Occupational Injustice and the Right to Play: A Systematic Review of Accessible Playgrounds for Children With Disabilities

Background Literature

Social participation is understood as a child’s ability to interact with their peers in their environment (Cosbey et al., 2012). Children who actively engage in social participation exhibit developmental growth in confidence, play, and communication with their peers (Fernelius & Christensen, 2017). Furthermore, physical engagement in play promotes development of necessary motor skills (Carlon et al., 2013). Children with disabilities, however, are often unable to fully engage in social participation as a result of barriers in playground structure and design (Fernelius & Christensen, 2017). The 2010 ADA Standards (U.S. Department of Justice, Civil Rights Division, 2010) outline standards for public play areas for children older than age 2 yr and establish how a play structure should be designed to be considered accessible. An accessible playground requires play components usable by children of all abilities to be integrated into a playground setting, including a transfer platform, ramp, and elevated play components (U.S. Department of Justice, Civil Rights Division, 2010). Despite these guidelines, in 2019, 65% of caregivers for children with disabilities reported that their child could not fully participate because of inadequate adaptations (Stanton-Chapman & Schmidt, 2019).

Physical accessibility is not the only barrier for children with disabilities (Umeda et al., 2017). For example, children with sensory processing disorder (SPD) struggle with modulating, identifying, and categorizing sensory information, which affects their ability to engage in social play (Crasta et al., 2020). In 2012, Cosbey et al. observed play behaviors between children with and without SPD on the playground. They identified differences in play behaviors between participants, such as increased conflict, lack of awareness of social cues, and increased secluded play for children with SPD. These concerns are not as easily addressed by the Americans With Disabilities Act of 1990 (Pub. L. 101-336) and remain hidden barriers to community engagement and accessibility for children with disabilities (Umeda et al., 2017).

Because occupational therapy is a client-centered profession, one of the occupational therapy practitioner’s roles is to advocate for their clients’ health needs. The Occupational Therapy Practice Framework (4th ed.; OTPF–4; American Occupational Therapy Association [AOTA], 2020b) illuminates the breadth of advocacy possibilities through multiple practice areas, such as the organizational, community and population, and governmental and policy levels. Because children with disabilities face barriers in exercising their rights to play, the OTPF–4 provides examples of how occupational therapy practitioners can intervene as advocates when injustice is present. This is further supported by an official document put out by AOTA (2020a) on occupational therapy’s role in the promotion of health and well-being. This document, Occupational Therapy in the Promotion of Health and Well-Being, provides case examples, one of which describes an occupational therapy consultant hired to assist in the development of an accessible school playground. The occupational therapist’s role includes tasks such as surveying the proposed area, ensuring that requirements are met, and reporting recommendations for equipment and landscaping to ensure that the playground is not only accessible but also fun and engaging.

Currently, research on how accessible playgrounds affect key areas of childhood development for all children is limited. This has led to calls for increased occupational therapy advocacy for children’s play and accessibility of these spaces (Grady & Bundy, 2019; Romaniak et al., 2019; Umeda et al., 2017). Consequently, we conducted a systematic review to better understand the relationship between accessible playgrounds and cognition, behavior, motor skills, play skills, and social skills for children with disabilities. The objectives of this systematic review were to (1) identify and synthesize existing research on the relationship between key areas of childhood development and accessible play settings for children ages 3 to 12 yr with disabilities and (2) create a body of evidence for occupational therapy practitioners to use in advocating for occupational justice and informing evidence-based interventions within pediatric disability populations. For the purpose of this review, play settings include outdoor school and community playgrounds, parks, and play areas.

Method

This systematic review was conducted using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines (Page et al., 2021). Studies were included if they were peer reviewed; written in English; published after 2012; set in a playground, play area, or park labeled as inclusive, accessible, or universal; included participants ages 3 to 12 yr with any disability; and had outcomes related to areas of childhood development, including cognition, social skills, motor skills, play skills, or behavior. Articles were excluded if they were not peer reviewed; written in a language other than English; published before 2012; a systematic review or meta-analysis; not set in a play setting labeled as inclusive, accessible, or universal; did not include any participants ages 3 to 12 yr with a disability; or had outcomes unrelated to areas of childhood development, as previously defined. This age group was selected because these children most commonly use play settings and are continually reaching developmental milestones (Flowers et al., 2019).

The initial research team, consisting of four reviewers (Kelsey Gately, Anna Zawadzki, Alyssia Mosley, and Alyssamarie Badua) completed database searches as a group on January 30, 2021, using Academic Search Complete/EBSCO, CINAHL/EBSCO, Education Research Complete/EBSCO, ERIC, OTseeker, and PubMed. The database searches included articles published from January 2012 to January 2021. The search strategy was developed to align with the Population, Intervention, Comparison group, and Outcome (PICO) model. The search strategy was adapted to meet formatting requirements for each given database’s search function but otherwise remained consistent. The following search strategy was used: (playground OR “play area” OR park) AND (inclusive OR accessible OR universal) AND (develop* OR play* OR social* OR cogni* OR behavior* OR motor*) AND (child* OR school-age OR student* OR adolescen* OR preschool*) AND (disab* OR disorder* OR impair* OR illness OR physical OR mental OR condition OR syndrome OR deficit OR autis* OR sensory* OR limit* OR blind* OR “developmental delay*” OR deaf* OR cerebral palsy OR spina bifida OR muscular dystrophy).

Articles were compiled from the database searches, and duplicates were removed. A total of four researchers (Gately, Zawadzki, Mosley, and Badua) were assigned articles. Two researchers were assigned to each article and independently completed the initial screening of assigned titles and abstracts. These researchers compared the screening results, and unresolved discrepancies were settled by a third independent reviewer, who was also a member of the initial research team. The third reviewer also screened the title and abstract in question, consistent with the two independent reviewers, and decided whether it should move forward to the full-text review. The full-text articles were then reassigned to the four researchers. Each article had two researchers assigned for an independent review of the full text. These researchers compared their results, and unresolved discrepancies were settled by a third independent reviewer who, consistent with the two independent reviewers, read the text in full.

This process was repeated for the extraction of specific variables for the evidence table (see Table A.1 in the Supplemental Appendix, available online with this article at https://research.aota.org/ajot). The following variables were extracted from each study included in the evidence table: author, year of publication, location, level of evidence and study design, participants, children’s disabilities, childhood development outcome measures, and results. The entire research term worked on variable extraction, and final entries were made by consensus. We assessed the studies’ level of evidence using the Oxford Center for Evidence-Based Medicine (2009) levels of evidence. To assess the risk of bias of the included studies, we used the Critical Appraisal Skills Programme (2019) Qualitative Research Checklist for qualitative studies and the National Heart, Lung, and Blood Institute (NHLBI, 2017) quality assessment tool for case–control studies and cross-sectional studies, respectively. Two researchers from the initial research team were assigned to each article and created a level-of-evidence table and assessed the risk of bias. These researchers compared results, and unresolved discrepancies were settled by a third independent reviewer, who assessed the level of evidence and risk of bias in the same fashion as the initial two independent reviewers.

The initial database search identified 561 articles (Figure 1). Of those, 174 duplicates were removed. Title and abstract screening resulted in an additional 322 articles being excluded. After the full-text review, 56 articles were removed on the basis of the exclusion criteria. Nine articles met the inclusion criteria and were included in this qualitative systematic review. Included studies were reviewed for variable extraction and level of evidence (Table A.1) and risk of bias (Tables A.2, A.3, A.4) using the aforementioned validated risk of bias tools.

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Figure 1.

Flow diagram for the selection of studies for the systematic review.

Results

This systematic review assessed the literature on accessible playgrounds and areas of childhood development, including cognition, social skills, motor skills, play skills, and behavior. We were unable to identify articles that focused on behavior or cognition and met the remaining inclusion criteria. However, we were successful in identifying literature that explored social skills, play skills, and motor skills. Included studies primarily explored these areas of childhood development through the lens of access and engagement. As such, the results were analyzed and divided into three categories on the basis of the outcome measures used in the included articles as they relate to social participation, play participation, and motor skills.

Discussion

This systematic review synthesizes existing research on the relationship between accessible playgrounds and childhood development among children with disabilities, but the literature was limited. Articles that met the inclusion criteria highlighted occupational injustice through common findings of inadequate accessibility and reduced occupational engagement in key areas that promote childhood development. Eight studies reported that children with mobility impairments frequently faced physical barriers to play, despite playgrounds being labeled as accessible (Horton, 2017; Jeanes & Magee, 2012; Locke et al., 2016; Ripat & Becker, 2012; Stanton-Chapman & Schmidt, 2016, 2017; Stephens et al., 2015; Wenger et al., 2021). Uneven pathways, lack of ramps, and inappropriate groundcover inhibited these children from using the spaces. As a result, researchers reported decreased engagement in play, social participation, and activities that promote motor skills development. In fact, only Jeanes and Magee (2012) reported a playground that was easy to navigate with a wheelchair, finding increased engagement in all areas as a result of adequate accessibility. Furthermore, children with mobility impairments in particular encountered physical barriers that prevented access to able-bodied peers, further decreasing opportunities to socialize. These findings indicate an area in which occupational therapy practitioners need to advocate for change in legislation regarding accessibility, especially as it relates to playground design. This is supported by a recent scoping review that identified and described the all-too- common practice of designing playgrounds to meet only the minimum standards necessary to be ADA compliant (Brown et al., 2021). Furthermore, because several playgrounds identified in this systematic review reportedly adhered to ADA guidelines yet remained inaccessible, guidelines need to be reevaluated.

Even on accessible playgrounds, participants across 4 studies reported social stigma as an invisible barrier to play and socialization (Horton, 2017; Jeanes & Magee, 2012; Stanton-Chapman & Schmidt, 2017; Wenger et al., 2021). Parents felt out of place as a result of discriminatory attitudes toward their children from others. Children with disabilities felt they belonged in an area separate from able-bodied or neurotypical children and felt ostracized from peers. Occupational therapy practitioners are poised to address this issue. Integrating education on adaptive coping skills and self-advocacy into school sessions would allow children with disabilities to be better equipped when facing discrimination or having unmet needs. Education on disability and normalizing disability would be meaningful for all children, teachers, and parents.

We have not reported results on the relationship between accessible playgrounds and cognition or behavior because no studies covered these topics and met our criteria. This glaring oversight requires research, the results of which would be incredibly beneficial when working with the pediatric disability population. Although the level of bias across the studies included in this review was relatively low, the evidence consisted of primarily Level 4 and 5 studies. Researchers should aim to conduct higher-level longitudinal cohort studies to better understand how accessible playgrounds affect all areas of childhood development over time.

Limitations

Studies focusing on outcomes for behavior and cognition specifically among children with disabilities on accessible playgrounds were scarce. In addition, findings on motor skills were limited in comparison with those on social and play participation. Nine studies met the inclusion criteria for this review, which restricted the quality of research included. Most of the studies consisted of Level 4 and 5 research, including cross-sectional surveys and qualitative research. Other common limitations were small sample sizes and convenience samples, lack of a universal definition of an accessible playground, and third-person interviews rather than interviews with children with disabilities, which do not fully illustrate the experiences of this population. Methodologically, there is potential for error in the search terms chosen to identify the relevant literature as a result of missing key terms. However, we used a comprehensive list of terms across development domains with assistance from the university librarian, and advanced Boolean modifiers were used to maximize the scope of the search. There is also always risk of error in each point of assessment procedurally, whether in screening titles and abstracts, reviewing the full text, and assessing level of evidence or risk of bias. However, we abided by rigorous PRISMA guidelines and used validated assessment tools whenever possible and multiple independent reviewers for each assessment in the review process.

Implications for Occupational Therapy Practice

These common findings of inaccessibility are a prime example of occupational injustice for children globally. We suggest that occupational therapy practitioners consider joining the field of playground design to address key areas of need while understanding the developmental and sensory needs of children through consultation. Occupational therapy practitioners are in the unique position to address environmental negligence that bolsters occupational injustice in a variety of both indoor and outdoor play spaces for children (Brown et al., 2021 ; Moore & Lynch, 2015). As a result, occupational therapy practitioners should address not only the environmental barriers, but also the political and social contexts that cultivate the unprecedented cultural stigma and exclusion of those with disabilities. As such, occupational therapy practitioners must move beyond their traditional practice settings to radical and pragmatic venues to dismantle the structural and societal stigmas that surround disabilities to create an inclusive environment. We recommend that occupational therapy practitioners

engage in nontraditional settings to develop more stimulating and accessible playground equipment,

Conclusion

It is important to further understanding of the value of accessible playgrounds because current research has shown that they affect childhood development for children with disabilities, resulting in occupational injustice. Evidence suggests that social and play participation are significantly affected by inaccessible playgrounds, social stigma, and discrimination. Extensive research is necessary to understand how the development of behavior, cognition, and motor skills are affected, because these topics have not been adequately explored. Future research should implement stronger study designs and include larger sample sizes of children with disabilities to gather findings that can be generalized to this overall population. Therefore, occupational therapy practitioners should conduct longitudinal cohort studies on the effect of accessible playgrounds on all areas of childhood development of children with disabilities. An audit of ADA-compliant playgrounds also needs to take place, because several ADA-compliant playgrounds were found to be inaccessible, and a study evaluating the efficacy of ADA guidelines for play spaces for children should be conducted.

Occupational therapy practitioners would greatly benefit from additional research on this topic because it would enhance their evidence-based practice knowledge of elements that influence childhood development among children with disabilities. Also, further research may expand knowledge of the occupation of play for this population, which would better equip occupational therapy practitioners to serve as advocates for occupational justice. The narrow research that is available should bring awareness to future playground developers and encourage them to strategize and construct playgrounds that meet the needs of children of all abilities.

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