Targeting the school environment to enable participation: A scoping review

Abstract Background Children with special educational needs experience limited levels of participation at school; their participation is influenced by the physical and social environment. Interventions that have been applied in school environments are described in the literature. Aims To illustrate the main features of interventions targeting school environments to support participation of children with special educational needs in mainstream education. Materials and methods A scoping review using a qualitative, thematic analysis was conducted in May 2021. Results We included a total of 20 articles. We found that intervention features contributed to children’s participation and targeted social and physical school environments. The majority of the intervention features focussed on applying supportive teaching methods to enable individual children’s participation. A small number of interventions described a systemic holistic approach that involved changes to the school environment. In these interventions, different professionals such as occupational therapists collaborated with teachers to adapt the school environment. Conclusions and significance A shift from individual child-focussed to environment-focussed approaches that target all children’s participation could impact classroom setup and teachers’ roles. Occupational therapists’ expertise in matching school environments and task requirements with individual children’s needs could be valuable in their collaboration with schools to support this transition.


Introduction
Children's education is a fundamental human right [1] that contributes to their social and emotional development [2] and participation [3]. Research has emphasised the importance of school participation on children's development and well-being [4,5], as it supports the development of skills, expression of creativity and self-identity and fosters the development of friendships [6,7]. Participation is defined by the World Health Organisation as 'involvement in a live situation' [8]. Imms et al. [9] added two essential elements to this definition: attendance (e.g. how often does the child conduct, for example, a writing activity) and involvement (e.g. how involved the child is in the writing activity). Attendance, as well as involvement, is seen as an essential aspect of experiencing participation. In the Netherlands, more than 1.5 million children (4-12 years) attend school during weekdays; of these, about 25% require extra support to be able to participate in daily education [10]. However, numerous studies have indicated that participation at school for children with special educational needs (SEN) remains limited in comparison to their peers without disabilities [11][12][13][14].
Children with SEN are defined as 'children who, for a wide variety of reasons, require additional support and adaptive pedagogical methods in order to participate and meet learning objectives in an educational programme. Reasons may include (but are not limited to) disadvantages in physical, behavioural, intellectual, emotional and social capacities' [15]. Previous research has indicated that children with SEN might experience problems with peer acceptance [16], have fewer social contacts [17], perceive more environmental barriers [18] and are more dependent on adults than their peers without a disability [19]. Furthermore, these children rated their interaction with peers and adults as lower than that of their peers [16].
For a number of years, schools have been obligated to provide children with SEN the opportunity to participate in mainstream education. For instance in the Netherlands, a new law aimed at inclusive education was introduced in August 2014 [20]. The process of adapting schools, classrooms and activities so all children can learn and participate together is internationally described by the term 'inclusive education' [21,22]. Further to this, research has demonstrated that a majority of Dutch teachers favour inclusive education [23]. However, teachers experience a high workload and tend to lack the skills and knowledge to effectively support the diversity of children with SEN in the classroom [24]. Therefore, Dutch teachers have emphasised the need to develop a repertoire of practical skills and knowledge for applying inclusive approaches in their daily teaching routines [25]. Moreover, Pijl [26] underlined the importance of providing opportunities for teachers to acquire this repertoire of skills on the job by working in teams. In these teams, teachers collaborate with outside professionals within the school environment to learn from each other in formal and informal ways [27,28].
Occupational therapists have started to play a growing role in supporting the inclusion of children with SEN at school [29], as they are experts in matching school environments and task requirements with the needs of children who experience restrictions in their participation [30]. The American Occupational Therapy Association has identified education as a key performance area for occupational therapists who work with children [31]. Recent studies have demonstrated the relationship between environmental factors and the level of school participation for children with SEN [32][33][34]. Bronfenbrenner [35] subdivided the school environment into different levels, each of which influenced children's development and participation at school. These levels are defined as the micro-, meso-, exoand macro-environment. The level which is closest to the child is called the micro-environment. The micro-environment encompasses the relationships, interactions and structures a child has in their immediate surrounding; as a consequence, the micro-environment directly influences children's participation at school. Besides identifying the levels, Bronfenbrenner [35] also distinguished between the physical environment (e.g. classroom, furniture, learning materials) and the social environment (e.g. peers, teachers, parents) in each level. Interactions in the microsystem have the most powerful influence on a child's engagement in school activities and their overall participation [36][37][38]; therefore, this study primarily focuses on children's microsystems, which are divided into their social and physical school environments.
Despite scientific insight into the importance of the environment in enabling participation, many educational support programmes still focus on the training of individual children (e.g. training to improve their social skills [39] or motor skills [40] without consideration of environmental factors). A recent study [41] has shown that rather than focussing on adapting the school environment, a majority of occupational therapists working with children with SEN still use pullout approaches with individual children to primarily address sensory, hand function or daily living needs. Literature has recently emphasised a shift in occupational therapy interventions from traditional pull-out approaches (individual interventions) to holistic approaches that are integrated into the student's classroom [42] and focus on the social and physical school environment [29]. Consequently, interventions that aim to enhance participation of children with SEN must focus on individual factors, on the nature of the participation activity and on factors in the environment in which the activity is being performed [43]. For example, a Swiss study found that occupational therapists reported a need to primarily experience the educational, social and physical school environment in order to understand its impact on a child's participation [44].
To our knowledge, little is yet known about existing school-based interventions that aim to enable school participation and focus on changing or enabling the school environment. School-based interventions have been defined as approaches that are integrated in the natural school context in collaboration with different stakeholders, including occupational therapists [29]. Therefore, mapping current interventions could shed light on this gap and help to identify the main features of school-based interventions that focus on the school environment. Such a synthesis could support future research on the enhancement of participation of children with SEN at school and the possible role of experts (e.g. occupational therapists). For this reason, we conducted a scoping review with a focus on the following research question: 'What is known in the literature about the main features of interventions that target the school environment to enable the participation of children with SEN in mainstream education?'

Scoping reviews
For this scoping review, we applied Arksey and O'Malley's [45] methodological framework. Therefore, the research team followed the following five main stages: (1) identify the research question, (2) identify relevant studies, (3) select studies, (4) chart the data and (5) collate, summarise and report the results. The method of a scoping review is chosen in order to identify gaps in the literature of existing interventions not limited to interventions (already) proven to be effective or studies that meet the criteria of a quality assessment [46]. Therefore, our use of a scoping review method will not necessarily identify research gaps if the research itself is of poor quality. We chose the most recent decade as the rational time period for this work.

Search terms and search strategies
This scoping review focuses on interventions that change the school environment to enable the participation of children with SEN within mainstream education. Therefore, we applied a search strategy that used the following formula: 'participation' AND 'children' AND 'environment' AND 'special educational needs' AND 'mainstream education' AND 'intervention'. Each search term was linked to several MeSH terms. Search terms for 'participation' included 'engagement' and 'inclusion' or 'involvement'. Search terms for 'children' included the MeSH terms 'kids', 'youth', 'child' or 'pupil'. MeSH terms focussing on the search term 'environment' included 'contextual', 'context', 'environmental', 'context-based' or 'schoolbased', while 'special educational needs' MeSH terms included 'special needs', 'impairment', 'limited', 'disability', 'disabled' or 'disabilities'. Search terms for 'mainstream education' included 'elementary school', 'primary education', 'elementary education' or 'primary school' MeSH terms. Finally, we also used the 'intervention' MeSH terms 'approach' and 'program'. We searched via the 'Zuyd Discovery Service' (DIZ), that included 'Academic Search Complete', 'Cinahl', 'ERIC', 'Medline', 'Psychology & Behavioural Sciences Collection' databases, and via 'PubMed' for the first time at the end of June 2019 (24/6/19). The articles that were searched were published between January 2009 and December 2019. We then conducted a second search to include recent literature that had been published between December 2019 and May 2021.

Study selection
Study selection criteria were identified in several stages of the study review, and we did not impose restrictions regarding the type of design. The study languages were limited to English, German and Dutch. Studies were included if they (a) provided information about a school-based intervention, (b) focussed on adapting, changing or using the school environment, (c) targeted primary school children (between the ages of 4 and 12), (d) targeted children with a special (educational) need (not necessarily referring to a diagnosis) and (e) aimed to enhance school participation or any related concept of school participation. Studies were excluded if (a) services were offered exclusively outside the school environment, (b) interventions were provided only in special school settings or (c) exclusively focussed on the child's level of function, such as improving tactile function. Both literature searches were conducted by the first author (SM), while SM and a second reviewer (HS) independently evaluated and scored the results of each stage based on the inclusion and exclusion criteria that have been described above. They recorded their evaluation by labelling each study as either relevant (R), irrelevant (I) or doubtful (D). Any that were rated as D were discussed with additional reviewers (BP, PH and DD; other authors of this article). Finally SM (first author) performed a preliminary full-text analysis.

Charting the data
The data extracting and charting process was developed with input from BP, PH and DD. SM extracted data such as publication year, country, aim of the study, target group and study methodology from the included articles (see Table 1). In addition, detailed information regarding intervention features, main findings and methods for outcome evaluation were extracted and charted using an Excel spreadsheet.

Collating, summarising, and reporting the results
A qualitative thematic analysis [67] regarding intervention features that target the school environment to enable participation of children with SEN was performed on the extracted information. Initial codes were generated, reviewed and collated into potential themes, which we then repetitively reviewed and defined. All of this article's authors were involved in the process of determining how best to describe the data. The resulting main themes are shown in Table 2.

Results
A total of 1283 articles from the 'DIZ' and 'PubMed' databases were identified as potentially relevant. After screening, 180 abstracts and 70 full-text articles appeared to be relevant. We evaluated all 70 of the articles on a full-text level, which resulted in a final total of 20 articles that were relevant for further analysis (see Figure 1).

Descriptive summary of the studies
The majority of the 20 relevant articles that remained after selection criteria was applied had been conducted in the United States, Canada and Australia. All of the articles had been published between 2009 and 2021; thirteen of the articles were quantitative studies, one was a qualitative study, five used a mixed method approach and one used an intervention description (see Table 1).   Narrative summary of the studies The qualitative thematic analysis resulted in an overview of intervention features organized along two major themes: (1) Changing the social school environment and (2) Changing the physical school environment. In Table 2, the intervention strategies are presented in relation to the major themes. Intervention strategies can be applied for an individual child, a group of children and/or the whole class. 'Individual child' means intervention strategies applied to support individual children with SEN, 'group of children' implies that at least two children of one class are targeted, and 'whole class' indicates strategies were applied for all children in one classroom.

Changing the social school environment to support children's participation
This theme is about changing the social school environment to support children's participation. In this scoping review, 'changing' refers to modifying the knowledge, ideas, strategies and approaches of the school team and/or individual school personnel to enable children's participation at school. This first main theme is distributed in five subthemes, each of which describes one of the emerged intervention features.
Applying supportive teaching approaches. A total of fifteen interventions incorporated features of applying supportive teaching approaches. Here, an approach is defined as a vision and use of teaching and learning strategies in the classroom situation. The description of supportive teaching approaches in the research varied between more general descriptions of frameworks to specific examples. The supportive teaching approach known as 'Response to Intervention' refers to designing teaching environments to foster skills development in all children. Within this approach, teachers were additionally supported to use differentiated instructions for groups of children and to apply accommodations for individual students [55,57]. Trussell et al. [62] evaluated 'Universal Design for Learning' teaching strategies that were applied for all children in the classroom, whereas Abawi et al. [47] described an approach in which support is matched to children's individual needs. Narozanick et al. [58], however, gave a more specific example of an intervention in which teachers were trained to use 'class passes' (visual cards) as an approach for improving classroom behaviour among children with disruptive behaviour. In this approach, children have the option of using their class pass to take an additional break during classroom activities when they need it. In line with this, Wagner et al. [65] trained teachers to implement the Alert Program V Roriginally developed by occupational therapiststo enhance the self-regulation skills of all children. In Selaniko et al.'s [50] study, training provided by occupational therapists enhanced the whole school team's knowledge and collaboration in order to provide children with more choices during curriculum activities. Panaerai et al. [59] and Strain et al. [61], meanwhile, supported teachers' use of alternative communication methods (e.g. implementation of visual schedules) instead of verbal or written information for individual children with autism. Furthermore, during the TEACCH intervention [59], teachers applied differentiated, alternative communication methods during education (e.g. additional visual instructions). Approaches targeting individual children who experience SEN in one classroom [47,48,54,[59][60][61][62] were found to be the most prominent, followed by groups of children [50,58] and the whole class [51,65,66]. Three interventions stood out as they targeted children on all three levels [53,55,57].
Promoting home to school collaboration. Five of the intervention studies described the feature of facilitating collaboration between parents and teachers [54][55][56][57]59]. One strategy used parent-teacher training to provide information about the value of visual support for individual children at home and in the classroom [54,56]. Visuals that addressed goals of an individual child were chosen in collaboration with the parents. Further strategies regarding collaboration were described in the 'Partnering for Change' (P4C) [57] intervention, in which an occupational therapist supported the exchange between parents and teachers to support individual children's school participation.
In TEACCH [59], the parents are recognized as the experts on their own child; for this approach they collaborated with the teacher at school and were given the role of co-therapist. Strategies to promote home to school collaboration were always applied to support participation of an individual child [54][55][56][57]59].
Adding curriculum activities. Adding curriculum activities means that an 'additional programme' is implemented over and above routine teaching activities. In the inclusive school-based resilience intervention 'Success and Dyslexia', teachers implemented a 'universal coping programme' during the education of all of the children in the class [53]. This intervention offers activities for children with dyslexia, and those children could also participate in additional withdrawal sessions with regard to a dyslexia-related goal. During the 'Superheroes Social Skills' intervention [60], a school personnel offered weekly training outside of regular curriculum activities for children with autism spectrum disorders (ASD). This training incorporated several evidencebased strategies (e.g. inclusion of typically-developing peers, self-monitoring procedures). Fillippatou et al. [52], Cassiere et al. [49] and Wagner et al. [65] trained teachers to implement an additional teaching approach (e.g. disability awareness training) within their own curriculum for all of their students that was aimed at enabling group work, academic performance and motivation [52], improving self-regulation [65] or enhancing disability awareness [67]. Only Nota [63] evaluated imbedded modules for all children for enhancing disability awareness, which was carried out by an independent psychologist. In all of the four included interventions, school personnel were trained beforehand to apply these additional programmes. In line with the previous subthemes, curriculum activities are most often applied to support an individual child [49,52,60], and only the school-based resilience intervention [53] integrated elements for all three levels.
Educating about special needs topics. The term 'education' in the context of this study refers to the activity of teaching something to someone. In practice, this refers to new information that is delivered to one or more recipients who are in turn responsible for transferring that knowledge into their own classroom practices. A total of three interventions [48,50,53] described features intended to educate school personnel about the needs of and possible support strategies for children with SEN. For example, the Success and Dyslexia program delivers information about dyslexia to the whole school team as a part of their professional development [53]. Two other interventions contained strategies in which some teachers were educated by speech therapists or occupational therapists regarding social engagement in children with ASD [48] or children with intellectual and developmental disabilities [50]. These educational sessions were implemented as additional training outside of regular teaching activities and targeted at least two teachers at the same time. As this subtheme is related to children's diagnoses, these intervention features were focussed on the group of children level.
Creating a shared vision. The creation of a shared vision of inclusion for the entire school team was encouraged in three of the interventions [47,51,55], though their main emphasis varied. For instance, Crosskey [51] focussed on building a communicationfriendly school environment (e.g. written instructions presented in differentiated ways) that is supported by language specialists. A pedagogical understanding shared by the entire school team [47] and schoolwide usage of inclusive teaching strategies [55] are enhanced by the establishment of engagement protocols in addition to training and collaboration with stakeholders (e.g. special education teachers, parents).
As the vision of the whole school team is encouraged, all strategies within this subtheme are related to the whole class level.
Changing the physical school environment to support children's participation This second main theme addresses intervention features that describe how the physical school environment could be changed in order to enhance participation of children with SEN. In this study, the physical school environment is defined as spaces in which school activities take place and objects (either fabricated or naturally occurring) that are present at school. In line with this definition, the theme is divided in two subthemes.
Using supportive tools. Eight of the interventions described the use of supportive tools during classroom routines. The majority of the interventions made use of visual aids which were printed, laminated and provided to the child in appropriate ways. For example, visual cards [51,54,64] or visual schedules and work systems [59] that keep students informed about the requirements of activities that must be done could be implemented. Other examples include written expectations used to remind a student of an individual goal [61] or a reward system [56,61]. Additionally, daily report cards were suggested as supportive tools for enhancing collaboration between school and home [56]; the use of class passes [58] that can serve as visual signals for students who may need a break was also suggested. Vazou et al. [66] evaluated a web-based plenary learning programme that combined physical activity or exercise with school tasks. Most of the supportive tools focussed on the individual child [54,56,59,60,64].
Changing classroom arrangements. Classroom arrangements refer to the setup of classroom furniture (e.g. chairs and tables, [smart] board, shelves, etc.) or study areas. Two interventions focussed on changing classroom arrangements [57,59]. Panerai et al. [59] explained environmental adaptations that address the layout or setup of the teaching and studying area. During the P4C intervention [57], teachers, with the help of occupational therapists, arranged their classrooms in ways that supported successful learning and restricted distraction possibilities. As the classroom is used by all children, all of the features within this subtheme are related to the whole class level.

Discussion
This scoping review explores the main features of school-based interventions that target the school environment for primary school children. Our results show that intervention features generally target the individual child, a group of children and/or a whole class. Furthermore, to enable participation of various target groups, intervention features could be divided into those that focus on changing the social environment or those that focus on intervening on the physical school environment. This review demonstrates that the majority of the interventions described in the literature have focussed on individual children. Only one intervention, the Partnering for Change approach [57], included all three of the target groups and focussed on adapting both the physical and the social school environment. Teachers collaborated with occupational therapists from outside the school within the school environment to learn from (and with) each other about how to support children's participation within the classroom setting. Support for teachers from other experts within the classroom setting was one of the most common principles used to deliver school-based services for children with disabilities [68]. The literature also underlined the importance of focussing on teachers' competencies [69,70]. Our results revealed that teachers applied supportive teaching methods in eleven out of the sixteen studies that were included in this work. Some examples of these methods described in literature include the Response to Intervention approach [71], Universal Design for Learning [72], tailored strategies [73] and the use of alternative communication and information [74]. The promotion of home to school collaboration was presented as the second strategy. Moreover, recent studies [e.g. 75] confirmed the effectiveness of collaboration between professionals (e.g. occupational therapists and teachers) and families for supporting children with SEN at school.
The results of this scoping review indicate that changes to the physical school environment must be implemented through the collaboration of teachers and other experts who are committed to learning from and with each other (e.g. special education teachers or speech therapists) within the school environment [47,[49][50][51]54,56,57,59,63]. In several of the studies included in this work, occupational therapists, as experts on environmental influences on participation, collaborated with teachers [49,50,54,57]. The importance of interventions that focus on the social environment rather than just the physical school environment has been confirmed by other studies [e.g. 68,76] that reveal that collaboration between teachers and occupational therapists is beneficial and valuable to children's participation [71,72]. However, most of the studies did not emphasize collaboration, but rather interventions performed by teachers. Strategies emerged that were related to the physical school environment; these were shown to be strengthened by others' studies. These strategies focussed on the adaptation of furniture (e.g. into dynamic furniture) [77], classroom design [78] and the use of supportive tools as visuals [79]. However, it is remarkable that the use of technology as a supportive tool as described by Roschelle et al. [80] was not identified in the interventions included in this review, with the exception of two examples of studies in which computer-based applications were used [60,66]; these were perceived to enhance children's active engagement and participation in groups.
This scoping review reveals that overall, intervention strategies were applied for individual children with SEN in the classroom. Only a small number of interventions [52,55,56] served children on all three levels (i.e. individual child, group of children and the whole class). Recent studies in education and health sciences have indicated that individual practices are well-known and commonly documented principles for organizing and delivering school-based services for children with disabilities both within the classroom [81] and outside the classroom [82]. In contrast to this, however, recent studies have encouraged the use of 'Universal Designs for Learning' interventions to effectively promote all children's school participation [e.g. 83]. Recent work has also supported the use of Response to Intervention tiers [e.g. 84,85]. Response to Intervention consists of three tiers [86]; at each tier, strategies are applied to enhance children's participation. The first tier includes strategies that are implemented for all children in the classroom, the second tier encompasses interventions in addition to classroom instructions that are provided in a small groupthese may take place in a separate locationand the third tier consists of additional support provided to individual children.
The literature indicates a trend towards schoolbased interventions that focus on more than one strategy for enhancing classroom participation [70], focus on the physical as well as the social environment [77] and not only target children that already experience SEN but also proactively target individual children, groups of children and the whole class [77]. In this scoping review, one intervention, P4C [57], stood out, as it integrates intervention features that target both the social and physical environments as well as children on all three levels.
It is interesting to note that this scoping review also revealed a small number of interventions that described a more systemic, holistic approach to serving the needs of more than one individual child. To evaluate their effectiveness on children's participation at school, more focus is needed on exploring the benefits of these systemic, holistic approaches in inclusive education. Future interventions must balance the level at which children should be targeted and address a combination of several target groups; they must also focus on changing and using both the social and physical school environments. A shift from an individual child-focussed approach to an environmentbased approach that targets the participation of all children will have a major impact on the role of teachers as well as classroom setup. In line with our findings, these changes will also have an impact on the education and work of health care professionals who work in the school context. The implication of this for health care professionals is that they are taking on a role as an enabling expert and collaborator rather than just a practitioner who intervenes with those in need of a treatment. In other words, teachers and occupational therapists become partners in codesigning strategies to optimize the school environment. Occupational therapists are experts in enabling participation through analysing the interaction of a child, their occupation and their environment. Therefore, their expertise can provide valuable insight when collaborating with schools to support this transition.

Methodological considerations and limitations
The results of this study may be hampered by some limitations. First, we may have missed studies due to database selection bias. This scoping review focussed solely on elementary students and mainstream education; therefore, studies that evaluated or described school-based interventions that have been implemented in other educational contexts were not considered. Furthermore, there is a minor possibility that some studies were missed, as the search was limited to the database search resultswe did not conduct extensive manual searching. Non-English studies may also have been overlooked as most of the reported studies were conducted in Canada and the US.
The findings of this study might also portray a limited picture of school-based strategies, as most studies were conducted in Western societies such as the United States and Canada. The first (SM) and second (BP) authors have held an interest in school-based occupational therapy for some years, which might have led to the development of preconceived notions that may have influenced the interpretation of the data. However, discussions with the other members of the research team are likely to have reduced this bias.