Inclusion of autistic students: promising modalities for supporting a school team

Abstract Purpose School staff who work with autistic students are at a high risk of exhaustion. More training and guidance are needed to enable them to respond to these students’ needs. The purpose of this study was to design and evaluate a professional development program offered by an occupational therapist to help a team of school staff facilitate the participation of autistic students and their peers. Methods A design-based research approach guided the development and evaluation of the modalities of the program. A case study was conducted in a school with nine school staff members using individual interviews, questionnaires, and a logbook. Results The program comprised five modalities: regular presence of the occupational therapist, a needs analysis, content focused on the features of an inclusive school, individual coaching, and team coaching. The following elements emerged as particularly helpful for the participants: frequent interactions with the occupational therapist, opportunities to collaborate, personalized support, experimentation of new practices with the occupational therapist, and concrete training content that can benefit all students. Conclusion The modalities of the program appear promising to help a school team facilitate the participation of all students, including those who are autistic. Implications for rehabilitation Occupational therapists can help school teams to facilitate the participation of autistic students and their peers. A combination of individual and team coaching sessions appears promising in helping school staff adopt practice changes to make their school more inclusive. Using a multi-tiered approach can help therapists collaborate with school staff members to first find solutions that will be applicable with all of their students.


Introduction
The mandate of elementary schools is to offer an inclusive education adapted to the diversity of the students in order to develop each one's full potential [1]. Inclusive education entails acting on obstacles to learning in a manner that promotes participation, acceptance, and achievements of all students, including those with special needs [1][2][3][4]. This represents a great challenge for autistic students, their teachers, and other school staff who work with them [1]. In fact, the growing number of autistic students, the complexity and diversity of their needs, and the lack of preparation and support for teachers and other school staff constitute obstacles to real inclusion of these students in the school environment [5][6][7]. Some studies have shown that teachers do not feel sufficiently supported and prepared to respond to the social, academic, and behavioral needs of autistic students and to create environments and activities that are conducive to their participation [8][9][10][11][12][13][14][15]. It is thus not surprising that teachers who have autistic students in their class generally experience higher stress levels than their colleagues and that several of them report low feelings of self-efficacy [16,17]. These teachers would like to receive more support and training to adapt their teaching [15,18,19].
There are several studies where researchers have proposed or evaluated training programs for teachers or other school staff who work with autistic students [20][21][22][23][24][25][26][27][28]. These programs have been implemented mainly by autism specialists, teachers, psychologists, or special education technicians. A large proportion of the studies aimed at transferring knowledge to teachers regarding clinical approaches that were tailored to the needs of one child in accordance with evidence-based practices in autism [20][21][22][24][25][26]. Implementing such interventions that are tailored to the needs of one child may be difficult for school personnel who have to manage with limited time and resources to respond to the needs of all the children in their classrooms [2, [29][30][31][32].
Studies also indicate that these evidence-based practices can be difficult to implement with high fidelity in the less controlled and predictable environment of the school setting [31][32][33].
Therefore, several authors have underscored the need to develop training programs that are better adapted to the school staff's reality and needs to promote the inclusion of autistic students [18,19,[34][35][36]. Considering the high prevalence of autism and complexity of the needs of autistic students, a systemic approach, involving training of the whole school team, is recommended to foster collaboration of the school staff to choose interventions, support generalization of the strategies in the various school contexts, and better face the challenges encountered [18,19,[34][35][36][37][38]. School staff would like to be accompanied in identifying concrete, practical strategies that could benefit several students in their groups, in the various school contexts, such as in a classroom, at recess, in the cafeteria, or in school daycare services [15,19,[34][35][36].
To date, there remain several unmet needs in terms of better support for the inclusion of autistic students. Various types of professionals can support school teams. Occupational therapists are well equipped to support the participation of autistic children or other children with special needs in their educational setting [39,40]. Their understanding of the personal and environmental factors or of those related to the requirements of activities that can help or hinder children's participation in their school environment makes these therapists relevant actors for promoting the educational success of students with special needs [41,42].
This study is part of the project Occupational Therapists for Inclusive Schools: Autism, which aim to develop and evaluate a new practice model for occupational therapists involved in the support provided to autistic students in schools. The first part of the project documented the main concerns of school personnel regarding the participation of autistic students as well as the actions needed to build school capacity [36]. The purpose of the present study was to determine how occupational therapists can contribute to the training and guidance of a team of varied school staff to promote participation of autistic students in all school contexts. The project integrated multi-tiered and coaching approaches, which are increasingly recommended to support the professional development of school staff and thus respond to the needs of a larger proportion of students with special needs [39,40,[43][44][45][46][47][48][49]. In a multi-tiered approach, three levels of support are offered to students [42,50]. In Tier 1, universal actions are advocated for promoting the participation or well-being of all students. In Tier 2, the actions target students who have or are at risk of developing difficulties. Finally, in Tier 3, intensive, individualized actions are offered to students for whom Tier 1 and Tier 2 actions are not sufficient. The use of a multi-tiered approach entails close collaboration between occupational therapists and teachers [50][51][52][53]. Several studies have supported the effectiveness of these models. However, to date, occupational therapy studies have not shown how a multi-tiered approach can be mobilized to respond to the diversity and complexity of the needs of autistic students [36]. A coaching approach to supporting school staff generally accompanies the implementation of these intervention models [39,45,48,50,53,54]. In such approach, the occupational therapist works with a significant adult involved in the lives of children, such as teachers or parents, to help them identify solutions to facilitate children's participation in their chosen activity [40,54,55]. Basyk et al. (2018) used coaching to build capacity of cafeteria supervisors to create a positive mealtime environment and found significant changes in supervisors' perception of their capacity to do so and students' appreciation of the time spent at the cafeteria. In Hui et al.' (2016) study, Occupational Performance Coaching contributed to significant improvements in teachers' satisfaction with the use of self-regulatory strategies with their students and to improvements in their sense of efficacy in managing students' behaviors in their classroom. It is a particularly promising approach for helping to improve teachers' feelings of competence and students' participation [40,56]. Occupational Performance Coaching focuses on accompanying the adult to analyze the child's occupations using the Person-Environment-Occupation model [57,58]. It appeared very useful to the project to help the occupational therapist and significant adults identify how they could maximize the fit between the characteristics of autistic students, the activities they do in school and the environment in which they occur.
In order to identify how occupational therapists could build school personnel capacity, the five core features of effective professional development programs outlined in Desimone's framework [59] were used (see Figure 1). These are: a focused content, opportunities to engage in active learning, coherence, extended duration, and opportunities for collaboration. This framework is based on the results of a rigorous literature review [60][61][62] and has been used in numerous studies to support the design or evaluation of professional development programs [63][64][65][66][67]. The first feature of effective professional development programs is the focus on specific learning content that is explicitly linked to student learning and applicable in teachers' daily activities [59]. The second feature highlights the need to provide teachers with opportunities to actively engage in their learning and in the analysis of their practice, which can be done by providing opportunity for reflection or feedback [59]. The third feature, coherence, highlights the importance for learning activities to be aligned with the needs of the school as well as the aspirations, knowledge and beliefs of teachers [59]. To address this, using individual coaching sessions or offering a choice between different training activities can be relevant when a heterogeneous group of participants are accompanied [68,69]. In addition, professional development activities that are intensive and are carried over an extended period of time are generally more effective since teachers must be given sufficient time to learn, practice, to reflect on new strategies and to mobilize them in their practice [59]. Finally, professional development activities that provide opportunities for collaboration among teachers sharing similar needs or challenges would lead to more transformations in practice [68]. According to Desimone's framework, a professional development program that integrates the core features will first help improve the teachers' knowledge, attitudes, and beliefs [59]. These changes will then have effects on the teachers' practices and, ultimately, on their students' learning. The framework also underscores the moderating role of the context in which the professional development takes place.
The purpose of this study was to design and evaluate a professional development program offered by an occupational therapist to a team of school staff to enable all students to participate, including those who are autistic. In the context of a first experimentation of the program, the evaluation was centered on the analysis of the modalities deployed and the viability of the program in a school context rather than on the outcomes in terms of school staff's practices and students' participation. The objectives were thus to: (1) design the modalities of a professional development program for school staff and (2) assess the elements perceived as helpful or limiting.

Methods
This study was part of a broad design-based research process grounded on theoretical knowledge and a partnership with practitioners to develop and assess solutions [70][71][72]. This methodology proved relevant to guide the process of designing a professional development program that is realistic and valid for school staff working with autistic students. Design-based research must involve multiple iterations featuring several cycles of analyzing, designing, evaluating, and adjusting the solution to ensure its continuous improvement [70][71][72]. This study thus corresponded to a first iteration of the Occupational Therapists for Inclusive Schools: Autism project, to help understand the promising modalities for a professional development program favoring the implementation of inclusive practices in a school. It was conducted according to a flexible process inspired by the three phases proposed by McKenney, Reeves [70]: (1) analysis and exploration, (2) design, and (3) evaluation. Only Phases 2 and 3 are presented in the methodology because the results of Phase 1 are summarized in the introduction. They were derived partly from discussion groups with occupational therapists and school staff [36] and partly from a review of the literature on occupational therapy practices in schools as well as on training programs for school staff working with autistic students.
The design phase was first grounded on knowledge derived from multi-tiered and coaching approaches. It was also based on the core features for effective professional development [59], which the team ensured were all addressed in the proposed modalities. This design phase was also influenced by experiential knowledge thanks to the involvement of several researchers and practitioners. The first versions of the program were created by a design team composed of three occupational therapists: one student researcher, one clinical occupational therapist who had over 15 years' experience with autistic children, as well as the principal investigator of Occupational Therapists for Inclusive Schools: Autism. This group collaborated with six other members of the research team as well as with an advisory committee of four representatives from the school community. The research team was composed of researchers and student researchers from several fields (education sciences, occupational therapy, speech and language therapy, and social services) whose expertise converged around professional development and social participation of autistic persons. The advisory committee from the school community consisted of an education advisor from a school services center, as well as three members of the participating school, namely the principal, a psycho-educator, and the school daycare supervisor. An iterative process of creation, validation, and modification was carried out to design the program and its various modalities. This phase lasted six months, during which the design team members met on a weekly basis. Consultation meetings were also organized with the other actors on the research team and the advisory committee members so they could provide comments on elements that were positive and on those needing improvement, as well as ideas to refine and adapt the program to the school context.
During the evaluation phase, a pilot project was conducted in a school in Quebec City (Canada) to assess the feasibility of implementing the professional development program and studying what was helpful in the participants' experience [70]. A case study approach was favored so the situation and the context would be taken into account [73,74]. The case study also proved relevant for describing and analyzing a specific problem [75,76]. Priority was given to the qualitative method to provide a deeper understanding of the modalities supporting the professional development of school staff. Descriptive quantitative data were used to draw a portrait of the participants.
The program was evaluated in an elementary school attended by several autistic students in both mainstream and specialized classes. Intentional sampling was used to recruit participants who could provide a deep understanding of the phenomenon [75,76]. The participants had to work regularly with one or several autistic students, as well as be motivated to receive support and to become involved in making their school more inclusive for autistic students. A team comprising from four to eight school staff members from varied professions who worked with students in similar school grades was sought, to favor a collaborative process that would help support the development of inclusive practices in the various school contexts [35,77]. The advisory committee decided to prioritize Grades 2, 3, and 4 staff, except for daycare workers because of high staff turnover in those grades. Nine school staff members participated in the project. They had on average 14.8 years' experience working in a school and 8.1 years' experience with autistic students. They worked directly with a total of seven autistic students. These participants' other sociodemographic characteristics are presented in Table 1. The school staff involved in implementing the project, the advisory committee members from the school, and the occupational therapist took part in the evaluation of the program. The occupational therapist implementing the program was the student researcher who was on the design team. She had received training in Occupational Performance Coaching. Data were intended to be collected from January 2020 to May 2020. However, in the context of the COVID-19 pandemic, the project had to be interrupted in mid-March 2020 due to school closures throughout the province of Quebec. The data collection tools were adapted to the situation. In the end, individual interviews, questionnaires, and a logbook were used. The interviews and the questionnaire administration took place after the project was interrupted. The student researcher conducted individual, semi-structured interviews online with the school staff, to obtain a rich description of what had been helpful in their experience in terms of support for their professional development [78]. The main theme of the interview was the contribution of the program to the change in practices used to support the participation of autistic students and their peers. The narratives were recorded and transcribed verbatim for the analyses. It was possible to interview seven of the nine participants. Then, an online questionnaire was administered to the school staff and to the advisory committee members from the school. It consisted of open-ended questions designed to document perceptions of the project modalities that had helped or hindered the professional development, as well as suggestions for improving the program. The questionnaire was chosen as a complement to the interviews to limit social desirability bias and to offer more flexibility out of respect for how busy these people were preparing for the students' safe return to class. Eight of the nine school staff members and two of the three advisory committee members filled out the evaluation questionnaire. Furthermore, throughout the implementation of the project, the occupational therapist researcher kept a logbook to document her observations and reflections regarding the modalities that supported or limited changes in the school staff's practices. This enabled the sources to be triangulated, in addition to reducing the researcher's personal biases by helping her to delve deeper into her analysis of the case under study [79].
A thematic content analysis of the qualitative data extracted from the questionnaires, individual interviews, and logbook was conducted according to a systematic and iterative process. This involved a mixed, deductive and inductive, approach [80][81][82] using N'Vivo 12 software. The deductive analysis was conducted based on the core features for effective professional development [59]. To ensure coding accuracy and precision as well as to refine the code descriptions [83], the entire body of data was double coded [83,84]. Differences between the coders were resolved through a process of discussion and consensus. Chosen quotes for the manuscript were translated from French to English by a professional translator.

Designing the professional development program
The professional development program was designed to train and accompany a team of varied school staff to encourage participation of autistic students in all school contexts, including the classroom, the schoolyard, specialty classes, and daycare. It comprised five modalities: (1) regular presence of the occupational therapist, (2) a needs analysis, (3) content focused on the features of an inclusive school, (4) team coaching, and (5) individual coaching. These modalities are described in Table 2 according to the core features for effective professional development. The program was tailored to the needs of the school. For instance, the advisory committee was involved in various choices, notably of the grade levels to be targeted and the frequency and duration of the coaching sessions. To favor dissemination of the practices beyond the nine participants involved in the project, coaching sessions were added for the entire school team upon request by the school.
Occupational Performance Coaching [86,87] was used and adapted to include a combination of team and individual coaching, as well as periods of participant observation and experimenting of strategies in pairs. In this project, the coaching sessions aimed to accompany school personnel to facilitate the participation of autistic students and their peers by helping them identifying how they could modify how the activities are done or the environment in which they are done to maximize the fit with students' needs (e.g., reduce noise, add visual support). A non-directive approach focused on equal relationship and participants' autonomy was adopted, as well as interviewing techniques relying on emotional support, opportunities for reflection, and information sharing [86,87]. Team coaching was chosen as a modality to encourage collaboration among school staff, as it is believed to be needed to facilitate the inclusion of autistic students [35,38,59]. The goal of team coaching is to create a shared vision by focusing on setting team goals and supporting the team in implementing actions to achieve those goals [77].

Evaluation of the modalities of the professional development program
The analysis of the interview transcripts, logbook content, and answers to the questionnaires was used to bring out the participants' perceptions of the relevance of the modalities for supporting the transformation of their practices and of the elements of the program or of the context perceived as restrictive. The short duration of the project, in the context of the COVID-19 pandemic, was a restrictive element mentioned by all the participants. It was interrupted after six of the twelve planned intervention days. Contrary to the plan, each participant had received two individual coaching sessions instead of four, one team coaching session (with the nine participants) instead of three, and one coaching session with the entire school team instead of two. The participants named helpful elements related to the five modalities of the program. One school staff member explained that it was all the modalities together that were helpful for her and not only one taken separately: "All that, it's important ( … ), it's a whole. I cannot remove one from it."

Regular presence of the occupational therapist
The school staff mentioned that the frequent interactions with the occupational therapist, which were adapted to each one's needs and availability, were helpful to support their learning and the implementation of new practices. One participant said the brief, frequent meetings fit well into her daily life: "We want help, but at the same time, it can't take up too much of our time ( … ). I was open to the occupational therapist coming, small meetings at lunchtime; I found that good, after school. It wasn't burdensome." However, some participants said that they were short of time, which limited the implementation of certain strategies in their practice. One of them mentioned limited free time due to the school context, which limits professional development: "lack of time for discussion, sharing, adjusting, experimenting ( … ), the impression that everything always goes too fast and that our days are too full. … have nothing to do with the project, but it's a reality that we have to live with." Two participants also mentioned that they had not spent enough time with the occupational therapist, which limited testing of several practices that could have been relevant.

Needs analysis
Regarding the needs analysis, the project centering on the school's and school staff's priorities appeared to be a helpful element for several participants. The fact that the project pertained to "a difficulty actually experienced in the environment" and that it began with a needs analysis seemed to have contributed to the team's openness to improving their practices. In this regard, one participant mentioned the following: I found that it really suited the project to say, "we will see according to the setting what the need is." Because it could have been like, "Well, I'm coming here; we're going to talk about snacks and that's what we will work on," without it meeting the needs of the students or the needs of the environment. It wouldn't have had the same impact ( … ) I don't think that attitude would have made us as open.
The adaptation of the program to the needs of the group but also to those of each school staff member proved especially helpful for the team of participants and the occupational therapist. In this regard, one committee member mentioned especially liking Presence of the occupational therapist at the school 12 full days, on the basis of two days per nine-day cycle over a four-month period. Contacts between the occupational therapist and the school staff each nine-day cycle (total of 12-15 h in contact per school staff member).
Extended duration: Regular presence in the school for a four-month period favors improvement of practices while being realistic with the resources available.

Needs analysis
Individual questionnaire administered to the participants concerning their priorities in terms of challenges in the participation of autistic students and their peers Sharing of needs and establishment of a common participation goal during a team coaching session with the various school staff members to decide on which type of activity they want to focus together. Specification of personal goals for each school staff member in the individual coaching sessions Coherence: An analysis of the school staff's needs favors coherence of the program with their priorities, values, and knowledge.

Content focused on inclusive activities and environments
The content is presented in the form of an autism-friendly school model describing the features of inclusive environments and activities that are conducive to the participation of autistic students in a variety of contexts and school activities, such as play, transitions, meals, and hygiene activities.
The content is centered first on the implementation of universal strategies that could benefit all students and then on targeted strategies for students who still need support, including autistic students.
The content is based on evidence-based practices in the field of autism [85] and the Person-Environment-Occupation model [58]. It will be presented in another article. A brief, 30-minute presentation on the autism-friendly school model was done to introduce all participants to the content focused on inclusive activities and environments. A participant's notebook including the inclusive school model as well as strategy sheets presenting concrete examples of potential changes in school environments and activities related to each feature as distributed.

Content-focused:
The model is centered on the different professionals' school activities and environments. The use of strategy sheets facilitates the translation of the content into school personnel lives.
Team coaching Team coaching sessions enabled participants to choose a goal related to participation in one type of activity in the school day, and then exploring strategies to adapt the environment or the activities to better meet the needs of autistic students and their peers. Three team coaching sessions with the nine school staff members: at the beginning, mid-point, and end of the project (2.5 h / session). Two coaching sessions were planned with the entire school team to share strategies tried by the participants (2 h, very informal).

Collective participation:
Team coaching aims at creating opportunities for school staff to collaborate by sharing effective strategies and seeking solutions to the challenges encountered.
Individual coaching Individual coaching sessions enabled to clarify the concrete goal for each school staff member, what this meant in his context, and then exploring and trying out strategies to adapt the environment or the activities to better meet the needs of autistic students and their peers in his classroom or context. Four or five sessions of individual coaching were planned for each participant (approximately one per nine-day cycle). Modalities were adapted to each one's needs (e.g., participant observation, experimenting of strategies in pairs). A short interactive interview concluded each meeting to follow up on the action plan relating to the features of inclusive activities and environments and referring to the strategy sheets as needed.
Coherence and active learning: Individual coaching favors coherence of the program with each participant's context as well as active learning thanks to the participants' involvement in the research, testing, and evaluation of practices that are more conducive to the students' participation.
that the project was "could be adapted to the needs." The occupational therapist noted that the needs analysis gave rise to reflections and discussions between the participants, which contributed to a better understanding and sensitivity of the participants relating to the students' needs in all school activities. One participant mentioned that: "The team reflection to target a need to prioritize was very enriching." The choice of a common goal by the participants favored subsequent mutual assistance and sharing of each one's experiences.

Content focused on inclusive activities and environments
The training content was helpful for the participants because it brought them a new analysis perspective directed toward the characteristics of the environment and activities that would influence their students' functioning. One advisory committee member gave this description: "It brings a new view of the difficulties encountered every day." One participant added that: "The occupational therapist can go respond to questions for which we had no answers with our practices or with the services that were already in place." As part of the project, the participants' objective was to improve the students' participation in transitions. The school staff realized that they expected too much of the students, including those who are autistic. One special education technician mentioned the following: This new perspective brought on by the project thus led several participants to begin making changes in their activities and interventions rather than acting on the students' difficulties. One participant described how she had incorporated more positive reinforcement and visual support: Our positive comments when we speak. Of course, I make some, but it made me aware of the importance of making some and of the importance of a routine too because maybe it needs work in my case, and visual ( … ) The little videos, that requires visual again. Sometimes, I think that I talk more ( … ). I see that with those children, with all the children, but mostly those children, it helps to have visual. This project made me aware of that.
A second theme that emerged from the analysis is that the school staff liked that the content proposed changes that were concrete, simple, and applicable with all students. In this regard, one participant said: "You know, it's really concrete things that I realized, that it's not too hard to do and that it has an impact. I want to continue to do that, for sure." Another one said: "Our need is at the group level because, yes, we all have our [students with] autism, but we all have the other profiles of students who are difficult also and who need that." The use of universal strategies would thus have contributed to making the training content accessible and helpful for the school staff by giving them the opportunity to implement strategies that are beneficial to everyone. One special education teacher explained how the project brought her to collaborate with the teacher to harness targeted strategies intended for one autistic student and apply them to the entire group, to support the learning of other students with special needs: "Often, I was focused on my student and it made me open my eyes. I can put this more to the whole class, actually ( … ). It really opened my eyes. It's important to also see it as a whole through that." Sharing the content through strategy sheets that included examples of changes to the environments and activities proved helpful for some participants: It was simple and it was clear. It can't be too detailed because we end up getting lost in it and we're short on time too ( … ). Me, I speak for the daycare. If it's simplified, it will be easy to include. However, other participants mentioned that despite the relevance of the content, they lacked time to assimilate it. One participant also suggested streamlining the strategy sheets and adding more pictures to make them easier to use. The occupational therapist also noted that time constraints limited the sharing of information related to the content of the strategy sheets during the coaching sessions.

Team coaching
Of all the modalities of the program, team coaching was the most frequently mentioned by the participants as being the most helpful for them: "These group meetings, it's essential. I think it gives us the pulse of the school." Collaboration between the school staff to find solutions proved particularly helpful for the participants. Team coaching fostered collaborative work on a common goal and sharing of strategies to improve students' participation, as mentioned by one participant who liked "seeing together, sharing ideas." She went on to say: "Even if there are people with whom we've worked for some time, we all work in our classrooms so, there, we saw ways of thinking and sharing of ideas, of concrete ideas." Some participants specified that team coaching fostered the development of collaborations that continued outside the coaching meetings. One participant from the advisory committee raised the fact that "having several types of school staff is certainly a guarantee of success." The occupational therapist had also noted that the coaching of a team comprising diversified school staff, such as teachers, special education technicians, and daycare workers, helped pool together various views about the students' participation, not only in the classroom but also in other contexts.
Several participants said that the opportunities to collaborate with other members of the school team were also helpful in the project. They said that the exchanges during one coaching session that was offered to the entire school team had given rise to reflection and a deepening of the learning: I was seeing what had been done in the other classrooms ( … ) we discussed, but we also pushed the reflection further and, that, I found that really interesting and it had channeled the ideas ( … ) we were in something concrete and in things that we had tried.
The non-directive relationship with the occupational therapist also appeared to be a helpful element for the participants: "The occupational therapist brings good reflections without positioning herself in a role of expert, which favors discussion and collaboration." That seems to have helped create a climate that encouraged school staff to become engaged in the search for new strategies: In fact, throughout the project, what I liked, the occupational therapist was like our focal point of reflection. Never did she claim to hold the truth or never was she closed to discussion: [she would never say] "and you're going to do that; that's what works." Some participants mentioned also that this non-directive relationship between the occupational therapist and the school team contributed to their openness to experiment with new practices: "It was easy. I wasn't embarrassed. We open our classroom; we know we have things to improve ( … ). With the occupational therapist, we didn't feel judged either. We were able to tell her things; that's good."

Individual coaching
The importance of personalized support in the school staff's natural environment through individual coaching emerged as helpful to several participants. They mentioned that the occupational therapist's presence in the classrooms helped make the program coherent with each one's needs and context. For example, one participant said: "Me, it's when you would come into the classroom and you would observe and, afterwards, we had the chance to discuss together because it was more concrete relative to my group." The occupational therapist also mentioned the benefits of integrating coaching in the school staff's real-life activities to accompany them in identifying solutions: "The observations were helpful for seeking concrete strategies with the participants concerning a situation that they had just experienced." A second theme that emerged as helpful for the participants was related to active learning, that is, being involved in seeking and trying out solutions with the occupational therapist. One participant said: "I liked very much that the work was done together, occupational therapist and teachers." Some school staff reported that the coaching had helped support them in the implementation of new practices: "We felt supported and backed. It's very motivating." One advisory committee member mentioned that this support had been particularly appreciated because several of them felt overwhelmed by the weight of their students' needs. The occupational therapist said that the periods of discussion with the school staff during the individual coaching fostered reflection to bring them to make a concrete plan on how they would implement changes in their activities.
Some participants mentioned that opportunities to experiment in pairs gave them confidence to try new practices. Both the successes and failures experienced in this setting helped them learn. One participant described it as follows: When you came into the classroom, experimenting together, we see what is realistic, what is not, and what happens when we experiment. Sometimes we fail, sometimes it works, sometimes it doesn't work. I found it fun that we experienced it together. That, that is really important.
In this regard, another participant explained it like this: Seeing the impact that it had on the children, how you would go about it, how you would address it ( … ) how you bring it to the children. I would see them react. You know, it's all that, the real, the concrete once again, directly with another person, but I am there and the impact that it had so that I could go look for things in there to bring them my own way, but that's what I liked, seeing.

Discussion
The objective of this study was to design and evaluate a professional development program offered by an occupational therapist to a team of school staff working with autistic students. An iterative, collaborative process led to the design of a professional development program tailored to the needs of a school environment that included five modalities: (1) regular presence of the occupational therapist, (2) a needs analysis, (3) content focused on inclusive activities and environments, (4) team coaching, and (5) individual coaching. The results indicated that the combination of these different modalities was particularly helpful for the school staff to develop practices that are more inclusive for autistic students. These results are consistent with the study by Higginson and Chatfield [88], who concluded that teachers of autistic students benefit from multiple opportunities to learn, including training workshops, team meetings, and individual mentoring sessions. Collaboration with the administration and the needs analysis with school staff were helpful for adapting the program to the priorities and needs of the school, highlighting the importance of establishing a partnership with the school team to favor coherence with the practices and context of the school environment [31,59].
The results of this study support the use of a coaching approach in a school context. In fact, as in other studies [86,89], the participants were satisfied with the exchange of information in the form of coaching and opportunities to participate actively in seeking and identifying strategies. The non-directive relationship of collaboration with the occupational therapist seemed to have also contributed to the participants' engagement in the analysis of the situations and the search for solutions. This is consistent with other authors' conclusions that close collaboration between the occupational therapist and the teacher helps to improve knowledge and understanding of their students' challenges and needs [46,48,50]. While other studies have demonstrated the effectiveness of the use of a coaching approach in schools on staff perception of their capacity [40,54], the current study adds that this approach also appears meaningful to school staff.
Furthermore, this was a first experimentation of Occupational Performance Coaching [86] with a team formed of school staff. The results suggested that the team coaching, carried out using Occupational Performance Coaching techniques, proved particularly promising for mobilizing a diversity of school staff. The participants found this modality to be helpful because it enabled them to compare their points of view, establish a common goal, and collaborate in seeking solutions that would encourage participation of autistic students. This confirms the added value of team coaching, which allows the team to focus on the issues that are important to them, to set goals and to receive support in developing new practices as a team [77,90]. This study thus confirmed the importance of accompanying a diversified team of school staff sharing a similar context to respond in a concerted and sustainable manner to the complex needs of autistic students [38,91]. The coaching session with the entire school team also proved helpful for the participants. This finding supports the importance of training activities among colleagues to develop practices that are conducive to an inclusive education [19,34,59].
Although team coaching is promising, the results also highlighted the fact that it benefits from being combined with individual coaching for school staff, to identify and experiment with practices in their particular context. This finding is consistent with the conclusions of Desimone and Pak [69], who indicated that individual coaching is a relevant modality for ensuring coherence of professional development activities with the values and needs of each school staff member. These results reinforces that when a program is offered to several school staff members, individualized support is necessary to improve coherence with each participant's particular needs [59]. The findings showed that the sessions incorporating observations and experimentation of new practices with the occupational therapist proved particularly helpful for supporting school staff in the implementation of new strategies. This is consistent with the conclusions of several authors to the effect that school staff working with autistic students would like to be accompanied not only in planning but also in implementing the strategies in their classrooms with autistic students [14,18]. This finding provides further support to Desimone and Garet's [68] indication that coaching offered in an authentic context is more easily applicable to teachers' daily activities, that it facilitates links with their activities or the material they use. This study thus suggests that adapting the Occupational Performance Coaching approach by adding coaching modalities in the participants' reallife activities is a promising avenue for fostering the engagement of school staff in the implementation of new practices. This is also supported by findings from Wilson and Harris [53] which indicate that teachers need the occupational therapist to come in their classes to observe and do activities with the students and the teacher. Furthermore, the integration of these individual coaching sessions within the school staff's real-life activities seemed to be helpful in offering sufficiently intense support while remaining realistic in terms of resources.
However, the results indicated that the participants were unable to sufficiently assimilate the content proposed during the activities offered in the training program within the time they had. In addition to the project interruption context and the small number of days planed, this challenge may be explained by the fact that no time had been allotted in the schedule specifically to support the uptake of the content. A short presentation paired with sharing of strategy sheets was advocated, rather than a training workshop, to encourage active learning and avoid positioning the occupational therapist as an expert. Nonetheless, it may be difficult to implement modalities favoring active learning by school staff in a context where they have little free time to reflect on new practices and to plan for their implementation [92,93]. Based on the results of this study, it appears vital that the professional development program be slightly adjusted to favor more uptake of the content by the participants and enable planning of the changes to be made in this regard. This could take the form of interactive training workshops with the participants, online training videos, enhancement of the participant strategy sheets, or more time for coaching without the presence of the students. This also reinforces the need for professional development programs to be planed over an extended duration [59], for occupational therapists to spend more time in the schools [53,94].
Moreover, this study helped clarify the occupational therapist's contribution in accompanying school staff working with autistic students. The training content, addressed according to a multitiered approach and centered on the features of favorable activities and environments, proved helpful for the school staff. In fact, it favored the implementation of simple, concrete changes that would benefit several students, including those who are autistic, which was particularly appreciated by the school staff. This finding is consistent with the research by Wilson and Landa [93] underscoring the fact that evidence-based practices in autism may benefit from being translated into simplified, accessible strategies in the school context to reduce the time and resources required for their implementation. The results of this study also support the proposal that transforming practices is easier when the strategies can apply to and benefit a larger number of students [28,36]. This study pertained more specifically to the occupational therapist's contribution to supporting the professional development of school staff to improve school inclusion of autistic students. The results of this study could inspire other professionals who are attempting to support school teams in the inclusion of autistic students or with other special needs.
Design-based research was used to obtain a tailored solution anchored in the reality of the practice, based on scientific and experiential knowledge. The shortened implementation of the project due to the pandemic context constitutes a major limitation because the school staff completed only half of the planned modalities. Nonetheless, since all the modalities were tested, the study still led to the identification of promising modalities for supporting the professional development of school staff and avenues to improve the program for future implementations. The context of confinement related to the COVID-19 pandemic demanded an adaptation of the data collection tools. The authors acknowledge the limitations of the questionnaires in terms of collecting qualitative information, the small sample of participants from only one school, and the potential bias stemming from the fact that the occupational therapist who implemented the project was also on the research team. They understand that the conclusions could be different in other school contexts and reiterate the importance of adapting the program in collaboration with representatives of the target schools. The occupational therapist's use of a logbook, the data triangulation, the conduct of the analysis by two people, and dialogue with the research team at every step of the study, for their part, reinforce the validity of the results.

Conclusion
This study highlighted the fact that a professional development program offered by an occupational therapist appears promising for helping school staff create a more inclusive school for autistic students. It also contributed to a better understanding of the school staff's perspectives regarding modalities that are helpful for improving their practices. An occupational therapist can thus contribute to the inclusion of autistic students through the professional development of a team comprising a diversity of school staff. The combined use of team and individual coaching sessions and a multi-tiered approach to support the creation of school environments and activities is conducive to full participation of autistic students and their peers. This study was a first experimentation of this professional development program in occupational therapy. Consequently, it must be enhanced based on the study results and adapted to various contexts. Although the project is promising, other studies are needed to measure the effects of a professional development program incorporating these modalities on school staff's practices and students' participation.

Disclosure statement
No potential conflict of interest was reported by the author(s).

Funding
This work was supported by an Insight Development Grant from the Social Sciences and Humanities Research Council. The first author was a master student supported by grants from: Fonds de recherche du Qu� ebec Soci� et� e et culture, Institut universitaire en d� eficience intellectuelle et trouble du spectre de l'autisme, and Fonds de recherche en inclusion sociale. The translation of this manuscript was supported by a grant from Institut universitaire en d� eficience intellectuelle et trouble du spectre de l'autisme. References 0[1] Conseil sup� erieur de l'� education. Pour une � ecole riche de tous ses � el� eves: S'adapter � a la diversit� e des � el� eves, de la maternelle � a la 5e ann� ee du secondaire. [For a school rich of all its students: Adapting to the diversity of the