How do School-Based Occupational Therapists Work with Participation Interventions at School? : A Systematic Literature Review

(1)

How do School-Based Occupational

Therapists Work with Participation

Interventions at School?

A Systematic Literature Review

Angelos Mantas

One year master thesis 15 credits Supervisor Interventions in Childhood Anna Karin Andersson

Examinator Name

(2)

SCHOOL OF EDUCATION AND COMMUNICATION (HLK) Jönköping University

Master Thesis 15 credits Interventions in Childhood Spring Semester 2020

ABSTRACT

Author: Angelos Mantas

How do School-Based Occupational Therapists Work with Participation Interventions at School?

A Systematic Literature Review

Pages: 31

Children with disabilities are equally entitled to a bright future with education being the cornerstone and a fundamental right for this achievement. Global organizations and policies are fighting for the inclusion of children with disabilities in mainstream schools. Nonetheless, inclusion is not enough if children's participation at school is not guaranteed. The provision of support services to ensure children's participation at school is an obligation of each state. Occupational therapists have a long tradition in the school context characterized by discrepancies. Therefore, this systematic literature review aims to map how school-based occupational therapists work with participation interventions to facilitate the participation of children with disabilities. After a comprehensive search in five databases, a selection process, quality assessment and data extraction, this paper resulted in nine qualitative, quantitative, and mixed design studies. The results presented under the scope of OTPF-3 and fPRC frameworks have revealed that occupational therapists traditionally use push-in and pull-out direct approaches as a medium to enhance the performance skills and activity competence of children. However, there is a shift of occupational therapists toward participation interventions with indirect ways through service delivery models focusing on the school's social and physical environment with their collaboration with teachers being of major importance. Children's establishment of a balanced and healthy school routine, as well as the adoption of a representative student role, are identified as chief aspects of facilitating participation. Results can not be generalized, but this paper gives incentive for further investigation of occupational therapy school-based vitality regarding school participation.

Keywords: occupational therapy, school, inclusion, participation, disability, direct - indirect interventions

Postal address Högskolan för lärande och kommunikation (HLK) Box 1026 551 11 JÖNKÖPING Street address Gjuterigatan 5 Telephone 036–101000 Fax 036162585

(3)

Acknowledgements

I must express my profound gratitude to my parents, my girlfriend, and my brother for providing me with unfailing support and continuous encouragement throughout the year of study and through the process of researching and writing this thesis. This accomplishment would not have been possible without them.

I wish to express my sincere appreciation to my supervisor Ms Anna Karin Andersson senior lecturer in nursing of the department School of Health at Jönköping University. The door to Prof. Andersson office was always open whenever I ran into a trouble spot or had a question about my research or writing. Also, I wish to thank all the professors whose assistance was a milestone in the completion of the first year of the master program at Jönköping University.

Thank you.

Author

(4)

1 Introduction

Twenty centuries ago, the Greek philosopher Plato regarded education as the means for children’s justice (entitlement) to develop their abilities to the fullest. Justice means excellence and Plato defined excellence as a virtue, whereas Socrates considered knowledge as the epitome of virtue; thus, knowledge is a prerogative for all (Koham, 2013). Accordingly, it signifies that everyone has the right to be educated. Education applies in the school context in which school consists of the primary and vital occupation of children during childhood (Rodger & Ziviani, 2006). In this context, children spend enough time daily to develop physically and mentally through their participation in school activities (Rodger, Ziviani, Lim & Ed, 2015). The school system has the responsibility to respond to the developmental needs of children and to enhance the expression of their instinctive biological needs through their participation in valued occupations of self-care, leisure, play and education (Lim, Law, Khetani, Pollock & Rosenbaum, 2016). However, in the presence of a disability, the school cannot fulfil children’s diverse needs without support. In its inability to adapt to different educational needs, the school context restricts the participation of those children (Macini & Coster, 2004).

Occupational therapists have a long tradition working in the school context with a primary aim to evaluate children’s ability to participate in school and to provide services that might enhance children’s learning, academic performance and participation (American Occupational Therapy Association [AOTA], 2014; Bazyk & Cahill, 2015). Although there are orders of global forces supporting school inclusion and participation, the role of occupational therapists is characterized as narrow with discrepancies and uncertainties on how they can achieve this in practice (Bonnard & Anaby, 2016; Grajo, Candler & Sarafian, 2020). Research indicates that although school-based occupational therapists aim to promote children’s participation, they focus on developmental or impairment focused approaches for literacy, motor or sensory functions (Barners et al., 2006; Spencer et al., 2006). Forthwith, the chief focus of this systematic literature review is to identify what is the role and how school-based occupational therapists work with participation interventions to facilitate the participation of children with disabilities in mainstream primary schools.

(7)

2 Theoretical Background

2.1 How is disability defined?

Disability is an evolving concept which depends on every era’s moral and political issues. Considering the self-organizations of individuals with disabilities, national policies and trends regarding human rights, the concept of disability is multidimensional (World Health Organization [WHO], 2011). Professor Stephen W Hawking considerably stated “Disability need not be an obstacle to success. I have had motor neurone disease for practically all my adult life. Yet it has not prevented me from having a prominent career in astrophysics and a happy family life” (WHO, 2011, p. ix). The International Classification of Functioning, Disability and Health: children and youth version (ICF-CY), frame disability as an umbrella term which arises from the interaction of individual’s health status or impairment with the influencing factors from its context and environment (WHO, 2007). Children with disabilities are in a higher risk of any exclusion, restriction or distinction on their meaningful and purposeful doing, which lead to discrimination (United Nations [UN], 2006). Those children characterized as in need of special support, especially in school which constitute their primary and vital occupation during childhood to ensure a successful transition into adulthood. The presence of a disability in a school environment may restrict children’s participation in daily activities and constitutes a barrier for their development (Rodger & Ziviani, 2006).

2.2 International situation about children’s disabilities

More than a billion people worldwide are defined as having a disability, thus accounting for 15% of the global population. Importantly, one in twenty children, that is ninety-three million people, live with moderate or severe disability (WHO, 2015). Fifty-eight million children are excluded from school; of those, nineteen million are children with disabilities (Sæbønes et al., 2015). The Oslo Summit on education for development and the United Nations children’s funds (UNICEF) emphasize the immediate need for school support by specialized professionals (e.g. occupational therapists) who facilitate learning and enablement of all students in the acquisition of school and life skills (Sæbønes et al., 2015; UNICEF, 2007).

(8)

Children with disabilities who attend schools are struggling to deal with many challenges, although there is supportive legislation about inclusion all around the world. Indicatively, they face barriers in accessing services in general education and participation in decisions regarding their future (WHO, 2015). The vision of the United Nations Convention on the Rights of Persons with Disabilities (CRPD) aims to overcome the barriers through collaboration of governments, non-governmental organizations, professionals, people with disabilities and their families, to secure the dignity, equal access, opportunities and the achievement of personal potentials and success for every individual (UN, 2006). To give an illustration, the need for legislation and laws that promote inclusion and participation is in line with article 4 of CRPD, which indicates the general obligation of the states against discrimination. Article 24 emphasizes the immediate need for an inclusive education system in which every child will have access to free education in general inclusive schools without discrimination and with access to appropriate support (UN, 2006).

2.3 International enactments for inclusive education

Inclusion is “a dynamic approach of responding positively to pupil diversity and of seeing individual differences not as problems, but as opportunities for enriching learning.” (Unites Nations Educational, Scientific and Cultural Organization [UNESCO], 2005, p. 13). Diversity is a feature which characterize mainstream classrooms in the 21st century. Therefore, inclusion refers to the practices that increase the participation of children by removing environmental and contextual barriers for children to reach their full potential (Borman & Rose, 2010). Inclusion does not remain in the classroom, but it is a broad concept. By ecological perspective, the environment and personal characteristics of children are in tandem and affect children’s development (Bronfenbrenner, 1999). Inclusion requires knowledge, skills training and collaboration between teachers, parents and professionals (Borman & Rose, 2010).

2.3.1 European laws for inclusive education

Salamanca’s statement and framework for action on special needs and education constitutes the cornerstone for inclusive education in Europe. Given the Salamanca framework, every child, regardless of disability status, gender, nationality, economic status, or anything else, must be provided with equal opportunities for education and life-long learning(UNESCO, 1994). Educating all children requires the adaptation of the school curriculum according to their needs, exempting them from every effort to

(9)

match them to the school curriculum (UNESCO, 1994). Two years later (1996), the European Agency for Special Needs and Inclusive Education notably enabled European countries to collaborate for the enhancement of participation of children with disabilities and the provision of special education programs into mainstream schools (European Agency for Development in Special Needs Education, 2011). Indicatively, some countries adopt a one-track approach in which all children go to mainstream schools with the appropriate support. Others applied the multi-track approach, in which children go either to mainstream or special schools, while other countries agreed with the two-track approach which forces children to attend special schools or special classes. (European Agency for Development in Special Needs Education, 2003).

Notwithstanding the above, the availability and the practices of health professionals (e.g. occupational therapists, speech-language therapists) and special education teachers who support the participation of children with disabilities in European mainstream schools is not clear. To give an example, during the academic year of 2006-2007 in Spain, 32% of children with special educational needs did not have school support (Smyth et al., 2014). The Constitutional Law for Education (LOE) indicates that all students should have the necessary support by special education teachers and health professionals (Ministry of Education, Culture and Sport National Institute of Educational Evaluation, 2016).

2.3.2 American laws for inclusive education

Two federal laws determine inclusive education in the USA: the Individuals with Disabilities Education Act (IDEA) of 2004 and Every Student Succeeds Act (ESSA) 2015 which is the revised law “No Child Left Behind Act” of 2001 (34 CFR Part 300 2016:243; U.S Department of Education, n.d.a). Under IDEA, each child with a disability participates in mainstream schools with the same curriculum as their peers; this is known as the least restrictive environment. Moreover, students with disabilities are assisted by appropriate professionals in terms of the Individualized Education Program (IEP) in the school setting. To that end, occupational therapists are a fundamental part of the school community (34 CFR Part 300 2016:243). Significantly, ESSA provides school communities with equity between all-level students, especially those who are disadvantaged or in high need. It assists teachers with the support of other professionals, such as the availability of occupational therapists in class (U.S Department of Education n.d.b). Simultaneously with IDEA, every educational context

(10)

should meet the criteria of section 504 of the Rehabilitation act (1973), which supports the provision of supplementary services and special education and related services to children with disabilities, if it is appropriate for their participation in the school context (U.S. Department of Education, n.d.).

2.4 Participation - A Family of Participation-Related Constructs Framework (fPRC)

An inclusive approach in which children with disabilities are provided with equal opportunities for learning and development leads to participation (Almqvist,Sjöman, Golsäter & Granlund, 2018). The fPRC framework was picked as a means of clarifying, interpreting, and approaching participation as well as its interrelationships among factors, for this paper (Imms et al., 2016). Participation is defined as ‘involvement in a life situation’ (WHO, 2007, p.9). Regarding health and educational settings, occupational therapists can adopt participation as either an entry or an end outcome of their interventions. In the individual level, participation is considered a universal outcome in which learning, development, health and well-being are enhanced. Participation consists of two interdependent components: attendance and involvement. Firstly, it requires the child’s presence, his/her frequency and variety in activities, secondly his/her internal motivation and connectivity with activities (Imms et al., 2016). Participation is subjective and depends on the child’s personal and intrinsic factors as well as the context (extrinsic factors) (Eriksson, Welander & Granlund, 2007). Even if there are equal opportunities for children with disabilities to participate in school activities, their involvement in the situation is the nodal point for participation (Granlund et al., 2012).

Mainly, fPRC framework indicates that intrinsic factors, activity competence, sense of self and preferences have a transactional relationship and connect with past and future participation of children. To give an illustration, children who can perform an activity (activity competence) engage in the process of acting and learning. Successful performance leads to increased confidence, self-esteem, happiness, autonomy (sense of self) and involvement in the situation, enhancing the engaging and perceiving process. Having the opportunity of engaging in a situation leads children to choose and comply (preferences) (Imms et al., 2016). Extrinsic factors have an immediate effect on children’s self-regulation processes and the expression of a good

(11)

performance. Self-regulation process coordinates children’s intrapersonal characteristics within the two dimensions of participation (Imms et al., 2016).

2.5 Occupational Therapy Practice Framework (OTPF-3): Domain & Process

Best practice in occupational therapy include working in the natural contexts of children such as school. For successful inclusion at school, occupational therapists should be part of the school community to collaborate systematically with teachers, parents and other professionals to respond positively to children’s diversity (Bazyk & Cahill, 2015). True inclusion requires the participation of children in everyday school activities (Almqvist et al., 2018). OTPF-3 provides occupational therapists with a structure through which they formulate a system or concept for their practice. It divides into two themes, the domain and the process which are in a transactional relationship and can contribute their practice regarding inclusion and participation of children at school (AOTA, 2014).

2.5.1 Domain

The domain illustrates an overview of the profession and the areas that occupational therapists have expertise in. All the aspects of the domain, as illustrated in table 2.1, are of equal value and interact to affect an individual’s occupational identity, health, well-being, and participation (AOTA, 2014).

Table 2.1

Definitions of domain aspects

Category Definition Occupation Education

Client factors Values, Beliefs and Spirituality, Body functions

Body structures

Performance skills Motor, Process and Social interaction skills Performance patterns Habits, Roles, Routines, Rituals

(12)

Context and Environment Cultural, Personal, Physical, Temporal, Virtual

2.5.1.1 Occupation: Occupation is “a goal-directed pursuit that typically extends over

time, has meaning to the performer, and involves multiple tasks” (Christiansen & Baum, 2005, p. 548). Occupation in the school context encompasses all activities needed for learning and participating in the educational process. Education is a part of instrumental activities of daily living and includes the participation of children in academic (e.g. math, reading, writing), nonacademic (e.g. lunch, recess), extracurricular (e.g. sports), and vocational educational activities (AOTA, 2014).

2.5.1.2 Client Factors: Client factors refer to the children’s capacities (e.g. affective,

perceptual, cognitive, sensory functions), characteristics, values and beliefs that affect their occupational performance, their performance skills and context-environment or vice versa are affected by context-environment. Occupational performance means the practice of ‘doing’ an occupation that gives a role and identity to children (Christiansen & Baum, 2005). In terms of the school context, occupational performance refers to the way children engage in academics, play and leisure, self-care activities as well as social interactions (AOTA, 2014).

2.5.1.3 Performance Skills: Performance skills are children’s abilities that are acquired and have developed over time through ‘small’ actions when engaging in an activity; their degree leads to the quality assessment of occupational performance. An example of performance skills is what a child does (e.g. jump rope) and it differs by the body functions which indicate what a child’s body system can do (e.g. joint mobility) (Fisher & Griswold, 2014). The transactional relationship among client factors, context, environment and occupational demands affect either positively or negatively the performance skills and in extend occupational participation of children (AOTA, 2014).

2.5.1.4 Performance Patterns: Under the process of participating in an occupation individual adopt roles, habits, rituals and routines. Roles reflect a specific behaviour which involves obligations, duties, and expectations (AOTA, 2014). A role, e.g. student, has cultural and personal meaning for a child and reflects routines and habits. If the school environment, the student itself or the combination of both is unable to

Note. Adapted from “Occupational Therapy Practice Framework: Domain &

(13)

fulfil the academic roles, habits and routines lead to inclusion and participation dysfunction (Harvey & Pentland, 2010).

2.4.1.5 Context and Environment: Occupational therapists recognize that body functions/structures are not enough for full participation. Contextual and environmental conditions (e.g. cultural, personal, temporal, physical, social characteristics of therapists, teachers, children) need to enhance the inclusion of children in the school community and their participation in purposeful and meaningful academic activities. School context and environment should be characterized by feelings of achievement, comfort, equity and inclusion (AOTA, 2014).

2.5.2 Process

The process is the delivery of occupational therapy services to achieve the participation of children in occupations (AOTA, 2014). Within the purview of the domain and the process, occupational therapists facilitate change and growth of client factors and performance skills for successful participation in the desired context. Notably, the systematic collection and analysis of data using an occupational profile and occupational performance analysis as well as the identification of targeted outcomes constitute the evaluation process, which is the first step of the occupational therapy process (AOTA 2014). The intervention process includes the intervention plan, intervention implementation and the intervention review.

Interventions are delivered either directly with a collaborative approach or indirectly with advocacy or consultative approach. Direct approaches concern therapeutic sessions with an individual child or a small group of children (AOTA, 2014). Regarding the school context, direct approaches are carried out in the class with the presence of the teacher and peers and are characterized as push-in interventions. Direct interventions which are conducted out of the class in the school environment are characterized as pull-out (AOTA, 2014). In the indirect interventions, occupational therapists collaborate with school teachers, school staff, parents, and interdisciplinary team, for the sake of the children. Clinical reasoning is used by occupational therapists to get a more in-depth glance of the interrelationships between aspects of the domain that affect occupational performance (AOTA, 2014; Chisholm & Schell, 2019). Finally, they reevaluate the whole procedure to see whether the transactional relationship

(14)

between the aspects of the domain improves the participation in desired occupations or not (AOTA, 2014).

2.6 Rationale

In the light of Eriksson, Welander and Granlund (2007) study, children with disabilities involve less than their peers without disabilities in school activities. Coster et al., (2013) point out restrictions in the participation of children with disabilities in all domains of school in Canada and U.S.A, mainly because of environmental barriers. They found that children with disabilities have less frequency and even less involvement in school activities than their peers (Coster et al., 2013). It appears that although there are supportive policies regarding inclusion and equal participation of all children in school activities, the involvement of those children in activities is restricted; a fact that questions the availability and the use of appropriate practices by occupational therapists in schools (Coster et al., 2013). Two studies indicate that most of the participating school-based occupational therapists adhere to traditional practices with an impairment or developmental focus on activity competence (e.g. handwriting) of children instead of participation itself (Beck, Barners, Vogel & Grice, 2006; Spencer et al., 2006). Yet, another study stresses that occupational therapists receive referrals regarding fine motor, handwriting or sensory processing skills and not referrals for other aspects of school routine in which children’s participation is inhibited, e.g. social interactions (Bolton & Plattner, 2019).

The role of school-based occupational therapy could be greatly framed through the OTPF-3 and fPRC frameworks (AOTA, 2014; Imms et al., 2016). Currently, there are discrepancies in the understanding and utilization of school-based occupational therapy practice regarding how occupational therapists work on inclusion and participation (Bolton & Plattner, 2019). School-based occupational therapists need to clarify their practice and to reflect on their role on how they can work with participation interventions both in in-class and out-of-class context to facilitate the participation of children with disabilities (Bonnard & Anaby, 2016). This systematic review will enlighten the nebulous current school-based occupational therapy practice into a promising emergent practice (Holmes & Scaffa, 2009).

(15)

3 Aim

This systematic review aims to map the role and current practices of school-based occupational therapists on how they work with participation interventions to facilitate the participation (attendance and involvement) of children with disabilities in the school context.

Research question:

How do school-based occupational therapists work with participation interventions to facilitate the participation of children with disabilities in mainstream primary schools?

4 Method

A systematic literature review was conducted to map what the role of school-based occupational therapists is and how they may facilitate the participation of children with disabilities in the school context. Systematic literature reviews are characterized by clear questions which are answered by a transparent, replicable method with the use of inclusion and exclusion criteria, quality assessment of the articles to avoid bias, extraction of data and syntheses of the results (Jesson, Matheson, & Lacey, 2011).

4.1 Search procedure

For this systematic literature review, five databases were used: AMED, CINAHL, ERIC all of them in the EBSCO platform as well as PsycINFO on ProQuest and Scopus on Elsevier. Explicitly these databases cover articles of medicine, alternatives to conventional medicine, allied health disciplines including occupational therapy, educational literature and resources, psychological aspects of these disciplines and humanities fields. Free search terms were used in all databases. Truncations of search words were used to assure the variety of the results. The search terms used differ as in some databases, e.g. Scopus; there were thousands of articles which did not articulate the research aim. All searches limited to the English language, full-text, peer-reviewed academic journals between 2000 to 2020. A table with the exact search terms is available in appendix A. The standard search terms used were (“occupational therap*” OR OT) AND (“school-based” OR “classroom-based”) AND (practice OR service OR delivery OR intervention*) AND (participation OR engagement OR involvement OR attendance) which modified depending on the database. In CINAHL, an extra filter for the age was used: childhood (0-12), school-age (6-12).

(16)

4.2 Inclusion & Exclusion criteria

To screen the articles, inclusion and exclusion criteria were applied according to the aim of the systematic review. Precisely, the population refers to occupational therapists, children, and teachers in mainstream primary school contexts. The age limit (6 up to 12 years old) was set as it is the most usual age that children attend primary schools. Studies which investigate both kindergarten and primary school children were included as well. In table 4.1, the criteria are illustrated in detail.

Table 4.1

Inclusion & exclusion criteria

4.3 Selection process

The three steps of the systematic review data collection process-article selection, data extraction and quality assessment-were performed by one researcher. The whole selection process is illustrated in figure 4.1 in the form of a flow chart.

Inclusion Exclusion

Availability: Full text in English Abstracts

Publication: Peer-reviewed articles Discussion papers, reports,

- published between January 2000 to January 2020 books, conferences

Population:

- children with disabilities and/or special needs - Only typically developed children

and typically developed children

- children between 6 to 12 years old

- Occupational therapists and teachers - Only OTs assistances and/or school staff and/or parents

Design: Qualitative, quantitative, pilot studies, mixed, -Systematic reviews

Empirical studies

Intervention: School-based occupational - Home-based or private

therapy direct and/or indirect interventions occupational therapy

and/or models, strategies - Interventions aimed at another outcome

Outcome: focus on participation

as an entry and/or end outcome.

(17)

4.3.1 Title and abstract screening

Two searches were conducted and yielded three hundred and forty-three (n=343) articles, all of which were transferred to Zotero. Zotero is a free software tool which assists and organizes systematic reviews and detect duplicates (Zotero, 2017). Notably, thirty (n=30) articles were removed as they were duplicates. Hence, three hundred and thirteen (n=313) articles were screened in the abstract and title level using an extraction protocol which is illustrated in appendix B. Two hundred and eighty-three (n=283) articles did not meet the inclusion criteria and were excluded. Most of the excluded articles (n=110) investigated occupational therapy interventions or practices out of the school context. Concerning the rest of the excluded articles, in some studies, the population was adolescents, adults or children under five years old (n= 60), some of them were not articles (n= 10), and in others (n= 15) there was no abstract, and it was difficult to determine the design. Similarly, studies which were conducted with school-based occupational therapists but did not include children’s participation as a start or endpoint were also excluded (n= 16) as well as studies with school-based occupational therapists in special/segregated schools (n= 12). Furthermore, some studies were not referred to as occupational therapy practice at all (n= 60).

4.3.2 Full-text screening

Full-text article review was applied to thirty (n=30) articles that entirely or partly fulfilled the inclusion criteria in the abstract and title level. Importantly, each article was reviewed in detail with the use of an extraction protocol, as it is illustrated in appendix C, to determine if the study was related to the aim and research question of the systematic review. During the screening, the focus was on both the method and results section. The reason is that in the method section, interventions, current practices, or occupational therapists’ perceptions about children’s participation in the school were described. Meanwhile, results were divided into categories to demonstrate if participation is considered in advance, in accordance with OTPF-3 as illustrated in table 2.1 and fPRC in the section 2.4 .

Out of thirty articles, twenty-three (n=23) were excluded due to wrong intervention focus (assessing or investigating occupational therapy frameworks n= 5, not focusing on participation n= 4), the context was special schools (N= 4), not the expected age (N= 1), was an overview of the current legislation and situation (N= 1), not clearly defined methodology (N=5). To ensure that non-relevant articles will be

(18)

excluded, a hand search took place in the final seven articles. From this search, two articles were added. Finally, nine articles remained for data extraction process.

4.4 Quality Assessment

To assess the quality of the articles, two quality assessment tools were used; the critical review form for quantitative studies (Law et al., 1998) and the critical review form for qualitative studies version 2 (Letts et al., 2007), for the mixed-method designs, both critical review forms were used. Some parts of both tools were adjusted to fit the needs of this systematic review; both tools are illustrated in appendix D. Accurately, studies were assessed on the size and justification of the sample, the use of reliable and valid measurements for interventions and participants perspectives, the selection and analysis of data and the clinical or future implication of the results regarding school participation. Another important aspect during the assessment was the ethical consideration of participants and the ability to withdraw for any reason from the research if they wish to do so; occupational therapists, teachers and parents had to give their informed consent and if children participated, their parents had given their permission and children their agreement to participate in it.

Depending on the number of quality criteria that were fulfilled in each quality assessment tool, they were marked on a scale of 1-100. Indicatively, articles that fulfilled >70% of the criteria were considered as high quality, four of the included articles fulfilled 80% and one 70% of the quality criteria and were considered high- quality studies. Those articles that fulfilled >50% to <70% of the criteria were considered as medium quality articles, one of the included articles fulfilled 65%, another one 60% and another one 50% as there were weaknesses about their sample and the reliability of measurements. Furthermore, articles that fulfilled <50% of the criteria were of low quality. Table 4.2 (before the results section) numerically describes the included studies with their quality score.

(19)

Figure. 4.1 Flow chart of the selection process DATABASES ERIC n= 55 AMED n= 200 SCOPUS n= 11 CINAHL n= 17 PsyINFO n= 60

Articles identified through databases search

n= 343

Duplicates removed n= 30

Articles reviewed for title & abstract

n= 313

EXCLUDED: N= 283 Not relevant age = 60 (adolescents, adults, children under 5 years old) Occupational therapy out of school context = 110 Not an article=10, No abstract found= 15, Special/segregated schools= 12 No focus on participation = 16, Other than occupational therapy = 60 Full text screening

n= 30 EXCLUDED: N= 23 n= 7 wrong intervention focus n= 6 special/segregated schools

n= 2 not expected age n= 1 overview of current legislation

n= 6 not clearly defined methodology

n= 1 low quality

Articles included

n= 7 _{Hand search of included}

articles

n= 2 Final articles included

(20)

4.5 Analysis

The results are presented with the content analysis method and in a deductive way. Within that way, the researcher analyzed the current theories, models, and interventions of occupational therapy to enhance the understanding of how occupational therapists facilitate the participation of children with disabilities in the school context. Through the deductive way of interpreting the results, the analysis structured a matrix with categories of OTPF-3 and fPRC framework (Elo & Kyngas, 2007).

Under the OTPF-3, data were split into categories according to the domain and process. Firstly, the process split into direct and indirect approaches, and then under the domain, each component was analyzed: occupations, client factors and performance skills, performance patterns. Participation was presented with the description of if and how intrinsic factors of fPRC are affected by the occupational therapy process— environment and context described at the end, combining the components of OTPF-3 and fPRC framework. The expected outcome was to map the role and current practices of school-based occupational therapists on how they work with participation interventions to facilitate the participation (attendance and involvement) of children with disabilities in the school context. Before the final presentation of the findings, the included articles were scrutinized with reference to their main findings in categories in an extraction protocol. It is illustrated in appendices E1, E2 (primary information: aim, method, participants & quality assessment scores of each study) and F1, F2, G1, G2 exemplify each component according to OTPF-3 and fPRC.

(21)

Table 4.2

Overview of the included studies

IN* - identification number of the study

**Double score: first quantitative and second qualitative

IN* Author (Year) Intervention Participation Components Quality

1 Bazyk, Demirjian, Horvath & Doxsey

(2018)

Indirect: Comfortable Cafeteria Program

Enjoyment of lunch & socializing

80% & 80% HIGH** 2 Cahil &

Lopez-Reyna (2013)

Indirect: problem-solving teams in Response to Intervention (RtI)

Student role 80% HIGH

3 Grajo & Candler (2016)

Direct: An Occupation and Participation Approach to reading intervention (OPARI)

Increase in frequency and involvement in reading 70% & 80% HIGH** 4 Campbell, Missiuna, Rivard & Pollock (2012)

Indirect: Partnering for Change model (P4C)

Protect student role before the diagnosis

80% HIGH

5 Richardson (2002) No intervention/ investigation of school social environment

Unnecessary adult help & peer relationships

80% HIGH

6 Echsel, Price, Josephsson, Schulze (2019)

OTs perspective (Direct & Indirect)

Enhancement of doing, being and students’ preferences

80% HIGH

7 Clough, (2018) OTs perspective (Direct & Indirect)

Work on individual needs, collaboration with teachers

65% MEDIUM

8

Benson, Breisinger & Roach (2018)

Direct & Indirect: Sensory based interventions in the classroom Self-regulation: better concentration 60% MEDIUM 9

Leigers, Myers & Schneck (2016)

Direct & Indirect Social participation (peers)

50% MEDIUM

(22)

5 Results

5.1 Overview of the studies

The results are presented according to the research question of this systematic review, which is to map how school-based occupational therapists work with participation interventions to facilitate the participation of children with disabilities in mainstream primary schools. Table 4.2 gives a brief overview of the included studies to make the search more accessible for their primary information throughout the results. Nine studies provide answer to the research question and fulfil the inclusion criteria—the majority of the studies conducted in the U.S.A (1,2,3,4,5,7,8,9) and one study conducted in Switzerland (6). Most of the included studies explore the experiences of occupational therapists on their practices and how they work with participation interventions. Results reveal the use of participation interventions such as service delivery models, programs and interventions indicating both direct and indirect services to facilitate children’s participation in the school context. Service delivery models are evident in study (2) with the RtI model and study (4) with the P4C model (see table 5.1). Study (1) evaluates a pioneering program intervention in the school cafeteria and study (3) pilots a clinical application of an occupation and participation approach to reading intervention (OPARI) (see table 5.1). Equally essential studies are those numbered 5, 6, 7, 8, 9 in which occupational therapists distinguish their service delivery decisions on participation and the importance of social interactions for children’s participation.

Table 5.1

Explanation of the models

Model Clarification

RtI (Response to Intervention team-based & multi-tiered model, problem-solving approach, support children with learning or behavioral needs and provide them with interventions

P4C (Partnering for Change): increasing occupational therapists and teacher’s collaboration

OPARI for children with reading difficulties, self-chosen reading tasks, aims to involvement in reading in different contexts

(23)

5.2 Process - Content of interventions

To better understand how occupational therapists facilitate the participation of children with disabilities, the process aspect of the OTPF-3 will be analyzed first. In the process, current practices will be described and then, through the fragment of occupational therapy aspects in the domain, the interaction to its aspects will be evident. Client factors and performance skills will be presented as one category to show how client factors underlie each performance skill.

5.2.1 Direct approach

Through direct approaches, occupational therapists address the social, sensory, fine and visual motor skills to assist children in improving their performance skills and their academic performance and in transferring the acquired skills in the general curriculum (3, 6, 7, 8, 9). It is rather uncertain (5, 7, 8) which type of direct service (push-in or pull-out) is more active. Push-in services are described as hindering occupational therapists’ efforts because, often, teachers are not prepared to adapt their practices and routines in accordance with occupational therapists’ recommendations. Furthermore, occupational therapists reported that they expect from teachers to know everything about occupational therapists’ role and as a result, they approach teachers in the wrong way. Therefore, many occupational therapists prefer pull-out services, in the context of school, with the belief that the acquired skills will be transferred in the classroom environment (7,9). An innovative pull-out direct intervention approach is the OPARI in which children have a leading role through self-generation strategies according to Cognitive Orientation to Daily Occupational Performance (CO-OP) (see table 5.2) with an increase in reading participation (3) as a primary purpose.

Table 5.2

CO-OPs Objectives

Skill acquisition - Development of cognitive strategies - Generalization of skills and strategies to everyday life - Transfer of learning to new skills and contexts.

5.2.2 Indirect approach

RtI and P4C service delivery models (2,4), as well as the comfortable cafeteria program (1), are state-of-the-art indirect participation intervention programs. Through these models, occupational therapists work for the benefit of children who have been

(24)

identified with various difficulties as well as typically developed children, and they focus on changing factors on their physical and social environment. They observe children in and out of classroom activities, interviewing teachers and inspect work samples to see at which point children’s participation is inhibited (2,4). Their primary aim is to develop teachers' knowledge, and skills to early identify children who struggle to participate in school activities. Occupational therapists consider the teacher’s role as a cornerstone in assisting children to maintain and extend their newly acquired skills from the direct therapies into the classroom context (6, 7, 9). They provide teachers with recommendations and strategies to enable them to vary their instruction and to adapt the classroom curriculum to the individual needs of all children. They still support that teachers can play a fundamental role in even the sensory needs of children in the incorporation of sensory strategies into the classroom routine (8). In this way, children with disabilities take an active, productive role as students; one that reflects their age and enables them to participate in activities according to their capacities and skills (1, 2, 4, 5). An essential tool for the achievement of collaboration was found to be the frequent communication between occupational therapists with teachers and stakeholders (e.g. cafeteria supervisors) to help the latter to carry over the intervention strategies in other contexts (1,2,4,6,7,8,9).

5.3 Domain

5.3.1 Occupation

Most referrals for the occupational therapy services are related to academic occupations with handwriting and reading being the most common ones. Teachers consider these occupations as fundamental for children’s participation in the school context (7, 9). Occupational therapists recognize the importance of academic occupations; this is obvious in study 3 through which OPARI intervention aims to increase the participation of children in reading; however, occupational therapists do not solely focus on these occupations. They also identified non-academic occupations as equally crucial for school participation. Socialization, interactions between children with disabilities and typically developed children (e.g. use of appropriate speech, not bully, informed peers about disability), play, self-care (e.g. navigation to the context of school, organize school-bag, coat, toilet), enrollment in clubs or sports, involvement and enjoyment during lunch are all activities and occupations in which school-based occupational

(25)

therapists are aiming to intervene for the facilitation of children’s participation (1,2,3,4,5,6,7,8,9).

5.3.2 Client factors & Performance skills

In all studies, the cyclical relationship was addressed through which activities, interventions and occupations affect client factors, performance skills and vice versa. Occupational therapists use top-down approaches through which they start looking where participation is inhibited and which are children’s abilities instead of intervening only in improving the performance outcomes (e.g. handwriting difficulties). They use interventions focusing on internal client factors such as visual, perceptual, executive function and sensory processing skills to enhance specific performance skills, e.g. change in behavioral and social skills (1) or social-emotional factors (2). Sensory integration interventions affect children’s vestibular, proprioceptive, and self-regulation system by engaging in relevant activities, which in turn, improve their attention levels and involvement in handwriting and reading activities (8). A critical point of their practice is the social interaction of children. Starting from the client factors, occupational therapists use both direct and indirect approaches to enhance social skills, to educate school personnel to promote social and behavioral skills, to better understand the sensory environment which constitutes a crucial factor for the participation of some children in order to become involved in enjoyable activities with their peers (1). The focus of occupational therapy practice is to facilitate the participation of children in occupations through addressing those client factors, performance skills and physical and social environmental characteristics that limit their full participation (1,2,3,4,5,6,7,8,9).

5.3.3 Performance patterns

Most of the participant occupational therapists recognize the importance of the adoption and fulfilment of the student role. Their perspectives (4,5,6,7,8,9) and services (1,2,3,4) converge to establish healthy routines and habits in children’s everyday school environment that facilitate a balanced and appropriate student role. Unprepared and untrained school staff may damage children’s routine, as shown in study (5) in which unneeded help inhibits children’s participation in school occupations;children rest on the provided help and they do not use their existing abilities. Through direct approaches, occupational therapists build children’s factors and performance skills. At the same time, through indirect approaches, they provide school staff with appropriate capacities

(26)

and skills to protect and enhance the student role and to ensure purposeful and meaningful engagement in occupations. Their primary outcome is the facilitation of health, well-being, and participation of children with disabilities as it is supported by P4C model (4) and studies (1,2,3,6,7). Examples include the increasing involvement in handwriting and reading, the establishment of social skills between typically developed children and those with disabilities, sensory functions and enjoyment of rituals and routines such as lunchtime or breaks (1,3,6,7,8,9).

5.4 Participation (fPRC) – Outcomes of interventions

5.4.1 Intrinsic factors

Occupational therapists identify children’s participation as a valuable compass for their school practice. They use participation through interventions as an entry point as well as an outcome of the intervention. The ultimate goal in both cases is the development of children’s self-regulatory processes that favor the development of their intrinsic factors. Currently, school-based occupational therapists start their interventions by identifying at which point children’s participation is inhibited and its consequences on their role as students. Through the models and practices as mentioned earlier, they use participation both as an entry and outcome point through activities or occupations which children with disabilities attend and become involved on a weekly basis in situations with the assistance of occupational therapists or trained school staff (1, 2, 3, 4). Children’s attendance and involvement in these activities/occupations are associated with improved components of sense of self, preferences, and activity competence (1,3). In study (1), students with disabilities who participated in the cafeteria program showed increased satisfaction, enjoyment, and engagement in weekly activities as well as improved social skills.

A characteristic feature of the occupational therapist’s practice is the emphasis on children’s preferences. This is obvious in studies (1,6,8) and the OPARI intervention in which children self-choose the reading activities; the qualitative findings indicate an increase in children’s frequency and enjoyment of their self-chosen reading tasks (3). RtI, P4C models and qualitative data of occupational therapists indicate a focus on the enhancement of children’s self-regulation practices to direct their emotions and actions to establish a daily routine that fit with their role as students (2, 3, 6, 7, 8). The development of their performance skills (e.g. social skills, sensory functions) enhances

(27)

their internal factors and leads to frequent engagement (e.g. emotional skills, activity competence) in in-classroom and out-of-classroom occupations.

5.4.2 Extrinsic factors – Context & Environment (fPRC & OTPF-3)

Context and environment are referred to in each study as a fundamental part of school-based occupational therapy. To facilitate participation in the school context requires the collaboration of all school personnel, the availability of equipment and a physical environment that meets the needs of all children. Good collaboration can be achieved concerning the cultural, personal, and temporal context of children, teachers and school personnel (1,2,3,4,6,7,8,9). Occupational therapists stress the necessity of the classroom's appropriate sensory and well-structured physical and social environment. Within that environment, children can express and develop their internal factors, capacities and skills, and their participation will be facilitated in activities and occupations. Examples include the availability of appropriate sensory equipment, use of music in the cafeteria to enable children's conversations and participation in reading in various contexts (1, 3, 8). Trained school staff (e.g. cafeteria supervisors), daily communication and collaboration with teachers (RtI, P4C), informed peers, communication with parents and with the school team, modifications and adaptations of physical environment, universal design for learning (2,4) constitute occupational therapy practices that aim to facilitate the participation of children. Hence, a cohesive team and an accessible school environment that support children's attendance and involvement in desired and age expected occupations are created (1,2,4,6,7,8,9).

Occupational therapists use direct approaches to enhance the occupational performance of children who, then, try to expand the use of this occupational performance to other contexts through indirect approaches (1,2,3,4,6,7,8,9). This does not mean that they "fix" the disability, but they emphasize on building capacities and create favorable environments that enable children to adopt the student role and to participate in age-appropriate routines (1, 2, 4, 7). Even when students have proper levels of activity competence, if the surrounding context is not a facilitator (e.g. adult or peer support), their self-regulation practices are not developed or carry-over in other contexts (3, 5, 7, 9).

(28)

6 Discussion

This systematic review aims to map the role and current practices of school-based occupational therapists on how they work with participation interventions to facilitate the participation (attendance and involvement) of children with disabilities in the school context. Study results were presented under the scope of OTPF-3 and the fPRC, indicating a broad scope of practice for occupational therapists. Their practice includes support for children, teachers, and other school personnel. On the one hand, indirect approaches were found to be an essential part of their practice with push-in or pull-out interventions aiming to enhance children’s abilities and skills and to generalize them to the broader school context (7, 8, 9). On the other hand, occupational therapists stressed the vitality of the environmental and contextual circumstances and the need to combine both direct and indirect approaches to facilitate the participation of children. A pilot study of OPARI (3) is an example of the shift from skill-based interventions to participation-based ones. Participation intervention indirect approaches like RtI and P4C models (2, 4) agree on a collaborative consultation practice aiming at capacity building and collaboration with school personnel (1,2,4,6,7,8,9) and early identification of children’s difficulties and provision of necessary therapies when appropriate (2, 4). They assist teachers in the carry-over of children’s acquired skills in the classroom, to modify and adapt the school curriculum (2, 3, 4, 7, 8), to enhance the social interactions of children (1, 4, 5) and to promote the independence of children in the school context (5, 7).

6.1 Reflections on findings and practical implications

6.1.1 European research

European published articles regarding school-based occupational therapy practice are limited in comparison to those from the US: eight out of nine studies included were conducted in the U.S.A. This disproportion occurs because, as shown in study (6), school-based occupational therapy is an emerging practice in Europe. During the search of European studies, the outcome that emerged was that it is at the primary stage in comparison to the US, where research has escaped traditional techniques. Swedish studies confirm that, despite the existing legislation and public policies about the inclusion of school-based occupational therapists into European schools, there are still barriers in its implementation. Indicatively, there is a gap in the collaboration of occupational therapists and teachers as well as discrepancies on their perceptions

(29)

regarding school participation and how it should be facilitated (Hemmingsson, Gustavsson & Townsend, 2007; Hemmingsson & Borell, 2000). Other European studies in Switzerland and the United Kingdom indicate the real separation between the educational and healthcare system, which still supports the traditional role of occupational therapy as an external collaborator with the school when necessary. Occupational therapists are not part of the school community as they are funded by the health care insurances separately and not by the educational system (Hutton, 2008; Kaelin et al., 2019).

6.1.2 Decision making on direct and indirect approaches

The decision on which occupational therapy approach, direct (push-in, pull-out) or indirect (consultative), facilitates the participation of children with disabilities at school is a source of considerable tension for occupational therapists. In study (7), occupational therapists stressed that pull-out services are more effective than push-in. Teachers’ aims differ from those of occupational therapists’ and make it difficult for occupational therapists to intervene while the rest of the children in the class are not on the same page (7). In the study of Huang et al., (2011), teachers consider occupational therapists necessary for the school functioning, but they expressed their uncertainty about pull-out interventions. Specifically, teachers stress that pull-out interventions exclude children from attending and involving in the classroom. Taking the child for pull-out therapies inhibit his/her interaction with other peers during the lesson (Huang et al., 2011). Most of the times, teachers are not informed regarding the purpose of these interventions, nor do they have frequented communication with occupational therapists (Huang et al., 2011). Active participation requires a reciprocal relationship between the child and the others or vice versa (Bronfenbrenner & Evans, 2000).

OPARI (3) is an example of a promising future pull-out intervention that includes the contribution of teachers in therapeutic planning and constant collaboration. Although there are no quantitative results to prove its effectiveness, the qualitative ones have shown a positive change in frequency and attendance of reading activities. However, findings indicate that further intervention that targets children factors and performance skills (e.g. phonetic) of reading is needed (3). In another study (Vincent, Stewart & Harrison, 2008) teachers pointed out the need for occupational therapists to be in the classroom and to get into the daily functioning of the class. In the literature,

(30)

occupational therapists are recognized by teachers as highly valuable contributors (Bolton & Plattner, 2019).

A plug-in model of intervention was suggested by teachers (Huang et al., 2011) in which occupational therapists are available and intervene either individually or in a group level in the classroom when there is a need to consolidate the participation of all children. Similarly, in the study of Rens & Joosten (2014), it was suggested that strategies for the whole classroom are more useful and could be embedded more easily in the daily routine. These findings are consistent with studies (2) and (4) since occupational therapists that worked with RtI model were in the classroom in which they assessed, evaluated, and intervened with children when there was a need. The idea of the plug-in is also evident in the P4C which includes differentiated instruction with occupational therapists present in the classroom and intervened with teachers through capacity-building and promotion of skills through curriculum-based activities in order to facilitate the participation of children (4).

6.1.3 Occupational therapists’ role – teachers’ collaboration

The pivotal importance of occupational therapists and teachers’ collaboration for the facilitation of children's participation is stressed throughout the results of this review. The occasional and incomplete collaboration between two parties leads to a mismatch in their practices and to the production of negligible results in terms of children's participation (6, 7). RtI occupational therapists (2) stressed that teachers are not informed about the therapists’ role and they wonder why they might refer children for occupational therapy. Occupational therapists attribute this shortcoming on them, as they are not familiar with the school operation and need some time to be adapted on it (2). P4C occupational therapists (4) highlighted the vital role for their practice to be an integrated part of the school community as they have more time to establish relationships, to be familiar and to be adapted with the cultural context of their collaborators. The more time occupational therapists spend with teachers, children and school personnel, the more understanding of each other's role is achieved. (Rens and Joosten, 2014).

In the study of Hargreaves et al., (2012), teachers indicate the need for occupational therapists to be colleagues and not co-workers for successful collaboration. In a well-established regular and quality collaboration, children's

(31)

participation is achieved. An evaluation of an occupational therapy pilot project with occupational therapists as part of the school, Occupational Therapy into Schools (OTIS) in the United Kingdom, verified the importance of this collaboration (Hutton, 2009). This study has produced positive results regarding the facilitation of school participation, mainly through the regular contact of occupational therapists with teachers, including the share of knowledge and understanding of childhood development (e.g. child's sensory needs or motor skills). Also, occupational therapists had the opportunity to explain their scope of practice and to understand teachers needs and roles. This collaboration led to good relationships between two parties and positive interventions that influence the school routine and curriculum (Hutton, 2009).

In study (8) occupational therapists indicate that collaboration with teachers has helped them to better understand children's sensory needs in the context of the classroom. Teachers’ recommendations and their feedback about recommended strategies (e.g. desk arrangement, sensory equipment), as to if they were practical or not, are essential for the carry-over of the practices in the classroom and the facilitation of participation (8). Similarly, the collaboration of occupational therapists with other school personnel is described in the study (1). Through training by occupational therapists, cafeteria supervisors facilitate the participation of children through behavior management, the establishment of positive social interactions and the provision of sensory stimulation (e.g. music) (1). Positive outcomes on the collaboration of occupational therapists and teachers are found by increased performance and satisfaction of teachers regarding self-regulation practices after a one-day group workshop and eight sessions of occupational performance coaching for children with disruptive classroom behavior and self-regulation issues (Hui, Snider & Couture, 2016). In this study teachers’ self-efficacy and utility of this new knowledge are considered after the training. The occupational therapists may enrich their practice if they do not solely focus on children skills but also if they consider the environmental and contextual aspects, such as teachers' perceptions in the plan and implementation of interventions (Hui, Snider & Couture, 2016).

6.1.4 Reflections on participation

The findings identify barriers, key points and methods that will support occupational therapists in order to evolve their practice regarding the facilitation of participation. The fPRC framework is directly related to the principles of the profession. Respectively,

(32)

OTPF-3 is an essential guide which structures their school practice with the application of core occupational therapy skills. Both frameworks show the interdependent relationship between children’s skills, abilities, roles, motivations with the environment and context and enable occupational therapists to facilitate participation. Some of the findings indicate that occupational therapists insist on the enhancement of activity competence of children as their primary outcome on direct approaches to achieve participation (5,7,8,9). On the other hand, other studies (1,2,3,4,6) show that occupational therapists using participation interventions aim to facilitate participation by activities or environmental adaptation in which children attend and involve. OTPF-3 does not distinguish what the difference between activity competence and participation is (AOTA, 2014). Therefore, another framework such as fPRC may fill this gap in their practice regarding how they work on participation.

The study of Granlund et al., (2012) indicates that focusing on the individual and contextual factors may enhance the attendance and involvement of children in physical activities. It is also stressed that participation should not be related to performance because it is a subjective experience, unique for each child (Granlund et al., 2012). Rosenberg, Jarus, Bart & Ratzon, (2010) determine that the perception of participation is quite different for children with disabilities. Notably, they found that the environment constitutes a significant value for participation but to a lesser extent upon children's performance skills and capacities. Good children's performance skills are a crucial motivational factor for their self-reliance and self-perception of their competencies which, in turn, increase their participation (Rosenberg et al., 2010).On the other hand, King et al., (2009) highlighted the environment as an equally valuable contributor to children’s participation.

Therefore, the role of the occupational therapists is to ensure a supportive environment in which children experience a sense of competence and self-efficacy when they participate in activities to increase their sense of belonging and create positive experiences (King et al., 2009). The positive experiences were found to be related to an increase in children’s motivation and their involvement in activities (King et al., 2006). OPARI (3) is an example of an intervention in which children could do activities on their own, to make mistakes, to learn and to have positive experiences. As the study of King et al., (2009) supports, enjoyment of activities is an intrinsic factor which enhances the development and expression of client factors and performance

How do School-Based Occupational Therapists Work with Participation Interventions at School? : A Systematic Literature Review