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Abstract

PURPOSE:

Assessing motivation and motivation-related factors will contribute to a better understanding of motivation and the development of optimal rehabilitation conditions. The purpose of this study was to determine the motivation level and investigate the relationship of motivation level with socio-demographic characteristics (i.e., age, gender, comorbidities), functional level, and family satisfaction with rehabilitation centers in children with disabilities.

METHODS:

Sixty-two children with disabilities were included in the study, and the socio-demographic characteristics were recorded. Children were assessed by the Pediatric Motivation Scale (PMOT) and the Pediatric Functional Independence Measure (WeeFIM). Also, parents were asked to complete a questionnaire titled, “A patient satisfaction instrument for outpatient physical therapy clinics.”

RESULTS:

The mean age of the children was 12.16 $\pm$ 3.19 years. Total PMOT and WeeFIM scores were found to be 93.71 $\pm$ 9.66 and 108.23 $\pm$ 22.14, respectively. There was a positive correlation between children’s PMOT score and the satisfaction score of their families that was statistically significant ( $r=$ 0.602, $p<$ 0.05).

CONCLUSION:

The level of family satisfaction with rehabilitation centers was found to be positively correlated with the motivation level of children. Improving family satisfaction with rehabilitation centers, potentially through modifying the physical conditions of rehabilitation centers and focusing on the interest of the family, may increase the motivation level of children, and thus may improve rehabilitation outcomes.

Keywords

Motivation disability rehabilitation satisfaction functional level

1. Introduction

Disability is a general term including impairments in body structures, activity limitations, and participation restrictions that negatively affect an individual’s environmental and self-interaction [1]. Conditions such as cerebral palsy (CP), spinal cord injuries, neuromuscular disorders, and brachial plexus damage lead to disability according to current literature [1, 2].

The meaning of the word motivation is “to want.” It is critical to setting a goal and achieving it. “Motivation” as a term attempts to capture the “how” and “what” that causes a person to act [3]. Motivation has two basic components: intrinsic motivation and extrinsic motivation [4]. Extrinsic motivation is to perform an activity in order to achieve a specific result. The prominent characteristic of extrinsic motivation is that the individual wants to do the activity for a specific purpose, not because they enjoy it [3, 4]. Intrinsic motivation is to want to do something not only for a purpose but also it is natural, interesting, or enjoyable [5]. Intrinsic motivation represents the most impactful type of motivation because it is completely independent and is related to one’s wish [4]. Motivation plays a crucial role in the rehabilitation of children with disabilities. Further, low motivation may reduce participation and could affect the efficacy of the rehabilitation.

Previous studies have shown that the motivation of children with disabilities is lower than their typically developing peers [6, 7, 8]. However, the lack of motivation could affect the effectiveness of treatment by reducing participation in rehabilitation [8, 9]. A study conducted by Simpson et al. stated that a child’s motivation to treatment significantly affects participation in treatment and its success [10]. Jarvikoski et al. found that the child’s motivation to participate in rehabilitation is a strong indicator of physical and psychosocial recovery [11]. Also, it is well understood that participation is critical for rehabilitation success, and patients’ participation in rehabilitation can only be achieved by satisfying their basic needs such as autonomy, competence, and relationship, in order to increase their motivation towards rehabilitation [12]. Although rehabilitation specialists have long recognized that motivation affects rehabilitation outcomes, the dynamic nature of motivation has made it difficult to evaluate motivation [13]. New methods and scales developed to evaluate motivation are very promising in this regard [12, 13]. Therefore, the purpose of this study is to determine the motivation level and investigate the relationship of motivation level with socio-demographic characteristics (i.e., age, gender, comorbidities), functional level, and family satisfaction with rehabilitation centers in children with disabilities. It was hypothesized that there would be a relationship between motivation and family satisfaction, comorbidities, and functional level, and there would be no relationship between the motivation level and the children’s gender and age. In order to increase motivation, it is necessary to have information about motivation and motivation-related factors. Assessing motivation and motivation-related factors will contribute to a better understanding of motivation and the development of optimal rehabilitation conditions.

2. Methods

2.1 Participants

This was a cross-sectional study. A sample size of 62 with $\alpha=$ 0.05, and an anticipated effect size $=$ 0.40 results in 90% power to detect a significant difference. Inclusion criteria were as follows: being between the ages of 8–18, diagnosed by a doctor as having a disability (such as CP, muscular dystrophy, spina bifida, obstetric brachial plexus injury, etc.), involved in the rehabilitation program longer than 6 months, adequate co-operation and adequate cognitive ability. Since the Pediatric Motivation Scale (PMOT) is a self-reported scale, to ensure adequate cognition level, the patient needed to score over the 5 points from each item of the social cognition subscale of the Pediatric Functional Independence Measure (WeeFIM). If a child did not meet the inclusion criteria, they were excluded.

2.2 Measurements

The PMOT was used to evaluate motivation. It has Turkish validity and reliability [14]. The scale was developed by Tatla et al. to evaluate children’s motivations for the rehabilitation program from the child’s perspective. It comprises six sub-scales (effort-importance, interest-enjoyment, competence, relatedness, autonomy, and value-usefulness) with a total of 21 items. While the 19 items of the scale are answered using a 6-point smiley face scale (1 $=$ absolutely false, 6 $=$ absolutely correct), there are 2 open-ended questions. It has been theorized that the interest-enjoyment sub-section is a direct indicator of intrinsic motivation; the competence, relatedness, and autonomy sub-sections (in the highly scored case) will increase intrinsic motivation, and value-usefulness and effort-importance sub-sections are indicators of extrinsic motivation. The high scores in each sub-scale indicate that the child’s motivation in that sub-section is high. A higher total score indicates that the motivation is intrinsically based, and that the child has high motivation. The scale shows good internal consistency, very strong test-retest reliability, and good internal structure validity [9, 13].

The WeeFIM was developed to assess the child’s level of independence [15]. The scale is appropriate for children between 6 months to 7 years, and in the case of disability, it can be used from 6 months to 21 years of age. The scale consists of six sub-scales (self-care, sphincter control, transfers, locomotion, communication, and social cognition) with a total of 18 items. All items are scored from 1 to 7. Scores from 1 to 4 mean that the child needs assistance at different levels to perform an activity. A score of 5 means that the child needs observation or direction to perform the activity. A score of 6 means that the child can independently complete the activity, but may need an assistive device. A score of 7 means that the child can perform the activity in a completely independent manner [16]. The scale has high validity and reliability [15].

The family satisfaction with rehabilitation centers was assessed by using a questionnaire titled, “A patient satisfaction instrument for outpatient physical therapy clinics”. This scale was developed to assess patient/family satisfaction with the rehabilitation centers and has 24 items scored between 0 (absolutely disagree) and 4 (absolutely agree) [17]. Higher scores indicate higher satisfaction. The scale has high validity and reliability (Cronbach alpha: 0.88) [17].

2.3 Procedure

This study was approved by Dokuz Eylul University Noninvasive Research Ethics Board (ref. no: 2017/15–30). At the beginning of the study, verbal and written approvals of the families and children were obtained. The study was carried out between January and December of 2017 in five different special rehabilitation centers whose written permission was given. All measurements were conducted by going to the special rehabilitation centers and interviewing face-to-face with the children and the caregivers.

Within the scope of the study, the demographic characteristics (age, gender, height, body weight, diagnosis, comorbidities) of the children were collected. Children were assessed using the PMOT and WeeFIM. Also, parents were asked to complete the questionnaire titled, “A patient satisfaction instrument for outpatient physical therapy clinics”.

2.4 Data analysis

Statistical analyses were performed using the Statistical Package for the Social Sciences (SPSS ${}^{\@setsize{\scriptsize}{8pt}{\viipt}{\@viipt}\textregistered}$ ) Windows 23.0. Descriptive statistics were used to characterize the sample. The relationship between motivation level (the PMOT score) and continuous independent variables (age, functional status, family satisfaction) was determined by administering the Pearson test for parametric conditions or the Spearman test for non-parametric conditions. The Mann-Whitney U test was used to determine between-group gender and comorbidity group differences. For all evaluations, $p<$ 0.05 was considered significant.

3. Results

3.1 Sample characteristics

Table 1
Demographic characteristics of children

	Mean $\pm$ SD or frequency
Age	12.16 $\pm$ 3.19
Weight (kg)	39.21 $\pm$ 13.16
Height (cm)	141.80 $\pm$ 18.87
Gender
Male ( $n$ )	51.6% (32)
Female ( $n$ )	48.4% (30)
Diagnosis
Cerebral palsy ( $n$ )	54.8% (34)
Muscular dystrophy ( $n$ )	11.3% (7)
Spina bifida ( $n$ )	6.5% (4)
Obstetric brachial plexus injury ( $n$ )	6.5% (4)
Spinal muscular atrophy ( $n$ )	3.2% (2)
Other disabilities ${}^{*}$ ( $n$ )	17.7% (11)
Secondary health problems
None ( $n$ )	80.6% (50)
Respiratory problem ( $n$ )	6.5% (4)
Epilepsy ( $n$ )	4.8% (3)
Cardiac problems ( $n$ )	1.6% (1)
Scoliosis ( $n$ )	6.5% (4)

${}^{*}$ : Developmental delay, extremity length difference, rheumatologic problems, and arthrogryposis multiplex congenita, SD: Standard deviation.

Table 2

PMOT, WeeFIM and family satisfaction scores of children

	Median (IQR 25/75)	Mean $\pm$ SD
Total PMOT	96 (87.00/101.25)	93.71	$\pm$ 9.66
Effort-importance	16 (15.00/17.00)	15.69	$\pm$ 2.03
Interest-enjoyment	18 (15.00/21.00)	18.08	$\pm$ 3.49
Competence	15 (13.75/17.00)	15.15	$\pm$ 2.41
Relatedness	17 (16.00/18.00)	16.74	$\pm$ 1.43
Autonomy	10.50 (9.00/13.00)	11.19	$\pm$ 2.80
Value-usefulness	18 (16.00/18.00)	16.84	$\pm$ 1.76
Total WeeFIM	118 (92.75/126)	108.23	$\pm$ 22.14
Self-care	38 (29.25/42.00)	33.94	$\pm$ 10.34
Sphincter control	14 (13.75/14.00)	12.77	$\pm$ 2.71
Transfers	20 (12.75/21.00)	17.03	$\pm$ 5.41
Locomotion	14 (9.00/14.00)	11.15	$\pm$ 4.12
Communication	14 (14.00/14.00)	13.45	$\pm$ 1.25
Social cognition	21 (20.75/21.00)	19.89	$\pm$ 2.34
Family satisfaction	86.25 (71.25/92.50)	83.17	$\pm$ 12.96

PMOT: Pediatric Motivation Scale, WeeFIM: Pediatric Functional Independence Measure, IQR: Inter Quantile Range, SS: standard deviation.

Table 3

Answers to item 20

Answers	$n$	%
I don’t need to be anything else, I’m already having fun.	14	22.58
If we played game, I would have more fun	17	27.42
I had more fun playing music while we were exercising.	4	6.45
I had more fun if I played ball.	6	9.68
If I had more toys I would have more fun.	8	12.9
I had more fun doing different exercises.	6	9.68
I had more fun if I did more difficult exercises.	3	4.84
If the exercises were easier, I had more fun.	4	6.45

%: Frequency.

Table 4

Motivation related factors

		Total PMOT		Effort- importance		Interest- enjoyment		Competence		Relatedness		Autonomy		Value- usefulness
Age	$r^{\text{a}}$	$-$ 0.	132	$-$ 0.	172	$-$ 0.	223	$-$ 0.	134	0.	000	0.	148	$-$ 0.	054
	$p$	0.	307	0.	181	0.	082	0.	300	0.	998	0.	250	0.	680
Gender	z, t	0.	489 ${}^{\text{t}}$	$-$ 0.	901 ${}^{\text{z}}$	$-$ 0.	247 ${}^{\text{t}}$	$-$ 0.	186 ${}^{\text{z}}$	$-$ 0.	892 ${}^{\text{z}}$	$-$ 0.	199 ${}^{\text{z}}$	$-$ 2.	052 ${}^{\text{z}}$
	$p$	0.	481	0.	368	0.	168	0.	852	0.	373	0.	842	0.	040 ${}^{*}$
Secondary health problem	z	$-$ 0.	187	$-$ 0.	199	$-$ 0.	206	$-$ 0.	814	$-$ 1.	005	$-$ 0.	180	$-$ 0.	632
	$p$	0.	851	0.	842	0.	837	0.	415	0.	315	0.	857	0.	528
WeeFIM
Total WeeFIM	$r^{\text{b}}$	$-$ 0.	017	0.	059	$-$ 0.	080	$-$ 0.	057	0.	005	0.	140	$-$ 0.	138
	$p$	0.	896	0.	650	0.	538	0.	658	0.	967	0.	278	0.	283
Self-care	$r^{\text{b}}$	0.	019	0.	044	$-$ 0.	067	$-$ 0.	004	0.	013	0.	169	$-$ 0.	132
	$p$	0.	884	0.	732	0.	650	0.	976	0.	920	0.	190	0.	307
Sphincter control	$r^{\text{b}}$	0.	007	0.	014	$-$ 0.	69	$-$ 0.	100	0.	149	0.	146	$-$ 0.	182
	$p$	0.	958	0.	916	0.	596	0.	439	0.	238	0.	256	0.	156
Transfers	$r^{\text{b}}$	0.	063	0.	000	$-$ 0.	056	$-$ 0.	165	$-$ 0.	108	0.	161	$-$ 0.	231
	$p$	0.	628	0.	999	0.	667	0.	199	0.	405	0.	212	0.	070
Locomotion	$r^{\text{b}}$	$-$ 0.	018	$-$ 0.	019	0.	062	$-$ 0.	114	$-$ 0.	152	0.	129	0.	167
	$p$	0.	890	0.	886	0.	635	0.	379	0.	238	0.	317	0.	195
Communication	$r^{\text{b}}$	0.	094	0.	140	$-$ 0.	046	0.	043	0.	145	0.	205	$-$ 0.	105
	$p$	0.	467	0.	279	0.	724	0.	740	0.	261	0.	109	0.	417
Social cognition	$r^{\text{b}}$	0.	006	0.	130	0.	178	0.	001	0.	220	0.	094	$-$ 0.	063
	$p$	0.	966	0.	312	0.	167	0.	991	0.	086	0.	466	0.	627
Family satisfaction	$r^{\text{b}}$	0.	602 ${}^{*}$	0.	348 ${}^{*}$	0.	358 ${}^{*}$	0.	611 ${}^{*}$	0.	467 ${}^{*}$	0.	183	0.	608 ${}^{*}$
	$p$	0.	000	0.	006	0.	004	0.	000	0.	000	0.	155	0.	000

${}^{*}$ : $p<$ 0.05, z: Mann Whitney U test, t: Student $t$ test, $r$ : correlation coefficient, a: Spearman’s test, b: Pearson’s test, PMOT: Pediatric Motivation Scale, WeeFIM: Pediatric Functional Independence Measure.

Sixty-two children experiencing disability with a mean age of 12.16 $\pm$ 3.19 years who participated in a rehabilitation program were included in the study. Fifty-four percent of children had CP, 11.3% had muscular dystrophy, 6.5% had spina bifida, 6.5% had obstetric brachial plexus injury, 3.2% had spinal muscular atrophy and 11.7% had other disabilities (developmental delay, extremity length difference, rheumatologic problems, and arthrogryposis multiplex congenita). While 80.6% had no comorbidities, 19.4% of them had comorbidities. The demographic characteristics of children were summarized in Table 1.

The average score of the children’s total functional level was determined as 108.23 $\pm$ 22.14, and the mean of the family satisfaction was determined to be 83.17 $\pm$ 12.96 (Table 2).

3.2 Level of motivation

The PMOT total score and individual sub-scale scores have been summarized in Table 2. The total PMOT score was found to be 93.71 $\pm$ 9.66.

The answers given to the 20th item (“How could this therapy session have been better?”), which was the first open-ended item in the PMOT was presented in Table 3. All of the children answered “None” to the second open-ended item, number 21 (“Do you have any other thoughts about what we did today?”).

3.3 Motivation-related factors

Age, gender, and comorbidities were not significantly correlated with total PMOT and PMOT sub-scale scores ( $p>$ 0.05, Table 4).

There was no correlation between the total scores of PMOT and WeeFIM. Likewise, there was no correlation between the sub-scale scores of the PMOT and WeeFIM sub-scale scores ( $p>$ 0.05, Table 4). However, there was a strong correlation between PMOT score and family satisfaction with rehabilitation centers ( $p<$ 0.05, Table 4).

4. Discussion

The motivation of children with disabilities is becoming increasingly important in the field of rehabilitation. However, there is no study to assess the motivation of children with disabilities who participated in a rehabilitation program in Turkey. This study is the first to assess motivation in this population, and it investigated the relationship of motivation level with socio-demographic characteristics, functional level, and family satisfaction with rehabilitation centers. The results of this study showed that the motivation of the children with disabilities who were participating in the rehabilitation program was relatively high. Children’s motivation level was significantly correlated to family satisfaction with rehabilitation centers but not socio-demographic characteristics and functional level.

Tatla et al. found that the PMOT score of the children participating in the rehabilitation program was relatively high which is consistent with the results of the current study [13]. However, autonomy sub-scale scores were lower in the current study compared to Tatla et al. The items in the autonomy sub-scale assessed how well the child managed their options of exercises during the rehabilitation session. The results of this study suggested that children have limitations in choosing exercise for their rehabilitation sessions. Providing children with the opportunity to choose the exercises or encouraging them to make suggestions may improve their motivation in the autonomy area. The increase in autonomy sub-scale scores may signify the development of intrinsic motivation which is the most impactful type of motivation.

Miller et al. stated that age and gender have no effect on motivation [6]. Majnemar et al. found no significant relationship between motivation and age and gender in children with cerebral palsy [18]. In the current study, the value-usefulness sub-scale which questions the patient’s belief in rehabilitation was observed to be more highly scored in females than males, but no significant difference was found between the total motivation scores of males and females. The results of the current study are consistent with the literature, showing that age and gender do not affect the motivation level. However, males’ and females’ belief in rehabilitation may be different.

Miller et al. found no association between the functional level and motivation [6]. However, Majnemar et al. stated that there is a weak to moderate relationship between motivation and functional level [18]. The results of this study are similar to those of Miller et al. In the current study, children’s total WeeFIM score was 108.23 $\pm$ 22.14 out of a maximum of 126 points. Children in Miller et al.’s study were at a high functional level, while children in Majnemar et al.’s study were at both low and high functional levels [6, 18]. It was assumed that the discrepancy between the current study and Majnemar et al. could be due to the difference in the functional level of children who were included.

The results of the current study also indicated that the satisfaction of families with the rehabilitation centers was moderately correlated with children’s motivation. The aforementioned result suggests that improving family satisfaction with rehabilitation centers, potentially through modifying the physical conditions of rehabilitation centers and focusing on the interest of the family, may increase the motivation level of children. To the best of our knowledge, there is no study about the aforementioned issue in the literature, so these results may direct future research in this area.

Penny et al. have shown that infants with comorbidities such as premature birth and seizure problems have lower motivation scores in their studies investigating factors influencing the motivation of infants [19]. In the current study, there was no significant difference in children’s motivation level based on presence or absence of comorbidities. Children without comorbidities comprised 80.6% of the study’s sample, and this high rate may have contributed to their high motivation levels.

Meyns et al. have shown that more complicated or simpler exercises according to the child’s functional level may reduce the motivation of the child, so the exercises should be adapted to their functional level [4]. Tatla et al. asked the open-ended question: “How could this therapy session have been better?” The responses of the children were as follows: “playing soccer,” “making another puzzle,” “no need for anything else,” “our rehabilitation program is already amusing” [13]. The same question was also directed to the children. The children in the current study answered that they were more fun and more motivating “to do exercises in the form of playing games, exercising in music accompaniment, playing ball, playing different games, doing different exercises, doing easier, and-or harder exercises.” Further, 22.58% of children stated that their rehabilitation programs were already fun. These results indicated that rehabilitation interventions should be determined according to the child’s functional level and interest during the rehabilitation process.

Regular participation in rehabilitation is crucial for success, and participation of patients in rehabilitation can only be achieved by increasing their motivation to rehabilitation [12]. Since interventions should be planned in an attempt to increase the motivation of children to rehabilitation, it may be useful to assess the motivation levels of children and motivation-related factors.

The current study has some limitations. Only children with high functional levels were included. Therefore, it is difficult to determine the relationship between functional level and motivation. For this reason, the results of this study should be interpreted with caution. Additionally, there are many factors that could not be eliminated in the current study, which may affect motivation in children such as socio-economic level, education level, income status of the family, and the number of years participating in a rehabilitation program. The lack of analysis of these factors has caused some of them to be overlooked, and they may be related to motivation.

In summary, the satisfaction of family with rehabilitation centers was related to motivation. However, age and gender were not related to motivation. It was also found that functional level and comorbidities were not related to children’s motivation. However, these results were obtained in the study including children with high functional levels and a high proportion of children without comorbidities. In order to obtain more robust evidence regarding the effects of the functional level and comorbidities on motivation, there is a need for research to be done with a wider distribution of samples in terms of functional level and comorbidities.

Footnotes

Acknowledgments

We would like to thank children and families who participated in this study for their time. We are also grateful to the special rehabilitation centers because they care for the children who we evaluate.

Conflict of interest

The authors have no conflict of interest to report. This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

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Motivation and motivation-related factors in children with disabilities

Abstract

PURPOSE:

METHODS:

RESULTS:

CONCLUSION:

Keywords

1. Introduction

2. Methods

2.1 Participants

2.2 Measurements

2.3 Procedure

2.4 Data analysis

3. Results

3.1 Sample characteristics

Table 1 Demographic characteristics of children

3.3 Motivation-related factors

4. Discussion

Footnotes

Acknowledgments

Conflict of interest

References

Table 1
Demographic characteristics of children