Participation of children with disabilities in school: A realist systematic review of psychosocial and environmental factors
Participation of children with disabilities in school: A realist systematic review of psychosocial and environmental factors
Donald MaciverID 0 1
Marion Rutherford 0 1
Stella Arakelyan 0 1
Jessica M. Kramer 1
Janet Richmond 1
Liliya Todorova 1
Dulce Romero-AyusoID 1
Hiromi Nakamura-Thomas 1
Marjon ten VeldenID 1
Ian FinlaysonID 0 1
Anne O'Hare 1
Kirsty Forsyth 0 1
0 Occupational Therapy and Arts Therapies Subject Area, School of Health Sciences, Queen Margaret University , Edinburgh, Scotland , United Kingdom , 2 Department of Occupational Therapy & PhD Program in Rehabilitation Sciences, Boston University, Boston, United States of America, 3 School of Medical and Health Sciences, Edith Cowan University , Joondalup , Australia , 4 Occupational Therapy, Faculty of Public Health and Health Care, University of Ruse, Ruse, Bulgaria, 5 Department of Physical Therapy, Occupational Therapy Division, Faculty of Health Sciences, University of Granada , Granada , Spain , 6 Saitama Prefectural University, Graduate School of Health, Medicine and Welfare , Saitama , Japan , 7 Amsterdam University of Applied Sciences, Faculty of Health, School of Occupational Therapy , Amsterdam, the Netherlands, 8 Child Life and Health , SMC Research Centre, Edinburgh University , Edinburgh, Scotland , United Kingdom
1 Editor: Tzipi Horowitz-Kraus, Cincinnati Children's Hospital , UNITED STATES
Data Availability Statement: All relevant data are
within the paper and its Supporting Information
Funding: Funding for this work was received from
the Salvesen Mindroom Centre for Learning
Competing interests: The authors have declared
that no competing interests exist.
In order to make informed decisions about how best to support children and young people
with disabilities, effective strategies that facilitate active and meaningful participation in
school are required. Clinical factors, diagnosis or impairments somewhat helpful in
determining what should be provided in interventions. However, clinical factors alone will not offer
a clear view of how to support participation. It is helpful then to look at wider psychosocial
and environmental factors. The aim of this review was to synthesise evidence of
psychosocial and environmental factors associated with school participation of 4?12 year old children
with disabilities to inform the development of participation-fostering interventions.
A systematic search and synthesis using realist methods was conducted of published
research. Papers had to include consideration of psychosocial and/or environment factors
for school participation of children with disabilities. The review was completed in accordance
with the Realist and Meta-narrative Evidence Syntheses: Evolving Standards (RAMESES)
and Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA)
guidelines. Papers were identified via Boolean search of the electronic databases MEDLINE,
CINAHL, PhycINFO and ERIC (January 2006-October 2018). Appraisal focussed on
contributions in terms of whether the articles are appropriate for the review (relevance) and
research quality (rigour). Data were analyzed using content and thematic analysis methods
using a realist framework. A narrative synthesis of results was reported.
Results and implications
We identified 1828 papers in the initial search. Seventy two papers were included in the final
synthesis. Synthesis of findings led to three overarching mechanisms representing
psychosocial factors for children (1) identity (2) competence and (3) experience of mind and body.
Environmental aspects (context) compromised five interrelated areas: (1) structures and
organization, (2) peers, (3) adults, (4) space and (5) objects. Our synthesis provides insights
on how professionals may organize efforts to improve children?s participation. Consideration
of these findings will help to proactively deal with suboptimal participation outcomes.
Development of theoretically determined assessments and interventions for management of
school participation are now required.
According to the World Health Organization?s World Report on Disability, an estimated 95
million children (5.1%) aged 0?14 years have some form of disability . Common issues
include Autism Spectrum Conditions, Developmental Delay, Behavioral Disorders and
Learning Difficulties . In many countries, these children have rights to be included in mainstream
]. For professionals who work with children this shift towards social and
educational inclusion has meant that practices have had to evolve in tandem. Rehabilitation
professionals now deliver a wide range of approaches to support early intervention and prevention
for children with diverse needs. This includes school-based approaches alongside teachers and
families to enable children?s full and active participation in school .
Participation or ?involvement in life situations?  is a key outcome. Participation may
take place anywhere. In this paper, we focus on the context of school. Participation in school
includes unstructured activities (e.g friendships, play), organized activities (e.g. sports, clubs,
arts), classroom based activities (e.g. group work, study) and engagement in social roles [
Children with disabilities are at significant risk for limited participation in school [
restrictions have significant lifetime consequences for achievement, quality of life and
]. There are several issues. Attendance for children with disabilities is reduced
compared to peers . Students with disabilities participate less in structured and unstructured
activities, and experience reduced interaction and playground participation [
with disabilities additionally show less engagement in the wider school world, including clubs
and organizations [
Whilst there is an urgent need to develop interventions that promote participation in
school, there is limited understanding of processes that may enable it . Research to date
has recognized the importance of psychosocial factors, though conclusions have been
hampered by heterogeneous populations and variability in design and outcome measures [
There is little in the way of specific school based research to guide practices. Moreover, a
requirement remains for comprehensive theories/models, as research has primarily considered
individual psychosocial factors in isolation. A trend is departure from ?medical? and ?social?
models. Both positions have been challenged as limiting [
]. The World Health
Organization?s International Classification of Functioning, Disability and Health (ICF)  has been
foundational to discussion with its definition of participation as ?involvement in a life
situation? and its assertion that the environment is a key determinant of participation (an
integration of the ?medical? and ?social? models). However, the ICF has also provoked confusion and
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inconsistency in the field [
16, 19, 20
]. Everything people do is ?involvement in a life situation?
and participation is classified together with ?activities? giving rise to conflicting interpretations
]. Driven by the ICF, there has also been a tendency to focus on a portfolio of actions
done in everyday life [
]. Such indicators of ?doing? say little about psychosocial drivers of
participation such as motivation, social connection, preferences, choice and meaningfulness
19, 22, 23
]. This paucity of theory leads to a situation whereby enhancement of participation
outcomes is often an aspiration, but reliable, environmental or psychosocial interventions are
To date only Imms et al. 2016 has conducted research which integrates various factors in a
useful new direction [
]. Their narrative systematic review, although it did not focus on
school specifically, concluded that the participation phenomenon is essentially dichotomous?
requiring children to ?attend? (be present) and also to be ?involved? (engage, experience and
so forth) [
]. A further insight has been to differentiate between participation and other
influencing or ?participation related constructs? which include preferences, sense of self and
activity competence [
]. This work highlights the importance of careful definition, as well as
identification of some import psychosocial factors. However, this work did not consider
environment factors in detail, and was based on an analysis of randomized controlled trials (RCT)
and intervention type studies only. Such restrictive inclusion criteria will have contributed to
limiting the data that could have been available. RCTs rarely focus on context, detail on
mechanisms of action or conceptual underpinnings [
]. Analysis of RCTs is less useful for
answering conceptual or theory based questions . Therefore, the present review employed a
realist review approach to identify a broad range of environmental and psychosocial factors
associated with participation, and to uncover the association between context, mechanisms
and participation outcomes in school-aged children with disabilities to guide the development
and implementation of interventions and assessments.
Materials and methods
The United Kingdom Medical Research Council?s (MRC) guidance on development of complex
interventions argues that new interventions must be underpinned by a conceptual framework
and a theoretical understanding of the key processes underpinning an intervention [
study uses realist review to address the requirement for theory and conceptual framework
development outlined by the MRC. The process drew on systematic review and realist review
methods. For systematic searching of the literature, we followed the PRISMA guidelines [
], as far
as was relevant for a realist review. Realist methods were completed in accordance with the
Realist and Meta-narrative Evidence Syntheses: Evolving Standards (RAMESES) guidelines .
We selected realist review as it meets requirements for dealing with complexity of both
topic and research methods [
25, 29, 30
]. Realist review is an interpretive, theory-driven
narrative summary which applies realist philosophy of exploring context, mechanisms and
outcomes . Developed in response to the weaknesses of traditional systematic review, realist
review focusses on refining and developing theory. Realist reviews are organized around
Context-Mechanism-Outcome (CMO) configuration [
]. Review aims to identify what works for
whom, in what circumstances, in what respects and how, by identifying processes
(mechanisms) that lead to outcomes in context [
25, 29, 30
]. The identification of open, embedded,
interactive systems is central to the process of analysis. These assumptions constitute a realist
philosophical ?lens? . The steps of realist review are: (1) identifying the review question; (2)
formulating the initial theory; (3) searching for primary studies; (4) selecting the studies and
appraise their quality; (5) extracting, analyzing and synthesizing data. The details are described
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Identifying the question
The review question was: ?What are the mechanisms and contexts which determine successful
participation in 4?12 year old children with disabilities in school?? In developing the question,
we drew from a range of perspectives. As the findings were indented for use internationally, the
research team included professionals from several countries (Japan, the United Kingdom, Spain,
Australia, Bulgaria, the Netherlands, and the United States of America). We ensured that team
members represented a range of voices from those with an interest in participation in schools,
representing expertise in psychology, rehabilitation, medicine, community pediatrics,
neurodisability, community health sciences, education, occupational therapy, disability theory, and
global health. The research team included professors, post-doctoral fellows and a range of senior
academics and expert clinicians. A wider advisory group included rehabilitation, social care and
educational practitioners and managers who provided regular input. Initial questions and review
direction were discussed over email between the research team and advisory group. This
included a discussion on realist informed approaches including an explanation of Context,
Mechanism and Outcomes and the basics of realist theory. The research and advisory groups felt
that the focus and question set was an authentic question which reflected curiosity about how
schools were working and interest in understanding how to improve children?s participation.
Formulating the initial theory
In line with a realist review approach, our initial thinking was informed by factors identified in
the literature as possible key drivers of participation outcomes in school. Key literature was
identified and synthesized through a scoping search [
1, 10, 16, 17, 19?21, 23, 24, 31?37
initial scoping helped to identify theoretical areas, concepts and perspectives (a summary of
the initial literature review is presented in Appendix A in S1 File). Amongst the main ideas
considered were Bronfenbrenner?s ecological systems model [
], the World Health
Organization?s International Classification of Functioning, Disability and Health (ICF)  and practice
models to support participation [
]. Using the above scoping review, discussion and analysis
amongst the research team and advisory group led to the development of initial mechanisms,
contexts and outcomes, and the target population. Initial mechanisms focused on personal
psychosocial factors which may drive participation outcomes: (1) children?s choices, initiative,
interests and skills and (2) patterning and performance of participation, including routines
(e.g. going to school, eating lunch, playing with friends) and roles. Initial thinking also
considered psychosocial factors related to common issues experienced by children with disabilities
including pain, anxiety, stress, or fatigue. In considering the context, we drew on ecological
systems theory, focusing on the ?microsystem? as the system closest to the person and the one
in which they have direct contact [
]. In this case, the characteristics of classrooms and
schools, denoting circumstances within school that may be considered as enablers or barriers.
This approach meant that issues pertaining to context outside the school (for example, the role
of parents, home life, or government policies) were not considered.
Participation in school was the outcome of interest. The most common definition of
participation originates in the World Health Organization?s International Classification of
Functioning Disability and Health referring to a person?s ?involvement in life situations? . As noted,
other authors have criticized this definition [
]. The definition used in the review builds
on the ICF definition, but also implies that participation must be meaningful, with personal or
social significance. Our definition reflects recent ideas  that participation has two essential
components: attendance and involvement. The definition is presented in Table 1.
The target population was defined as children who have a physical, developmental,
behavioral, or emotional condition and who also require health and education services of a type or
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School participation includes active and meaningful (from a personal or socio-economic perspective) activities
which are required or desired to fulfil the role of the school pupil within or around the school context. Participation
in school is not only classroom activity, school work or achievement. Participation includes school events, trips,
teams, clubs, relationships with adults and friendships with peers. School participation can be understood in terms
of how much, how often and what activities the child does (attendance), as well as their subjective experience
amount beyond that required by children generally [
]. Middle child hood (4?12 years) was
selected as the target group. During middle childhood (defined as ages 4 to 12), a child?s
mastery of developmental challenges is strongly influenced by school experiences, hence exploring
participation in this context is important. Children are moving from nursery/kindergarten
provision to increasingly formal education settings, but have not yet entered the adolescent
phase where a number of other unique challenges appear.
Systematic searching process
Searches were conducted for English Language papers in MEDLINE, CINAHL, PhycINFO
and ERIC databases covering the period January 2006 and November 2018. This span was
chosen in order to capture a contemporary conceptualization of participation. Searching was
completed by DM and SA. The search strategy utilized text word searching in the title or abstract
along with database Subject Headings. Terms included disability ?special needs?, ?additional
needs?, ?disabled persons?, ?motor disorders?, ?developmental disabilities?, ?intellectual
disability?, ?communication disorders?; age ?child?, ?children,? ?pediatric?, ?girl?, ?boy?,
?schoolchild?, ?participation?, ?inclusion,? ?involvement?, ?engagement?, ?life situations,?
?environment?, ?surroundings?,?setting?, ?context?, ?school?, ?education?, ?class?, and
?teacher?. Strategies were developed with support from an information professional
(Appendix B in S1 File illustrates the strategy used in MEDLINE). In addition, a hand search compiled
by DM and SA checked reference lists from relevant articles, including all those included in
Selection and appraisal of studies
Members of the research team screened a portion of the titles and abstracts (DM, SA, MR).
The potentially relevant records identified by individual members of the research team were
then discussed with the other authors to confirm eligibility. This was followed by screening the
full text of potentially relevant studies to determine eligibility for inclusion.
Overall, if papers contained evidence relevant to school participation (or related proxy
outcome, e.g. school attendance), for children with a disability/special educational need, with
discussion of environmental and/or psychosocial factors, the document was retained for further
review. In keeping with realist methods, selection criteria regarding study design were not
25, 29, 30
]. Methodologically, papers could include any type of peer-reviewed
paper including intervention studies, observational research, qualitative research and literature
reviews. Literature reviews may be included in realist review if they provide relevant
theoretical insights [
25, 29, 30
]. We did reject all purely descriptive accounts (e.g. opinion pieces or
editorials) and grey literature as there was ample peer-reviewed material. We also excluded
psychometrics focused papers, due to their general interest in identifying what participation
was, rather than its influencing factors. Children with disabilities were identified via medical
diagnosis or other support needs (e.g. identified as requiring ?special? education). Papers
focusing solely on community or leisure participation were rejected, although papers which
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discussed school participation amongst other settings were included. We aimed to identify
studies of relevance to middle childhood which we defined as 4?12 years. Studies close to this
age range were passed onto the next stage for further assessment if the findings were viewed by
the team as potentially relevant and generalizable to middle childhood. In some cases the
assessment of age was not necessary, as the participants were teachers, parents or health
professionals, and in the case of some reviews. Initial screening criteria are in Table 2.
In accordance RAMESES guidelines , final selection of papers focused on contributions
in terms of whether articles were appropriate for the research question (relevance) and quality
of evidence (rigour) [
25, 29, 30
]. This was an iterative process, and disagreements were dealt
with via discussion (DM, SA and MR). Review of relevance was used to ensure a systematic
process and to reduce selection bias. A system of questions was used to identify whether an
article was relevant by examining content, insights provided by the study and focus (see
Table 3). Assessment of rigour was used to judge quality, credibility and trustworthiness of
evidence . Each reviewer appraised each paper by asking key questions on research quality
. Papers could be excluded on the basis of relevance or rigour. Each paper was scored 0
(failed to meet criteria) or 1 (met criteria). Studies scoring 0 on either criteria were excluded.
Data extraction, analysis and synthesis
Data were extracted using predefined forms by DM, SA and MR, regularly checking each
other?s work. Data were extracted on: country and author; sample characteristics: sample size;
participants? age and gender; diagnostic category (if available); key findings; relevance and rigor
mechanisms, contexts, and outcomes.
Analysis were done by DM, SA and MR following a staged process based on careful review,
coding and frequent return to primary studies as necessary. Broad aspects of context and
mechanism were identified and coded first. The key analytic process in realist review involves
iterative testing and refinement of theoretically based explanations for why outcomes happen,
using research papers as data sources [
25, 29, 30
]. In our case we were focused on participation
in the school, and we attempted to find and synthesize evidence to demonstrate that particular
mechanisms were important in generating school participation outcomes and to identify
which aspects of context mattered. Data were synthesized using qualitative methods (content
and thematic analysis) , using realist concepts as a framework [
]. Context and
mechanisms were operationalized using codes and sub-codes as in typical qualitative analysis [
Community, home or leisure participation only
Books, editorials, conference proceedings, commentaries,
abstracts, theses, dissertations and other grey literature
Prior to December 31st 2005
Published in languages other than English
Population is typically developing
6 / 22
Is the paper relevant enough? (relevance)
1. Do the questions/aims refer to participation of children with disabilities in the school context?
2. If not, do they focus on related concepts (e.g. engagement, friendships,school work, activities, or roles?) and are
the findings relevant to the review?
3. If the sample mean does not include children aged 4?12 are the findings generalizable/transferable to the 4?12 age
4. Does the study provide any insights about how children?s participation can be supported in school through
5. Does the study provide insights about which factors (child or environment) are most important for school
participation and why?
Is the paper good enough? (rigour)
1. Is the design appropriate?
2. Is the context or setting adequately described?
3. Is the sample adequate to explore the range of subjects and settings, and has it been drawn from an appropriate
4. Was the data collection or review method adequately described and rigorously conducted?
5. Was there evidence that the data analysis was rigorously conducted?
6. Do any claims to generalisability follow logically, theoretically and statistically from the data?
In the early stages very many individual codes were created and grouped. For example all
aspects relating to the child?s motivations were grouped into a broad ?motivations? category
and all aspects of the physical environment were grouped into a ?physical environment?
category. Specific aspects were then identified and coded with sub-codes, e.g. social aspects,
physical access, or assistive devices. As analysis progressed, more refined codes were created and
sorted and grouped to identify mutually exclusive categories of mechanisms and contexts
which were coherent and could be designated a single unifying label.
As the analysis progressed, evidence of which mechanisms and context were important was
carefully mapped against the emerging taxonomy. Tables were derived, including categories
and sub-components, including each article relating to the sub-component. Regular meetings
were held and interpretations shared across the research team and advisory group, including
re-examination the original articles. Further refinement of the findings continued until
agreement was reached. Following final assessment, two members of the research team reviewed
once again the articles, and checked the findings. We also attempted to identify disconfirming
data or data that might challenge or refute ideas. During this process there was a point at
which no new categories of mechanisms or context emerged i.e. saturation was attained. Final
labels were then assigned to each area and the narrative summary was written.
The electronic literature search and hand search identified 1828 papers, 1168 of which were
removed at the title and abstract stage. Next, 172 papers were reviewed in full. On review, 100
papers were excluded, leading to 72 papers in the final synthesis (Fig 1) (full details of all
papers are provided in Appendices C and D in S1 File). Type of disability was consistent with
issues commonly seen in schools (including Autism Spectrum Disorders, Cerebral Palsy,
Learning Disability, Learning Difficulty, Developmental Delay, and Physical Disabilities)
(Appendices C and D in S1 File). Forty-six percent (n = 33) of the research was quantitative in
design (including trials, cross sectional studies, observational studies and quasi-experimental
studies), with the remainder consisting of mixed-methods (n = 4, 5%), qualitative (n = 17,
24%) and review papers (n = 18, 25%). Sample size ranged from 6 to 47 participants in
7 / 22
Fig 1. Study selection process (PRISMA diagram).
qualitative research, and 14 to 3,752 participants in quantitative (excluding two very large
national studies ranging from 18,119 to 64,076 (weighted) participants) (Appendix C in S1
File). Studies from Europe (n = 28), the USA and Canada (n = 22) accounted for 70% of papers
with the remainder coming from Australia (n = 11), Brazil (n = 1), Chile (n = 1), Israel (n = 4),
Japan (n = 1), New Zealand (n = 1), Taiwan (n = 1), India (n = 1) and Thailand (n = 1)
(Appendices C and D in S1 File).
The initial analysis identified 72 contexts and 79 mechanisms. These were the psychosocial
child and environment factors driving participation outcomes in schools. Further analysis
revealed three synthesized mechanisms, and five synthesized contexts. Based on the evidence,
we constructed a conceptual framework that depicts mechanisms and contexts influencing
school participation for children with disabilities (Fig 2). Details on specific categories of
mechanisms and context are provided below.
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Fig 2. Conceptual framework of mechanisms, contexts and outcomes. Context and mechanisms hypothesized to be vital intervening factors
in predicting children?s participation. Context provides opportunities and constraints. Mechanisms drive participation outcomes. Participation
as an outcome has two components: attendance and involvement [
]. As children participate, they experience feelings, sensations and
perceptions which may be adaptive or maladaptive (e.g. enjoyment, boredom, amusement). There is a cyclical relationship between
participation, context and mechanisms.
Synthesis of findings led to three overarching mechanisms representing psychosocial issues
and the child?s experiences (supporting studies are presented in Table 4 and Appendix E in S1
(1). Identity?these mechanisms were associated with ?being?, or the thoughts and feelings
the child had about themselves (e.g. believing in themselves, having confidence,
understanding their roles or feeling a like a member of the school community) as well as
perceptions of activities and tasks in school (e.g. interests, preferences or perceived
(2). Competence?these mechanisms were associated with ?doing? or what the child did in
school (e.g. following rules, showing interest, being confident, or following a routine).
(3). Experience of mind and body (symptoms)?these mechanisms were associated with
issues commonly experienced by children with disabilities in schools: pain, anxiety,
mood and fatigue/tiredness.
Identity. Analysis indicated that these mechanisms related to the child ?being?, and how
children perceived and made sense of their participation within school. Firstly, the
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Understanding & knowledge of roles; feeling like a ?legitimate? participant;
feeling included; feeling membership & school identity
Familiarity, knowledge, preparedness, and automaticity of habits and routines
Showing initiative; being proactive; acting on interests
Working towards goals; perseverance; independence; self-reliance; being
Following rules and norms; fulfilling role expectations; routine performance in
school and other roles
Having routines; following routines; having habits; doing what?s expected
Sequencing; concentration; memory; organization skills
Gross and fine motor skills
Expressive/receptive language; social communication skills
Experience of mind
Cognitions; catastrophizing; withdrawal
Energy level; fluctuating symptoms; sleep disturbance; withdrawal
Fear; frustration; anger; aggression; withdrawal
Sadness; depression; withdrawal
information extracted from studies overwhelmingly and specifically demonstrated the
relevance of mechanisms related to motivations, preferences, and interests. The key mechanisms
were children?s own interests and preferences including selection of certain activities based on
interests/preferences and perceptions around potential enjoyment (or not) of activities which
motivated choices [
14, 24, 42?46, 46?52
]. Participation was also strongly influenced by
children?s self-perceptions, including self-esteem, self-efficacy, confidence, and perceived
competence?all of which influenced children?s activity in-the-moment and over time, influencing
current and future participation[
24, 46, 48?58
]. Perceptions around meaningfulness were also
identified as an influencer of participation, including perceptions around activities that were
valued or especially significant to children, as well as perceptions of personal satisfaction and
pleasure associated with activities[
14, 21, 24, 45, 50, 51, 59, 60
Children?s internalization and understanding of routines and habits emerged as conditions
influencing participation in school. Studies highlighted children?s internalization of
habit/routine, familiarity with habit/routine and automaticity of habit/routine were mechanisms for
44, 53, 62?64
]. Knowing the steps involved in activities or routines led to
reduced demands on the child to understand, process, or plan, and when internalized as
patterns of actions, facilitated participation by providing a set of rules to navigate the school
context. Routines of the school day were noted to shape children?s daily participation, with
references to the fact that children?s participation in school was supported by structured
activities and programs [
], and that regularized activities in the classroom supported
participation for children with disabilities . Children themselves perceived that rules, norms and
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routines are important in structuring their participation [
]. Parents also indicated that
routines influence participation [
Children?s knowledge, understanding and subjective experience of roles influenced their
participation. In the school, possible roles included being a pupil, friend or member of a club.
Disabled children tended to occupy less ?desirable? roles within the school. Roles considered
desirable by children, especially those including being good at something (e.g. best in class) or
?best friend? roles were seldom held by children with disabilities [
]. Children with
disabilities also engaged in less ?doing roles? (such as athlete, leader, helper and tutor) and more were
likely to be classified into negative roles including ?challenged learner?, victim or bully [
Mechanisms influencing participation were internalization of roles (either positive or negative
roles), leading to positive or negative self-perceptions, and understanding/knowledge of role
]. Related mechanisms included self-perceptions relating to inclusion,
focusing on children?s subjective experiences of social inclusion, sense of membership and
sense ?school? identity .
Competence. Competence mechanisms reflected ?doing? or behavioral aspects and how
children engaged in participation. Well-supported mechanisms enabling participation were
children taking initiative, being proactive and acting on interests [
14, 24, 44, 52, 53, 65?68
Research also demonstrated that seeking independence and autonomy, showing responsibility
and commitment, displaying persistence and perseverance were drivers of participation [
47, 51?53, 57, 68?72
Other competence mechanisms related to following routines and having daily habits [
] as well as consistency of behavior, including being predictable, being systematic and
preparedness for routines [
]. Also identified as important conditions for participation were
children meeting teachers? expectations and following the school?s rules [
]. Finally, patterns
of behaviors that followed from particular roles were identified as shaping quality and quantity
of participation, including patterns of behaviors associated with friendship roles and patterns
of behaviors associated with school-based roles (for example sports team member) [
57, 61, 70,
Studies exploring relationships between skills and participation were common. In total, 27
papers provided data. However, researchers are now concluding that deficits or improvements
in skills, although related to participation, are not related in a direct or linear fashion. The
evidence challenges the idea that an increase in skill equates to an increase in participation.
Psychological characteristics, personality and preferences are also important [
]. The evidence
did indicate, however, that skills were important for the completion of certain types of
activities in certain situations. For example, social skills are often required to access play situations
]. The mechanisms related to skills identified as important for participation were
organisation and planning (e.g. sequencing, concentration and memory) [
35, 46, 49, 51, 52, 55, 56, 63,
70, 72, 74
]; communication/social skills [
14, 15, 42, 49, 51?53, 67, 72, 74
] and motor skills [
14, 49, 51, 52, 55, 58, 70?72, 74?80
Experience of mind and body. The literature provided good support for the influence of
symptoms associated with disability on participation. These were pain, fatigue, anxiety and
mood. Twenty-two papers provided data. Identified mechanisms were concerned with
experiences related to symptoms. These were: pain (especially cognitions and catastrophizing) [
52, 71, 75, 79, 81?83
]; fatigue, including lowered energy, tiredness, and sleep disturbance[
46, 58, 71, 80, 84?86
]; anxiety and its consequences including fear, frustration, and anger [
51, 53, 58, 60, 71, 80, 87?89
], and low mood, sadness or depression [
13, 52, 71, 80, 81, 84, 89
Fundamental underpinnings were closely related across the different symptoms, drawing
on social learning and cognitive-behavioural theory, suggesting that illness behaviours or
responses generate negative behavioural patterns which may be maintained and strengthened
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10, 15, 17, 21, 24, 35, 42?44, 49, 52, 54, 57, 58, 61?
65, 67?70, 72, 80, 90?96
over time [
8, 13, 71, 75, 81, 83
]. These mechanisms lead to reduced participation through
disengagement from activity and a cyclical pattern of attempts to control symptoms through
increasing withdrawal from activities.
The next step was to explore how and which contexts facilitated or provided opportunities for
participation versus contexts which restricted/constrained participation. This twofold role of
context was evident throughout. Context comprised five interrelated areas: (1) structures and
organization of the school, (2) peers, (3) adults, (4) physical spaces and (5) objects.
Sub-components of each area were identified by the reviewers, focusing on opportunities (supports) or
constraints (barriers) to school participation (supporting studies are presented in Table 5 and
Appendix F in S1 File).
Structure and organization. Structure and organization was a well-supported aspect
focusing on the ways things were done in the school. Facilitative aspects were described as
being tailored to the child, responsive to needs, individualized, and child led [
10, 15, 17, 21, 24,
42?44, 49, 52, 54, 57, 58, 62?65, 67?70, 80, 90?94, 96
]. Facilitative structures/organization
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were also described as adaptable and flexible [
10, 14, 36, 44, 52, 64, 65, 68, 69, 80, 96, 97, 98
predictable  and well-planned [
10, 68, 69, 93, 96, 98
]. The most common constraint to
participation identified was lack of individualization [
15, 20, 42, 44, 49, 53, 57, 58, 65, 66, 69, 71,
72, 80, 91, 97, 98
]. Other identified constraints included rigid routines [
10, 14, 67, 80, 84, 92,
93, 97, 98
] or routines which were unpredictable or disordered [
Adults. There was abundant evidence that adults (referring to teachers and other staff
within school) were key in creating opportunities for participation and were also influential in
shaping the quality, frequency and range of children?s roles [
16, 21, 42, 43, 52, 57, 61, 64, 66,
96, 97, 99
]. Adult?s positive and sympathetic attitudes were facilitative of participation [
96, 99, 100
] as were individuals who were competent and knowledgeable [
44, 62,49, 68, 96,
]. Good collaboration between adults was also facilitative [
14, 68, 93, 96, 99
]. Attitudes were
identified as restrictive, as well as adults who were unsympathetic [
10, 44, 47, 53, 58, 71, 72, 80,
93, 99, 100
] or lacking in knowledge [
14, 35, 49, 101
]and institutional collaboration [
]. Adults were also noted to play a part in shaping negative roles (e.g. by ?pigeonholing?
children with disabilities as less able and therefore offering them fewer participation opportunities,
or by being reluctant to allow students to learn or play independently) [
Peers. The evidence indicated that facilitative peers (referring to other children within the
school) provided practical and emotional support enabling participation [
10, 15, 16, 21, 43, 44,
46, 49, 57, 58, 60, 64,68
]. Facilitative peers also provided opportunities for friendship [
61, 71, 73
]. Positive attitudes were also identified as important in creating opportunities for
24, 36, 46, 69, 93, 100
]. Studies also identified non-supportive actions and
behaviours, including bullying [
15, 43?45, 57, 61, 71, 73, 80, 92, 99
], negative attitudes [
53, 58, 78, 80,92, 93, 100
], and friendship avoidance [
15, 49, 60, 66, 71, 87
Spaces. Supportive spaces were described as being accessible and usable [
10, 14, 21, 24, 36,
44, 45, 59, 60, 65, 67, 68, 69, 71, 78, 97, 99
] with suitable design/layout and suitable sensory
53, 60, 62, 68, 86, 96, 99
]. Constraints to participation focused on restricted access to
areas where activities happen [
10, 14, 35, 47, 49, 52, 53, 60, 65, 71, 78, 92, 97, 99, 103
issues included unsuitable sensory qualities, spaces which were unfamiliar, and spaces which
were crowded or difficult to navigate [
35, 52, 53, 60, 65, 97,99
Objects. Research on objects focused on the availability of objects needed to participate in
specific activities, for example, wheelchairs and assistive devices [
10, 14, 21, 24, 35, 36, 52, 59,
60, 62, 63, 65, 91, 99
]. Usability and acceptability to the child were noted as important [
50, 52, 53, 60, 71, 72, 99
]. Research on constraints associated with objects was fairly limited.
Objects being unavailable [
10, 60, 65, 72, 99
], difficult to use [
35, 53, 50, 99
] were identified as constraints to participation.
This realist review has developed a conceptual framework for children?s school participation,
and identified the processes (mechanisms) and contexts influencing participation outcomes.
The synthesis is of key issues that decision-makers and interventionists may consider to help
children to participate in school.
The findings support the hypothesis that identified mechanisms and contexts are important
factors associated with participation outcomes. Specifically, the findings show mechanisms in
three clusters focusing on identity, competence and the child?s experience of mind and body.
The context (environment) is conceptualized in terms of adults, peers, the schools? structures
and routines and spaces/objects. Unlike most models designed for dealing with specific
impairments or diagnoses, this model is useful with any child with any health related need or
disability experiencing problems with their participation. This is a middle range theory. The
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term ?middle range? theory refers to the level of abstraction at which useful theory for realist
work is written: detailed enough and ?close enough to the data? that testable hypotheses can be
derived from it, but abstracted enough to apply to other situations as well . Middle range is
useful because it offers an analytical approach to linking findings from different situations
. The outcomes of a realist review are ideally framed as middle range theory?that is,
theory that can usefully be applied across a range of situations, or in a number of domains .
Findings are (by design) age limited (4?12 years old), but are independent of gender, disability
category or ethnicity, supporting application across a range of clinical and educational settings.
Ideas reflect a contemporary conceptualization of participation drawn from 72 research
papers. The model imagines mechanisms and contexts in dynamic and transactional
relationships. This is a ?generative causality? model. Explanation is not a matter of a singular
mechanism or a combination of mechanisms asserting influence on an outcome. School
participation emerges out of a cooperation of factors.
No single factor fully explains variance in participation [
]. Previous research provides
indications of which features of the child significantly affect the participation of students
with disabilities, including focus on psychosocial factors for participation, such as
]. Our findings support the significant importance of children?s preferences,
interests and motivations for participation. Our review also adds to the literature by providing
detail on habits and routines which are novel elements not commonly considered. Based on
our findings, we recommend that issues associated with habits and routines are closely
considered in future. We have found that deficits in routine and habits are important
contributors. Habit and routines are performed repeatedly and are relatively automatic. They specify
what the child will do and in what order, and, thus, constitute key mechanisms for
participation. Habits and routines must be understood and internalized and there are additionally ties
to environment. As noted by Engman and Cranford (2016), the quality of habitual action is
not equally easy for all?in some environments ?non-normative embodiment? (i.e.
disability) is less likely to make habitual behaviour achievable than in others [
]. The structure of
the environment enables or restricts consistent, structured and planned schedules and
routines. Adults facilitate breaks, social routines, setting of rules and expectations, while objects
(timetables and other prompts) provide specific routines (e.g. for gathering information, or
which classes to go to).
Our model focusses on participation as a key outcome which is influenced by
environmental factors. In line with the ICF , and in the wider literature, the environment is noted
to have a significant influence on participation [
8, 75, 78, 92, 100
]. We advance thinking by
identifying specific environment factors and offering potential for comprehensive
assessment and intervention. This is important, as the potential selection of environmental factors
is vast. The issue is to identify specific matters facilitating or obstructing participation in
school. The identification of issues must be completed in tandem with a contemporary
model of participation itself. Small aspects of the school microsystem can go unnoticed if
attention is not drawn to them. A focus on the school environment explicitly defined will
support guidelines for working to support participation. The current study findings indicate
contextual influence of the school is not just a sum of the people, objects and spaces, but also
?how? things are done, or expected to be done within the school (the structures and
organization of the school) and the important part adults play in providing opportunities for
participation and social roles. Our findings highlight the importance of a nuanced understanding
of the environment and not just consideration of physical aspects. Identification of physical
aspects of the school, whist important, should always be considered alongside the social
14 / 22
Implications for practitioners
International practice is moving towards the adoption of system/ecological views, but the field
still operates predominantly from a unidirectional perspective where ?something? is provided
to ?fix? the person with a disability [
], rather than operating from more contemporary view
of participation as a phenomenon that can be mobilized at different levels. The findings of this
review show that individual and environmental interventions should be developed promote
participation outcomes in schools. Identified mechanisms offer a potential basis for developing
psychosocial child-focused interventions. Mechanisms (e.g. preferences, perceptions of self,
perceptions of roles, internalization of routines) are appropriate targets for intervention. These
ideas are congruent with recent studies emphasizing that individually tailored coaching and
mentoring may help to improve children?s participation [
]. As noted, however, change will
not be effective if it is only targeted at the child. Contextual elements interact with mechanisms
to make participation more or less likely and must also be a focus for intervention.
With a focus on school, teachers? knowledge is of key importance [
]. Efforts are required
to assist teachers? regarding knowledge and confidence in enhancing participation. Teachers
work with increasingly diverse groups of learners and are responsible for attempting to achieve
positive outcomes [
]. Concerns have been expressed that education remains less effective
for learners with disabilities [
]. Concerns are understandable particularly when schools and
teachers tend to be rated on achievement, rather than participation [
]. Existing supports,
strategies and approaches for children with disabilities, along with theoretical underpinnings,
are frequently superficial and lacking in detail [
]. Practical aspects of how to ?do? inclusion
or participation are therefore difficult to see and implement. Previously developed supports
and interventional resources have also tended to focus on specific issues or diagnoses (e.g.
Autism, Dyslexia, Learning Disability)?leading to ?a programme for every problem? [
This has two consequences. Firstly, educationalists follow a medical or disease orientated
model, with the consequential issues around disempowerment and depersonalization of
people with disabilities [
]. Secondly, those with responsibility for supporting children with
disabilities may feel overwhelmed by the range of options [
]. The complexity and number of
programs makes selecting the right option for the right child at the right time difficult.
Implications for research
Future research could explicitly link intervention components to mechanisms as described in
this review. Following methods which use formal means for developing theoretically
determined interventions [
], ?theory-based? rather than ?theory-inspired? interventions, may be
developed. Such research is closely aligned to the UK MRC framework for development of
complex interventions [
]. Identified mechanisms offer a basis for understanding how and
why therapeutic or educational interventions for children may or may not be effective at
improving school participation. Identification of strategies for the detection and cultivation of
facilitative contextual elements would also follow from the above methods.
Further research activities include selection of appropriate items for school participation
measurement. Parent-report methods have been commonly used in medical and psychological
research to collect participation information [
]. However, researchers should also consider
other data collection methodologies, particularly report by teachers [
While we have attempted to make our search as sensitive as possible (and erred on the side of
sensitivity as opposed to specificity), participation continues to be a diverse area spanning
several disciplines with limited consensus on terminology. It is difficult to design a perfect
15 / 22
strategy. Given the methodological assumptions of realism, other reviewers could come to
different conclusions. However, themes and concepts driving the model were apparent across
different types of difficulties/disabilities, across studies that used different research methods, and
across a range of international contexts. Consistency in identified features provides evidence
to support conclusions.
This was the first realist review to explore mechanisms and contexts for school participation of
children with disabilities. This paper presents a conceptual framework including child
psychosocial factors, such as understanding of routines, sense of self, and perceptions of role, and as
well as characteristics of the school environment. We encourage researchers, practitioners,
and policymakers to consider these contexts and mechanisms when addressing school
participation among children with disabilities. Consideration of interventions, designed specifically
to enhance participation by targeting mechanisms, contexts and the processes identified in
this review, is now key.
S1 File. Appendices.
S2 File. PRISMA standards.
S3 File. RAMESES standards.
The study was initiated by a partnership between the Salvesen Mindroom Centre in the
University of Edinburgh and the CIRCLE Collaboration (Child Inclusion: Research into
Curriculum, Learning and Education) research team at Queen Margaret University, Edinburgh. We
would like to acknowledge Miriam Crowe, Deborah McCartney and Cathleen Hunter for
support and critical comment on the manuscript. Funding for this work was received from the
Salvesen Mindroom Centre for Learning Difficulties.
Conceptualization: Donald Maciver, Marion Rutherford, Jessica M. Kramer, Janet Richmond,
Liliya Todorova, Dulce Romero-Ayuso, Hiromi Nakamura-Thomas, Marjon ten Velden,
Ian Finlayson, Anne O?Hare, Kirsty Forsyth.
Data curation: Donald Maciver, Marion Rutherford, Stella Arakelyan.
Formal analysis: Donald Maciver, Marion Rutherford, Stella Arakelyan, Jessica M. Kramer,
Janet Richmond, Liliya Todorova, Dulce Romero-Ayuso, Hiromi Nakamura-Thomas,
Marjon ten Velden, Ian Finlayson, Anne O?Hare, Kirsty Forsyth.
Funding acquisition: Donald Maciver, Anne O?Hare, Kirsty Forsyth.
Investigation: Donald Maciver, Marion Rutherford, Stella Arakelyan, Jessica M. Kramer,
Janet Richmond, Liliya Todorova, Dulce Romero-Ayuso, Hiromi Nakamura-Thomas,
Marjon ten Velden, Ian Finlayson, Anne O?Hare, Kirsty Forsyth.
16 / 22
Methodology: Donald Maciver, Marion Rutherford, Anne O?Hare, Kirsty Forsyth.
Project administration: Donald Maciver, Marion Rutherford, Stella Arakelyan.
Supervision: Donald Maciver, Anne O?Hare, Kirsty Forsyth.
Writing ? original draft: Donald Maciver, Marion Rutherford, Stella Arakelyan, Jessica M.
Kramer, Janet Richmond, Liliya Todorova, Dulce Romero-Ayuso, Hiromi
NakamuraThomas, Marjon ten Velden, Ian Finlayson, Anne O?Hare, Kirsty Forsyth.
Writing ? review & editing: Donald Maciver, Marion Rutherford, Stella Arakelyan, Jessica M.
Kramer, Janet Richmond, Liliya Todorova, Dulce Romero-Ayuso, Hiromi
NakamuraThomas, Marjon ten Velden, Ian Finlayson, Anne O?Hare, Kirsty Forsyth.
17 / 22
18 / 22
19 / 22
20 / 22
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