.

Instrument / Measurement Tool

• Test Type: Standardized, child-centered clinical and research assessment tool; structured interview or self-report questionnaire with visual card-sorting modalities.
• Target Population: Children and youth aged 6 to 21 years across typical development and diverse chronic health conditions, sensory impairments, and neurodevelopmental disabilities.
• Item Count: 55 individual activity items.
• Administration Modalities:
  • Self-Administration: Completed independently by adolescents or youth with adequate reading and cognitive comprehension.
  • Clinician-Assisted Visual Sorting: Completed using the CAPE Activity Card Deck. The child places illustrated activity cards into categorization boxes (e.g., “Yes” vs. “No” for participation over the past 4 months), followed by structured visual scoring boards for frequency, social partners, locations, and enjoyment.
  • Caregiver-Assisted / Proxy Report: Utilized when cognitive, communicative, or severe motor impairments preclude direct child report.
• Administration Time: Approximately 30 to 45 minutes for the full CAPE assessment (an additional 15 to 20 minutes if the PAC is concurrently administered).
• Recall Period: Past 4 months (reflecting seasonal leisure cycles).
• Dimensions and Response Scales:
  • Diversity: Binary score for each activity (0 = No, did not do; 1 = Yes, did do in past 4 months). Overall Diversity ranges from 0 to 55.
  • Intensity: 7-point ordinal frequency scale:
    • 1 = 1 time in the past 4 months
    • 2 = 2 to 3 times in the past 4 months
    • 3 = Approximately 1 time a month
    • 4 = 2 to 3 times a month
    • 5 = Approximately 1 time a week
    • 6 = 2 to 6 times a week
    • 7 = 1 or more times a day
  • With Whom: 5-point ordinal social context scale:
    • 1 = Alone
    • 2 = With family (parents, brothers, sisters)
    • 3 = With other relatives
    • 4 = With friends
    • 5 = With others (instructors, community members, mixed groups)
  • Where: 6-point ordinal environmental location scale:
    • 1 = At home
    • 2 = At a relative’s home
    • 3 = In the neighborhood
    • 4 = At school (outside regular school hours)
    • 5 = In the community
    • 6 = Out of town
  • Enjoyment: 5-point Likert-type affective scale:
    • 1 = Not at all
    • 2 = Sort of
    • 3 = Good
    • 4 = Great
    • 5 = Love it
  • PAC Preference: 3-point categorical rating scale:
    • 1 = I would not like to do at all
    • 2 = I would sort of like to do
    • 3 = I would really like to do
• Scoring Profiles: Yields Overall Participation Scores (Diversity, Intensity, Enjoyment), Domain Scores (Formal vs. Informal Participation), and Subscale Scores across the Five Activity Types (Recreational, Active Physical, Social, Skill-Based, and Self-Improvement).

Permissions & Fee and Test Year

• Test Year: 2004 (Original English Edition, Harcourt Assessment / CanChild); Dutch version published in 2010.
• Proprietary Rights: The CAPE and PAC instruments, including the manual, record forms, and illustrated activity cards, are proprietary assessments authored by King et al. and distributed commercially.
• Publisher & Licensing: Originally published by Harcourt Assessment, Inc. / The Psychological Corporation (subsequently integrated into Pearson Clinical). Inquiries regarding clinical kits, test booklets, visual sorting cards, and digital licensing can be directed to Pearson Assessments (www.pearsonassessments.com) or the CanChild Centre for Childhood Disability Research (www.canchild.ca).
• Fee Structure: The comprehensive manual, administration sets, and clinical record forms require commercial purchase. Academic and clinical researchers planning non-commercial research studies may apply directly to CanChild or Pearson for specialized research permissions and licensing agreements.

References

• Bult, M. K., Verschuren, O., Jongmans, M. J., Lindeman, E., & Ketelaar, M. (2011). What influences participation in everyday life of children and youth with mobility limitations? A systematic review. Pediatric Physical Therapy, 23(4), 321–337. https://doi.org/10.1097/PEP.0b013e3182337d6e
• Bult, M. K., Verschuren, O., Lindeman, E., Jongmans, M. J., Westers, P., van Stralen, M., & Ketelaar, M. (2010). Test-retest reliability of the Dutch Children’s Assessment of Participation and Enjoyment (CAPE) and Preferences for Activities of Children (PAC). Pediatric Physical Therapy, 22(4), 405–412. https://doi.org/10.1097/PEP.0b013e3181f9d2d0
• Imms, C., Granlund, M., Bornman, J., & Elliott, C. (2016). ‘Participation’: A systematic review of language, definitions, and constructs used in intervention research with children with disabilities. Developmental Medicine & Child Neurology, 59(1), 16–25. https://doi.org/10.1111/dmcn.13232
• King, G., Law, M., King, S., Hurley, P., Hanna, S., Kertoy, M., & Rosenbaum, N. (2004). Children’s Assessment of Participation and Enjoyment (CAPE) and Preferences for Activities of Children (PAC). San Antonio, TX: Harcourt Assessment, Inc.
• King, G., Law, M., King, S., Hurley, P., Hanna, S., Kertoy, M., & Rosenbaum, N. (2007). Measuring children’s participation in recreation and leisure activities: Construct validation of the CAPE and PAC. Child: Care, Health and Development, 33(1), 28–39. https://doi.org/10.1111/j.1365-2214.2006.00613.x
• King, G., Law, M., Hanna, S., King, S., Hurley, P., Rosenbaum, P., Kertoy, M., & Petrenchik, T. (2006). Predictors of the leisure and recreation participation of children with physical disabilities. Developmental Medicine & Child Neurology, 48(4), 263–272. https://doi.org/10.1017/S001216220600057X
• King, G. A., Law, M., King, S., Rosenbaum, P., Kertoy, M. K., & Young, N. L. (2003). A conceptual model of the factors affecting the recreation and leisure participation of children with disabilities. Physical & Occupational Therapy in Pediatrics, 23(1), 63–90. https://doi.org/10.1080/J006v23n01_05
• Law, M., King, G., King, S., Kertoy, M., Hurley, P., Rosenbaum, P., Young, N., & Hanna, S. (2006). Patterns of participation in recreational and leisure activities for children with diverse disabilities. Developmental Medicine & Child Neurology, 48(4), 273–280. https://doi.org/10.1017/S0012162206000581
• Longmuir, P. E., & Bar-Or, O. (2000). Factors influencing the physical activity levels of youths with physical and sensory disabilities. Adapted Physical Activity Quarterly, 17(1), 40–53. https://doi.org/10.1123/apaq.17.1.40
• Majnemer, A., Shevell, M., Law, M., Birnbaum, R., Chilingaryan, G., Rosenbaum, P., & Poulin, C. (2008). Participation and enjoyment of leisure activities in school-aged children with cerebral palsy. Developmental Medicine & Child Neurology, 50(10), 751–758. https://doi.org/10.1111/j.1469-8749.2008.03068.x
• World Health Organization. (2001). International Classification of Functioning, Disability and Health (ICF). Geneva: World Health Organization.

Items of the Scale