Children and Teens in Charge of Their Health: A Feasibility Study of Solution-focused Coaching to Foster Healthy Lifestyles in Children and Young People With Physical Disabilities
Phase: NA
Conditions: Spina Bifida, Cerebral Palsy, Health Behavior
Sponsor: Holland Bloorview Kids Rehabilitation Hospital

RESEARCH PROTOCOL  
Children and Teens in Charge of their Health: A feasibility study of solution-focused coaching to foster healthy 
lifestyles in children and young people with physical disabilities 
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Principal Investigator:  
• 
Amy McPherson, PhD, CPsychol. Scientist, Bloorview Research Institute, Holland Bloorview Kids 
Rehabilitation Hospital, Toronto.  Assistant Professor, University of Toronto, ON. 
 
Co-Investigators:  
• 
Elaine Biddiss, PhD, PEng, Scientist, Bloorview Research Institute, Holland Bloorview Kids 
Rehabilitation Hospital, Toronto.  Assistant Professor, Institute of Biomaterials & Biomedical 
Engineering, University of Toronto, ON. 
 
• 
Paige Terrien Church, MD. Physician Lead, Holland Bloorview Kids Rehabilitation Hospital, Spina 
Bifida/Spinal Cord Injury Program.  Assistant Professor, Paediatrics, University of Toronto, ON. 
 
• 
Gillian Alison King, PhD. Senior Scientist, Bloorview Research Institute, Holland Bloorview Kids 
Rehabilitation Hospital, Toronto. Professor, University of Toronto. ON. 
 
• 
Désirée B. Maltais, PhD, PT. Associate Professor, Department of Rehabilitation, Université Laval, 
Quebec City, QC. Researcher, Centre for Interdisciplinary Research in Rehabilitation and Social 
Integration, Quebec City, QC 
 
• 
Chantal Mérette, PhD, pht. Researcher, Center for Interdisciplinary Research in Rehabilitation and 
Social Integration, QC. Professor, Laval University, Quebec City, QC. 
 
• 
Hélène Moffet, PhD, PT. Researcher, Center for Interdisciplinary Research in Rehabilitation Faculty of 
Medicine, Quebec City, QC. Professor, Department of Rehabilitation, Université Laval, Quebec City, QC. 
 
• 
Fiona J. Moola, MSc., PhD. Scientist, Bloorview Research Institute, Holland Bloorview Kids 
Rehabilitation Hospital. Assistant Professor, Dalla Lana School of Public Health, University of Toronto 
 
• 
Heidi Schwellnus, PhD, Collaborative Practice Leader, Holland Bloorview Kids Rehabilitation Hospital, 
Toronto. Status Lecturer, University of Toronto, ON. 
 
Collaborators: 
 
• 
Patricia J. Baldwin, B.Sc.(OT), MTS. Certified Solution-Focused Coach, Independent Consultant, 
London, ON. 
 
• 
Lorry Chen, B.Sc., RD. Clinical Dietitian, Holland Bloorview Kids Rehabilitation Hospital, Toronto.   
 
• 
Janke F. de Groot, P.T, PhD. Associate professor Research Group Lifestyle and Health, HU University 
of Applied Sciences, Utrecht, the Netherlands. Program leader Quality and Organization of Care, 
Netherlands Institute for Healthcare Services (NIVEL), Utrecht, the Netherlands. 
 
• 
Sarah Keenan, MPH, CSFC. Life Skills Coach and Transitions Strategy Team Lead: Solution-Focused 
Coaching, Holland Bloorview Kids Rehabilitation Hospital. Clinical Team Investigator, Bloorview 
Research Institute 
 
 

Children and Teens in Charge of their Health: A feasibility study of solution-focused coaching to foster 
healthy lifestyles in children and young people with physical disabilities.  
 
 
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OVERVIEW 
This three year study explores the feasibility and acceptability of conducting a full randomized 
controlled trial (RCT) of a promising coaching intervention for improving and sustaining physical 
activity (PA) and healthy dietary habits in children* with physical disabilities (CWPD). Thirty children 
will spend 12 months in the study. All will receive usual care and basic printed information about 
healthy lifestyles. In addition, 15 will receive a coaching intervention for the first six months. Pre-
defined success criteria will assess the feasibility of trial processes. Acceptability of trial participation 
and impact of coaching will be explored qualitatively. Health indicators and psychosocial outcomes will 
be assessed four times, at the start of the trial, immediately post-intervention and at three and six months 
post-intervention.  
RESEARCH PROBLEM 
The World Health Organization’s Global Strategy on Diet, Physical Activity and Health Promotion 
highlights that PA and dietary habits are central to disease prevention and lifelong health [1]. Canadian 
children have increased health risks as their activity levels are drastically lower than recommendations 
[2] and ~26% are classified as overweight or obese [3, 4]. The situation is even more critical for children 
with disabilities; 4.2% of Canadian children have disabilities and this number is rising [5, 6]. Due to 
complex and intersecting factors, CWPD are more sedentary [7-9], have lower PA rates [9, 10] and 
poorer quality diets [8-10] than their non-disabled peers. It is therefore both unsurprising and concerning 
that CWPD are 2-3 times more likely to be classified as overweight or obese than those without 
disabilities [11]. Annual health care costs of obesity related to disability are estimated at $44 billion in 
the US [12], supporting the need to start health promotion activities early in life. Despite the serious 
proximal and distal consequences of this health profile, we lack robust evidence on effective strategies 
                                                          
* Refers to children and young people between the ages of 10 - 18 years inclusive 

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healthy lifestyles in children and young people with physical disabilities.  
 
 
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to foster and sustain health habits for CWPD. Our team’s research over the past 5+ years has provided 
three key learnings: i) CWPD have far fewer opportunities to engage in health promotion programs than 
their typically developing peers [13, 14]; ii) Although prescriptive exercise/dietary interventions can be 
efficacious, they are unsustainable due to the extensive resources required [15, 16]; and iii) CWPD often 
need support to identify health promoting activities that are engaging and grounded in their abilities and 
daily life [17]. Our review of 34 health promotion intervention studies for CWPD [18] showed: 
• 82% of the programs required professional supervision (on average 35 sessions over 12 weeks) 
• 94% used prescriptive intervention strategies (i.e. not tailored to the individual’s circumstances)  
• 90% of interventions focused on one specific health behaviour (i.e. PA or diet, but not both) 
• Only 28% used a control group 
• No article reported on how positive health outcomes might feasibly be supported long-term 
A new intervention paradigm that produces sustainable results without undue burden (on families or 
services) is therefore urgently required to address the health promotion needs of CWPD. Interventions 
must empower individuals to make lifestyle changes that are personally meaningful in order to promote 
motivation and encourage sustainable changes [19, 20]. Critically, interventions must also consider the 
child’s circumstances (individual, environmental, familial) to ensure that health habits can be integrated 
into everyday life and thereby have a long-lasting impact [21, 22]. And, researchers must rigorously 
evaluate such interventions to provide evidence-based recommendations on improving the short- and 
long-term health of this under-served population [23, 24]. 
We propose that a strengths-based coaching approach may meet all of these requirements. In 
coaching, clients are guided to identify their goals, develop strategies to meet them and monitor their 
performance [25, 26]. In particular, Solution-Focused Coaching in Pediatric Rehabilitation (SFC-Peds) 
has been recommended as a coaching model for children with disabilities, for its strong theoretical basis 

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healthy lifestyles in children and young people with physical disabilities.  
 
 
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and ability to be customized to children and families’ resources, environmental settings, child age and 
developmental stage [27]. Taking a strengths-based approach (such as SFC-Peds) is a departure from 
usual rehabilitation research and practice, which has largely been problem-focused (i.e. what a child 
can’t do). This can lead to feelings of ineptitude, learned helplessness, poor self-concept and low self-
efficacy [27]. Instead, a strengths-based approach can result in hope, motivation and action [28]. 
Strengths-based approaches are also much briefer than most existing interventions, and behaviour 
change is less costly using strengths-based approaches than problem-based approaches [29].  
However, given that we will be the first to use SFC-Peds to promote healthy habits with CWPD, a 
feasibility and acceptability study is essential. Evidence of feasibility is a critical prerequisite for a RCT 
[30], especially for complex interventions that have multiple interacting components and/or target 
multiple behaviours (such as SFC-Peds) [30, 31]. Feasibility studies rigorously examine the processes 
(e.g. recruitment and retention), resources (e.g. personnel, time required to complete measures), 
management (e.g. coordination of research personnel, quality of data entry) and science (e.g. appropriate 
methodology and outcomes) of the intended RCT [32, 33]. It is also critical to evaluate the acceptability 
of interventions for the target population (e.g. satisfaction with duration, intensity, level of interest, 
perceived impact) [34], as well as those allocated to the control arm (e.g. acceptability of not receiving 
coaching, perceived burden of assessments) [35-37]. Examining all of these issues before the efficacy 
trial begins increases the likelihood of success [30, 38]. Feasibility studies such as the one we are 
proposing help ensure that resources are invested in efficacy trials likely to generate clinically 
meaningful results [38] and therefore have maximum impact on health care knowledge and outcomes.  
KNOWLEDGE TO DATE 
The health promotion needs of CWPD are considerable and unmet. Health habits must start 
early [39-41], as adult habits often begin in childhood [42]. This is particularly pertinent for CWPD, 

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because they often experience a range of physical, social and psychological restrictions leading to sub-
optimal health habits [8-10]. Fatigue, pain, incontinence, lack of professional support, and inaccessible 
fitness/recreational facilities have all been cited as PA barriers [43-46]. Low PA can lead to mobility and 
functional restrictions, osteoporosis, depression, social isolation and reduced overall health and well-
being [24, 47]. The current obesogenic environment provides easy access to energy-dense food for all 
children, but CWPD report eating less fresh produce, more ‘fast food’, more high-fat food and more 
chocolate than their non-disabled peers [8-10]. Environmental settings significantly influence daily 
health habits in children [21, 48]; this is salient for CWPD, who spend more time at home [49, 50] and 
have fewer opportunities to participate in sports and recreational activities than their nondisabled peers 
[49, 51, 52]. Parents of CWPD experience high stress [53, 54] and reduced incomes [55], which may 
also affect their child’s engagement in health promotion activities [49, 56]. Conversely, we know that 
health habits have substantial positive benefits for children with physical disabilities; for example, 
young people with spina bifida (SB) and cerebral palsy (CP), Canada’s most prevalent non-progressive 
childhood physical disabilities [57], demonstrate higher fitness levels, muscle strength, and social 
inclusion when engaged in active lifestyles [58-60]. Despite this, PA and diet interventions are rarely 
tailored to CWPD [61-63]. Given the increasing number of Canadian CWPD [6], robust evidence is 
needed regarding intervention strategies to improve and sustain positive health habits in CWPD.  
Coaching is a theoretically-based intervention for changing behaviour. Coaches use real-world 
situations to promote positive, long-term behaviour change. The primary aim of coaching is to enhance 
self-determination, that is, the feelings of choice and control over one’s life [64]. Self-determination 
theory (SDT) posits that there are 3 basic psychological needs essential for behaviour change [65]: i) 
Autonomy, the opportunity to make meaningful choices [66]; ii) Competence, also termed ‘self-efficacy’ 
[27], an individual’s innate sense of belief in their ability to be successful at a particular activity [67]; 

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healthy lifestyles in children and young people with physical disabilities.  
 
 
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and iii) Relatedness, feelings of support and acceptance that provide affirmation [68]. The resulting 
intrinsic motivation is a powerful mechanism to foster sustained behaviour change through genuine 
interest, satisfaction and engagement [65]. It is operationalized in coaching through co-constructing 
goals with children around new habits, supporting clients to identify realistic strategies for goal 
attainment and facilitating client reflection/monitoring of goal progression [25, 26, 69]. 
There is evidence of coaching efficacy for health promotion. Coaching has been used to 
improve and sustain a range of health habits in typically developing children [19] and adults with 
physical disabilities [70]. For example, telephone coaching of children and their parents led to dietary 
improvements and increased fitness [71]. Reduced Body Mass Index (BMI) was also reported in 
children with obesity after group coaching [72]. Adults with physical disabilities reported fewer exercise 
barriers and improved eating habits following telephone coaching [70]. Coaching in CWPD also show 
promising and sustainable behavioural change e.g. improvements in mobility-related behaviours in 
children with CP were sustained 6 months after a coaching intervention [73].  
Solution-focused coaching is a promising approach to promote health habits in CWPD. There 
are a number of reasons why SFC-Peds is promising for promoting healthy habits in CWPD. First, SFC-
Peds is based upon solution-focused brief therapy, which has strong evidence of behaviour change [74-
76] and requires considerably fewer resources than those used in more traditional interventions [27]. 
Second, SFC-Peds is the only coaching model using all eight of the evidence-based coaching features 
shown to promote positive behaviour change [77]. These features map onto the 3 psychological needs 
described by SDT: a) autonomy: through the use of strategic questions to help children identify 
personally meaningful goals and develop practical solutions to move toward a vision of their “preferred 
future”; b) Competence: through empowering children to assume ownership over their goals and 
develop robust self-regulatory behaviours; and c) relatedness: through the use of active listening, 

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empathy and affirmative language [27, 69, 78, 79]. The resulting intrinsic motivation is associated with 
positive health behaviour changes [18]. Third, strategies used in SFC-Peds are tailored to the child’s age, 
developmental stage, abilities and environmental settings, so that the same coaching processes can be 
used with a heterogeneous sample [27]. Finally, early pilot work by our team showed that children with 
physical disabilities (5 children with Duchenne muscular dystrophy) were able to engage with SFC-Peds 
and attained at least 1 PA or dietary goal after 12 weeks [80, 81]. The feasibility and acceptability of 
conducting a full RCT with a 12 month commitment remains unknown, however.  
SIGNIFICANCE AND IMPACT OF THE RESEARCH 
Physical, environmental and psychosocial restrictions mean that CWPD are adopting worrying 
PA and dietary habits. Despite this, we currently have limited evidence to inform interventions that may 
enhance lifelong health in CWPD. We suggest that a paradigm shift is needed, one that moves beyond 
traditional prescriptive programs to a strengths-based approach where intervention strategies enable new 
health habits to be integrated seamlessly into children and families’ everyday lifestyles for long-term 
sustainability. Research such as our proposed study will ensure that this potentially transformative 
approach is rigorously examined and used in an evidence-based manner. As little is known about 
effective and acceptable behaviour change interventions for CWPD, this study’s findings will make 
significant contributions to the field: i) Greater understanding of ecologically valid interventions that 
have the potential to enhance the long term health of CWPD; ii) Insight into how two different 
rehabilitation populations respond to SFC-Peds; and iii) Data on the responsiveness of outcome 
measures to a SFC-Peds intervention. These insights will enable us to design acceptable, feasible and 
rigorous interventions that will result in robust data for informing both research and clinical practice. 
 
 

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OBJECTIVES & RESEARCH QUESTION 
Primary objective: To evaluate the feasibility (study design, methods, processes) and acceptability 
(family/child/clinician satisfaction, perceived usefulness) of conducting a RCT of a novel, brief, 
coaching intervention (SFC-Peds) for improving and sustaining PA and dietary habits in CWPD.  
Secondary objective: To determine the responsiveness of selected outcome measures to SFC-Peds 
coaching over 12 months.  
Principal research question: “Is an efficacy trial to evaluate a six month SFC-Peds intervention to 
improve PA and dietary habits feasible to implement and acceptable to CWPD and families?”  
APPROACHES AND METHODS  
Design: We will use a pilot RCT design [82] with two groups: One group (n=15) will work with a coach 
trained in SFC-Peds eight times over six months. The other group, the control group (n=15), will receive 
only standard printed materials at the start of the study. These materials will also be available to the 
SFC-Peds group to control for bias on study measures. The control group will allow us to control for 
information, maturation, repeated testing and attrition over the 12 month study [83]. All participants will 
receive standard care from existing clinicians who will not be delivering the SFC-Peds study 
intervention. The feasibility of trial processes, management, and resources will be assessed 
quantitatively. The acceptability of trial participation and coaching processes will be explored 
qualitatively. Qualitative enquiry lends insight into potential mechanisms of change and barriers to 
implementation and is therefore highly recommended when evaluating complex interventions [34]. 
Sample: Thirty children aged 10–18 inclusive and their parents who live within approximately two 
hours of Holland Bloorview Kids Rehabilitation Hospital (Toronto, ON) up to Thames Valley 
Children’s Centre (TVCC) (London, ON) will participate. The sites serve diverse socio-cultural 
communities.  

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Child inclusion criteria:  
i) 
Between the age of 10 – 18 years inclusive 
ii) 
Diagnosis of SB or CP 
iii) 
Has physical capability to execute independent body movement with or without device 
iv) 
Cognitively able and willing to set PA or dietary goals 
v) 
Can communicate in English and respond to questions requiring some reflection and insight 
vi) 
Home internet connection 
vii) 
Lives within 2 hours driving distance from Toronto up to London, Ontario OR willing to 
travel to either HB or TVCC for first in-person coaching session if randomized into coaching 
group 
Child exclusion criteria: 
i) 
Surgery in past 6 months or upcoming 12 months that may impact PA or dietary intake (e.g. 
orthopedic surgery or neurosurgery)  
ii) Medical condition severely restricting diet 
iii)  Underweight (less than fifth percentile)  
iv) Receiving specialist dietetic services 
Parent inclusion criteria: 
i) 
Primary caregiver to a study participant 
viii) 
Can communicate in English and respond to questions requiring some reflection and insight 
Sample size 
Feasibility studies do not assess intervention efficacy and therefore do not require formal sample 
size calculations [33, 85]. The sample size (n=30) was set as a minimum needed to assess the key 
feasibility issues, as per feasibility best practices [86]. Fifteen SFC-Peds participants will suffice to show 

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a tendency (p<0.10) within the intervention group of behavioural change assessed by Goal Attainment 
Scaling (GAS; see ‘Outcomes’), equal to an effect size of 0.55 with a power of 0.80. The responsiveness 
of the secondary outcome measures will be compared with goal scores for evidence of concordance, e.g. 
a tendency of correlation between behavioural change and the Arc’s Self-Determination Scale. Post hoc 
estimates of variance will be key for the full trial’s design as they will inform the power calculations of 
the eventual RCT [85]. The sample size will allow us to assess recruitment success and show whether 
testing procedures, coaching goals and follow-up sessions are consistent across groups, mobility levels 
and sites. This sample size will also provide sufficient data for the qualitative work we are proposing to 
explore acceptability [87, 88]. 
Recruitment 
We will recruit 15 children with SB and 15 children with CP (a total of 30 participants) and their 
parents from Holland Bloorview and TVCC.  
Recruitment at Holland Bloorview 
Children will be recruited from the Child Development Program at Holland Bloorview. 
Specifically we will solicit participation from clients in the Spina Bifida Service, LIFEspan Program, 
Hypertonia Clinic and through physiotherapists (PT’s) and occupational therapists (OT’s) in the 
Neuromotor Program. Following Research Ethics Board (REB) approval, a designated clinical member 
from the Spina Bifida Service, LIFEspan Program, Hypertonia Clinic as well as all PT’s and OT’s in the 
Neuromotor Program will identify eligible clients who meet study inclusion criteria and will provide 
study flyers and information letters. Clinicians may request the RC on site to speak directly to interested 
families about the study in further detail. Clients will be encouraged to review the information letter and 
discuss the study with their family members if they wish. The RC may obtain consent on this day if the 
family is ready. Otherwise, the RC will obtain permission from the family for a follow-up phone call to 

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confirm interest and schedule an appointment time to obtain written informed consent. Families may 
contact the RC for more information at any time.   
In addition, flyers for the study will be posted on the Bloorview Research Institute’s “Participate 
in Research” page and around approved areas of the hospital for any potential participants to self-refer to 
the study (see Appendix 1). They may call the number provided on the flyer where the RC will explain 
the study in greater detail and confirm that they are eligible for the study. On May 1st, 2018, we will 
begin to use centralized recruitment system at the Bloorview Research Institute.  
Recruitment at Thames Valley Children’s Centre 
 
A research contact who is a designated staff member at the TVCC will introduce the study to 
clients seen in the SB and CP service. They will then obtain permission from families for the Holland 
Bloorview RC to contact the family to discuss the study. The TVCC research contact will share the 
family’s contact information with the RC who will then contact the interested family and describe the 
study in more detail and confirm their eligibility to participate.  
If recruitment is insufficient using these channels, the Spina Bifida and Hydrocephalus 
Association of Ontario (SBHAO) will distribute information letters to all families on their distribution 
list meeting the age and diagnosis criteria. Families who are interested in the study can contact the RC 
for more information and to confirm eligibility for the study. 
Informed Consent 
After a telephone or in-person conversation to confirm eligibility and interest (see Appendix 2 
for script), a convenient time and date will be arranged for the RC to meet with clients and parents at 
their nearest assessment site (Holland Bloorview or TVCC) to complete informed consent followed by 
the first assessment session.  

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At this session, the RC will clarify any concerns, and answer any questions clients or parents 
might have and will judge the child’s capacity to provide informed consent, guided by a structured tool 
(see Appendix 3). If the RC judges the child to have answered questions about the study with reasonable 
understanding, the child will sign the Informed Consent Form (ICF) (see Appendix 4). Otherwise, a 
parent will sign the ICF and the child will provide their assent (see Appendix 5). For parents who are 
willing to participate in the interviews and parent measures the parent will sign the ICF for their own 
participation in the study. The RC obtaining informed assent from prospective participants (children) 
will familiarize the potential participant about assent by explaining what free, informed consent is and 
how research is different from clinical care. The RC will have an open and age appropriate discussion 
with each child to assess readiness for assent. The RC may consult the parent to identify 
accommodations to assist in decisions to participate. The assent and consent forms will be provided 
prior to this discussion in order for families to review them on their own. While meeting with the client 
and parent, the RC will clarify any concerns, and answer any questions clients or parents might have. 
During this process, the highly experienced RC will observe and listen for any verbal and nonverbal 
indications of dissent. Furthermore, the RC will ensure ongoing informed assent by reconfirming 
agreement to participate throughout the study. At the end of the study, the family will receive a study 
summary letter at the end of the study. The local REB fully endorses these processes.  
 Randomization 
Once participants have provided written informed consent and completed all baseline measures, 
they will be randomized into the study. The PLAN procedure of SAS/STAT software will create a 
random sequence to test randomization. Randomization block size will not be known to research staff to 
ensure blinding. Group allocation occurs after baseline assessment, stratified by diagnosis and 
recruitment site.  

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Standard care 
All participants will receive standard care throughout. This may vary with the child’s age, 
diagnosis, functional level and co-morbidities. Our previous work shows that advice related to PA/diet is 
rarely given with standard care [89]. However, to document any potential co-interventions, all 
interactions between study participants and their service providers will be recorded on a standard form 
see Appendix 6). The study will thus identify any differences in standard care between groups and 
across sites, and will inform recruitment, stratification and data analysis in the full RCT. We will 
identify if any service providers have SFC-Peds training. Coaches will not be part of participants’ 
standard care.  
Control information 
  
After randomization, all participants will be given basic printed information relating to PA and 
healthy diets based upon Health Canada’s Eat Well and Be Active Toolkit (www.health.gc.ca/eatwell-
beactive), which has been reviewed for suitability by expert team members (Church, Chen, Maltais). 
This ensures that all children have exposure to information on healthy habits, thereby meeting our 
ethical imperative and ensuring a scientifically rigorous control group. It also helps to control for bias of 
responses on outcome measures (see Appendix 7 for booklet). 
Intervention training 
 Coaches will be clinicians with physiotherapy, kinesiology, therapeutic recreation, dietetics or 
similar training who have already been trained in SFC-Peds. They will undertake a half day of training 
from expert team members, including Canadian PA and diet guidelines [90, 91], and their application to 
children with SB and CP (Church, Maltais, Chen). 
Intervention implementation 

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Children randomized into the SFC-Peds group (n=15) and their parents will be allocated a coach 
for eight 60-min SFC-Peds sessions over six months. A six month intervention is supported by meta-
analyses of health promotion studies for typically developing children [92] and adults [93]. Time is 
allowed between sessions for children and parents to work on their goals [27, 70] (see Appendix 11 for 
coaching schedule). 
Coaching will be guided by a framework developed by SFC-Peds clinicians at Holland 
Bloorview to integrate the Canadian Occupational Performance Measure (COM) and Goal Attainment 
Scaling (GAS) outcome measures into SFC-Peds (see Appendix 8 for framework). The first coaching 
session will take place in the family’s home to establish rapport. Parents play an important supportive 
role in the coaching process, although the level and type of support they provide will be customized to 
the age and abilities of their child. SFC-Peds is ideal for establishing ‘common ground’ between 
children and parents so that they are working towards goals that they both deem important, maximizing 
the chances of sustainability. To enhance child self-determination, the coach will first support the child 
to identify their ‘preferred future,’ i.e. the ‘big picture’ the participant wants to work towards in the 
context of health habits. Then, the child, parent and coach will co-create actionable goals to help 
children to work towards it. Focusing upon goals that are personally meaningful to the child fosters 
autonomy [94]. The coach and parents will then support the child to identify realistic, real-world goal 
attainment strategies using their own strengths and resources, supporting the development of 
competence. The use of active listening, empathy and attentive body language creates a trusting 
relationship, and promotes a sense of relatedness [95]. Parental involvement in the coaching sessions 
will ensure that goals and goal-attainment strategies are realistic for the child, his/her environmental 
settings and the family. For example, if the parent cannot transport a child to an organized activity to 
meet their physical activity goal, then a different strategy would be co-created that is appropriate for the 

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child’s circumstances and available support systems (e.g. use of an active video game). This flexibility 
and customizability is a key strength of SFC-Peds. The coach will help parents to identify their own 
resources and action steps for supporting their child’s goals, appropriate for their age, developmental 
stage and abilities. Children will each set at least one PA or one dietary goal. See Appendix 9 for 
examples of the coaching and goal setting process (supported by their parents). If this happens, the time 
taken to achieve goals will be recorded and used to inform future coaching protocols. 
To reduce family burden and enhance adherence [43], the remaining coaching sessions will be 
held remotely usingZoom an online meeting tool used by Holland Bloorview requiring children only to 
have internet access. It enables coaches and families to have secure, face-to-face contact without 
onerous and expensive travel.. Remote coaching has previously demonstrated feasibility in typically 
developing children [71, 80]. 90% of Canadians have Internet access with 70% accessing the Internet 
daily [96]. Any instances of internet access being a barrier to study participation will be noted and will 
inform our assessment of study feasibility.  
At every coaching session, coaches will employ SFC-Peds best practices and ask key questions 
that: Elicit any changes since previous sessions (e.g. What’s better? What worked?); Amplify successes 
(e.g. How did you figure that out?); Reinforce key learnings (e.g. What have you learned as a result of 
that success?); and Review the child’s action plan (e.g. With your new skills, what’s next?) [97]. After 
each coaching session, coaches will complete a standardized fidelity measure (see Appendix 10) to 
ensure intervention consistency (the Solution-Focused Fidelity Instrument, internal consistency of 0.83 
[98]), which will be reviewed weekly by the team’s coaching experts, and feedback provided. Coaches 
will randomly record 2–3 sessions each for review by the coaching team members and have ongoing 
supervisory sessions. Participant engagement will be measured using the Pediatric Rehabilitation 

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Intervention Measure of Engagement – Service Provider (PRIME-SP)  (see Appendix 11) and will be 
assessed by the coaches after each coaching session [126].  
 
STUDY OUTCOMES AND PROCEDURES 
Study Procedures 
After enrollment into the study, participants will complete the following assessments at the time 
points outlined below (see Appendix 12 for assessment schedule). Children in the SFC-Peds group will 
receive the eight 60 minute coaching sessions between Time 1 and Time 2. 
Assessment Timings 
To assess participant retention, the feasibility study will use four assessment points over 12 
months as in the planned efficacy trial: Time 1 Baseline (immediately preceding randomization); Time 
2 (immediately post-intervention or 6 months post-baseline for control group +/- 2 weeks); Time 3 
(three months post-intervention or 9 months post-baseline for control group +/- 2 weeks); Time 4 (6 
months post-intervention or 12 months post-baseline for control group +/-4 weeks).  
Study Assessments 
PRIMARY OBJECTIVE: To evaluate the feasibility and acceptability of conducting a RCT of a novel, 
brief, coaching intervention (SFC-Peds) for improving and sustaining PA and dietary habits in CWPD. 
Trial feasibility will be assessed using the following pre-identified criteria (as recommended [82]): 
Recruitment 
2–3 participants/month recruited over 12 
months (for target sample size n=30) 
≥ 10% recruitment response rate achieved 
(min. feasible RCT response rate [99]) 
Attrition 
85% participants successfully complete 
study (i.e. complete T1 & T4 evaluations) 
75% participants complete all assessments 
(i.e. protocol adherence) 
Adherence 
Successful completers participate in ≥75% 75% of the participants complete 

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meetings with coach 
evaluations in ≤2 hrs (to assess burden) 
Stratification 
Intervention/control groups similar for age 
and gender 
Intervention/control groups comparable on 
diagnosis and functional mobility 
Fidelity 
High intervention fidelity (>8/10 on the 
Solution-Focused Fidelity Instrument [98]) 
Challenges/ease 
of 
remote 
coaching 
(coach, child, family report) 
 
Trial acceptability will be explored qualitatively: 
Semi-Structured Survey 
Time 1: All child participants (n=30) and parents (n=30) will complete a semi-structured survey 
exploring expectations, motivations and views on health habits upon entering the study (see Appendix 
13 for Baseline Interview Survey).  
Qualitative Interview Time 2 (SFC-Peds group only) 
Time 2: SFC-Peds participants (n=15) and their parents (n=15) will be interviewed (separately 
where possible) by a qualitative interviewer to explore: i) Satisfaction with coaching sessions (e.g. 
relationship with coach, experiences of virtual coaching; whether they would recommend it to others); 
ii) Coaching experiences (e.g. new opportunities, challenges experienced); iii) Perceived optimal 
coaching dose; iv) Role of SFC-Peds in children’s and family’s health habits (if any); v) 
Role/extent/experiences of parent involvement in supporting coaching goals and activities (see 
Appendix 14 for Time 2 interview guide).  
Photovoice (SFC-Peds group only) 
SFC-Peds participants will be given a digital camera (or they may use their cellphone, depending 
upon preference), and asked to take 1–2 naturalistic photos per month between Times 2 and 4, to 
provide insights into their lifestyles post-coaching (termed ‘Photovoice’ [100]). Photovoice uses 

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photographic images taken by participants to help researchers understand what is meaningful for them 
[101-105]. Data produced through this method enables participants to reflect their lived experiences and 
enhance our understanding of the acceptability and perceived impact of coaching. Children will be given 
guidelines on the types of photos they could potentially take (see Appendix 15). They will be reminded 
twice a month using their preferred method of contact (phone, email, or text message). 
 
Time 3: No acceptability data collected.  
Qualitative Interview Time 4 (SFC-Peds group only) 
Time 4 (SFC-Peds group): Children and their parents in the SFC-Peds group will undertake 
separate in-depth interviews facilitated by a qualitative interviewer to explore their experiences after 
coaching completion, perceived impact of intervention, barriers/facilitators to maintaining PA and 
dietary habits, and any unmet needs (see Appendix 16 for interview guide). Children will be asked to 
select 6-8 of their photographs taken since Time 2 to share with the interviewer. This will help remind 
children of their lifestyles in the previous six months, and enable them to speak in more depth about 
their feelings and experiences [106]. Each child will first be asked to explain why he/she took the photo, 
its meaning, what it shows of his/her coaching experience and the time since it ended.  
Survey Time 4 (Control group only) 
Time 4 (Control group): Children in the control group (n=15) will complete a Time 4 survey 
(see Appendix 17) regarding what they liked most/least about the study, any changes in health habits in 
the previous 12 months, acceptability of not getting the intervention, and tolerance of assessment 
protocols [30].  
Qualitative Interview (Coaches only) 
 
Time 4 (Coaches): Coaches will be interviewed to explore their experiences of delivering the 
intervention, e.g. challenges/facilitators, optimal coaching doses, use of technology (see Appendix 18). 

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SECONDARY OBJECTIVE: To determine the responsiveness of outcome measures to SFC-Peds 
coaching over 12 months.  
 
The following measures (excluding gender and date of birth) will be administered at Times 1, 2, 
3, and 4 for all participants (approximately 1.5 hours duration). Issue identification and goal attainment 
measures are administered to SFC-Peds participants only with the first assessment conducted during the 
first coaching session. Measures have been selected based upon evidence of their responsiveness to 
change and psychometric properties in previous health promotion interventions [18]. Parent and child 
report questionnaires may be completed at home or online if the family prefers.  
Participant characteristics  
 
DEMOGRAPHICS: Gender, date of birth, ethnicity, diagnoses, medications, current sports involvement 
(see Appendix 19 for demographics form). Questions from the International Study of Childhood 
Obesity, Lifestyle and the Environment survey (see Appendix 20) about the child’s environment (e.g. 
accessibility of play areas) will also be collected [107]. 
FUNCTIONAL MOBILITY: The six-minute walk test for walkers [108] and the six-minute push test for 
non-walkers [109] (see Appendix 21). 
Primary outcome measure  
ISSUE IDENTIFICATION AND GOAL ATTAINMENT (CHILD REPORT):  
Within-group change will be assessed using the Canadian Occupational Performance Measure 
(COPM) (see Appendix 22), which identifies the person-centred goal performance issues to improve, 
and assesses changes in occupational performance and satisfaction. Participant goal attainment will be 
assessed using Goal Attainment Scaling (GAS) (see Appendix 23), by defining five levels of goal 
attainment, thus ensuring that all attainment levels are mutually exclusive and measurable. This is an 

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objective measure of behaviour change [110]. To minimize bias, GAS and COPM re-assessment will be 
conducted by a coach who has not worked with the child.  
 
Secondary outcomes measures: 
Between group change will be examined using the following measures: 
BEHAVIOURAL ASSESSMENTS (CHILD REPORT):  
Physical activity: The Habitual Activity Estimation Scale [111] (see Appendix 24) estimates 
time spent inactive, somewhat inactive, somewhat active, and very active, and shows good correlation 
with moderate to vigorous PA measured by accelerometry in our population (p=0.02) [112, 113].  
Diet: The Dietary Screener Questionnaire (see Appendix 25) assesses dietary intake over the past 
30 days and is validated against 24 hour multiple recall [114]. 
PSYCHOSOCIAL ASSESSMENTS (CHILD REPORT):  
Self-determination: The Arc’s Self-Determination Scale (see Appendix 26) has excellent 
reliability/validity with children with disabilities [64] and will assess self-determination to provide 
insight into potential mechanisms of behaviour change.  
Self-efficacy: The PA Self-efficacy Scale (see Appendix 27) assesses confidence in the ability to 
be physically active when faced with challenges [115], with good internal consistency (α=.54- .71) and 
test-retest reliability (ICC= .61-.82). High self-efficacy scores are significantly associated with greater 
moderate-vigorous physical activity [116]. Self-efficacy for healthy eating (see Appendix 28) assesses 
participants’ feelings of competence for making healthy food choices in: social, emotional, and typical 
situations [117]. Higher scores are associated with healthy food intake (β = .33, p < .01), test-retest 
reliability (ICC= .80) [118].  
BODY COMPOSITION (CHILD ASSESSMENT):  

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Weight, height/length, waist circumference, and skinfold thickness (see Appendix 29 for record 
form) will be assessed, using standard guidelines [119].  
Weight: Participants will be weighed minimally clothed (e.g. t-shirt, light shorts) without shoes 
to the nearest 100 grams using a chair scale.  
Height: Those able to stand will be measured to the closest millimeter with a portable 
stadiometer or length measuring board. For those with severe contractures, careful segmental 
measurement will be conducted of the child’s length in supine. Arm span and ulna length will also be 
measured  as they offer useful proxies for length in children with lower extremity deformities [127, 
128].  
Body Mass Index (BMI): BMI will be calculated using both height and length as kilograms per 
meter squared (kg/m2) and classified using Centres for Disease Control and Prevention cut-offs (85th–
95th centile=overweight, above 95th percentile=obese) [120]. 
Waist circumference: Waist circumference (WC) has been shown to correlate well with fat mass 
as measured by dual-energy X-ray absorptiometry (DXA) [129-132] and has been specifically 
recommended for assessing body fat of children with SB [133] WC will be measured using a flexible 
tape measure at the narrowest level between the lower costal border and the iliac crest, over light 
clothing. Children with WC ≥ 90th percentile have shown to be at higher risk of cardiovascular 
indicators [134, 135]. The RA will confirm lesion level using medical records and note any bulky 
masses, liposuction incision marks or spinal curvature.  
Skinfold thickness: Skinfold thickness (SFT) is strongly associated with cardiovascular risk 
factors in children [136]. Tricep and subscapular skinfold thickness will be assessed, as per best practice 
[137] using Lange callipers (Cambridge Scientific Industries). Subscapular SFT in particular has 

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previously demonstrated excellent test-retest reliability when conducted by skilled practitioners [127, 
133]. The Slaughter equation will be used to assess body fat [138]. 
HOME AND ENVIRONMENT ASSESSMENT (PARENT REPORT):  
The Family Eating and Activity Habits Questionnaire (see Appendix 30) is a 32-item parent-
report assessment to assess the health behaviours of family members as well as the nature of the home 
environment [121]. It has high internal consistency (0.76-0.87) and test-retest reliability (0.75-0.89). 
These data will provide context for the children’s behavioural outcomes, and allow us to examine the 
impact of the coaching on the family over time, which will also be examined in qualitative interviews 
with parents and children. 
Post-Study 
Following completion of the study, both child and their parent will be thanked and provided with 
a $20 gift card for each visit ($25 for the final visit) as a token of appreciation. Participants will also be 
offered volunteer hours. Families will be reimbursed for their parking expenses. Additionally, all 
participants who have completed all of the assessments will be entered into a prize draw for a gift card 
of $150 at the end of the study. Participants and their parents will be asked if they wish to receive a 
summary of the research once the study is completed.   
DATA ANALYSES 
Sample characteristics will be summarized using descriptive statistics. Inferential statistics are 
not used in feasibility studies [82].  
PRIMARY OBJECTIVE: Feasibility will be assessed using descriptive statistics using our a priori 
success criteria [82]. We will explore any sample/group differences between completers (complete 
Time 1 and Time 4 measures) and non-completers. We will also determine if there are sample and 

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outcome variable differences between sites, disabilities and functional mobility, which will guide our 
target sample for the efficacy study. 
Surveys completed by participants at Time 1 (all participants) and Time 4 (control group only) 
will be analyzed with descriptive statistics and thematic analysis [122]. Verbatim transcripts from in-
depth interviews with the SFC-Peds group at Times 2 and 4 will undergo interpretative thematic 
analysis [123] informed by the phenomenological research tradition to identify acceptability of the 
intervention (e.g. satisfaction with coaching, perceived impact). Team members will independently code 
transcripts with a flexible, inductive coding system consistent with research objectives. Similar codes 
will be grouped, from which a consolidated list of master themes will be created that show patterns in 
participant experiences, supported by data. Characteristics (e.g. child age, gender, diagnosis and 
functional mobility) will be considered to understand the context of the participants’ experiences. The 
research team will play a key role in data synthesis/interpretation. Code-recode, peer examination and 
team discussions will help establish trustworthiness.  
Data from the Photovoice portion of the Time 4 in-depth interview will be read multiple times to 
embed the research team in the stories of the participants. The research team will code each transcript by 
noting words, phrases, or data segments that occur commonly in participant’s narratives. Next, the 
research team will group these commonly occurring data segments into categories. At the next stage of 
analysis, the research team will perform this coding activity on each transcript. Subsequently, the 
research team will search accords the entire group of transcripts to develop commonly occurring 
categories and themes across the data set. The derived themes will be refined carefully. Dr. Moola will 
supervise the coding activity. The themes will be written into a thematic overview of how children with 
SP and CP see the body, health and physical activity from their own situated life worlds. 

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SECONDARY OBJECTIVE: Measure responsiveness will be established by pre-post intervention 
differences using effect sizes (Cohen’s d) and confidence intervals both within and between groups. It is 
well accepted to examine mean score changes for clinically significant differences pre and post 
intervention without calculating statistical significance (e.g. a score change of at least 2 points on the 
COPM is considered clinically significant [38]). We will therefore be able to assess the potential value 
of SFC-Peds over receiving printed materials only by examining goal scores over time. Our secondary 
outcomes will be compared with objective behaviour change (goal attainment) for concordance (e.g. 
whether successful goal attainment corresponds with increased self-determination). We will examine 
differences in outcome measures by disability, functional mobility, gender and age. 
CHALLENGES 
Our intervention (SFC-Peds) is largely virtual to reduce burden and enhance adherence [43]. All 
participants will receive gift cards for completing assessments to reduce attrition; this is a key feasibility 
outcome, especially in the control group. To reduce possible biases, participants will not meet during the 
study and coaches will not be involved in standard care. Standardized training (by 3 certified coaches) 
will be provided. Assessors will be asked which group they think participants are in; blinding success is 
indicated by accuracies at or below chance level. If adaptations are needed for the RCT, ‘A process for 
Decision making after Pilot and feasibility Trials’ (ADePT) [124] will be followed. 
KNOWLEDGE TRANSLATION (KT) 
A KT planning template [40] will ensure our findings have maximum reach yet are appropriate 
for feasibility study outcomes. The plan capitalizes on close collaboration of knowledge users and 
researchers within our investigative team. Integrated KT is promoted throughout the project by the 
involvement of clinical, family and knowledge user stakeholders, to ensure that the outputs meet the 
needs of the end users [125]. Holland Bloorview Research Family Engagement Committee members 

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have reviewed the proposal. Clinicians are team members, as are 2 parents of children with CP and SB 
and a young man with CP (see letters of support). End of grant KT will be: i) a refined proposal for a 
full RCT submitted to CIHR for consideration; ii) dissemination of study findings using traditional 
knowledge diffusion strategies: i.e. conference presentations and publications; iii) communications to 
lay forums with summaries, stories and infographics. The latter will be facilitated through our 
knowledge users and partners: Variety Village (a well-established Toronto organization offering 
resources for active, healthy lifestyles for all abilities), Spina Bifida and Hydrocephalus Association of 
Ontario, and Childhood Cerebral Palsy Discovery Network (CP-NET). They all have regular events (in 
addition to print and online platforms) where we can discuss strengths-based PA and dietary strategies 
that have been deemed useful in the study with parents and young people. We will keep a log to track all 
KT activities (e.g. presentations given, # attendees, paper requests, # infographic downloads). These 
activities will inform integrated KT for the future RCT. See letters of support from all partners. 
EXPERTISE, EXPERIENCE AND RESOURCES 
McPherson: health promotion expert in paediatric disability, has overall study responsibility. 
Maltais: physiotherapist, expert in health-related fitness in pediatric disabilities. King: social scientist, 
has written about the use of SDT, coaching and child health outcome measurement. Schwellnus: 
occupational therapist, has conducted seminal work using SFC-Peds to promote life-skills in children 
with CP. Keenan: life-skills coach, has extensive expertise applying SFC-Peds in clinical settings and is 
a trainer for GAS. Moffet: expert in RCT methodology, will ensure concordance with rigorous 
standards. Mérette: biostatistician, responsible for randomization procedures, database development, 
quantitative data analyses. Biddiss: biomedical engineer, expertise in rehabilitation telemedicine and PA 
in CWPD. Church: developmental pediatrician, will train coaches on the medical needs of CWPD. 
Moola: expert in the philosophy/application of qualitative methodologies (esp. Photovoice) in childhood 

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chronic illnesses. de Groot (PA interventions for CWPD) and Chen (nutritional needs of CWPD). 
Baldwin: developed SFC-Peds, will provide intensive SFC-Peds training and monthly supervision. 
Allison: Director, Access and Awareness at Variety Village, will play a Knowledge User role. 
The core experts required for running the study are located in Toronto. The other team members 
will provide expertise at specific points of the study (e.g. Merette setting up the database). Tech-
nological strategies (e.g. e-mail, Adobe Connect, googledocs) will ensure the engagement of team 
members throughout the study (e.g. discussions and decisions, interpretation of findings, KT activities). 
Research will be coordinated by Bloorview Research Institute (BRI), situated within Canada’s largest 
pediatric rehabilitation hospital, Holland Bloorview Kids Rehabilitation Hospital, known internationally 
for its leadership in childhood disability. TVCC, the 2nd recruitment site, provides rehabilitation 
services to children and youth with physical, communication and developmental needs in Southwestern 
Ontario. The hospitals have a close relationship through the Ontario Association of Children’s 
Rehabilitation Services (OACRS), which also offers extensive KT opportunities. 
 
TIMELINE 
 

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