Social participation becomes particularly important in middle childhood, as it contributes towards the acquisition and development of critical life skills such as developing friendships and a sense of belonging. However, only limited literature is available on the impact of communication difficulties on social participation in middle childhood. This study compared the participation patterns of school-age children with and without physical disabilities and complex communication needs in extracurricular activities. Participants included five children between 69 years of age with moderate-severe physical disability and complex communication needs, and five matched peers. Findings showed that children with physical disability and complex communication needs engaged in activities with reduced variety, lower frequency, fewer partners and in limited venues, but reported higher levels of enjoyment and preference for activity participation, than their matched peers. These children also had fewer same-aged friends, but more paid workers in their social circle. This small-scale descriptive study provides some preliminary evidence about the impact of severe communication difficulties on participation and socialization.