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Participation of Students With Physical Disabilities in the School Environment

Article  in  The American journal of occupational therapy.: official publication of the American Occupational Therapy Association · May 2009
DOI: 10.5014/ajot.63.3.264 · Source: PubMed

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Participation of Students With Physical Disabilities
in the School Environment

Snaefridur Thora Egilson, Rannveig Traustadottir

KEY WORDS OBJECTIVE. We investigated the factors that facilitate or hinder school participation of students with physical
•  disabled children disabilities and explored the interaction of those factors.
•  education METHOD. The study used a mixed-methods design that used qualitative and quantitative data. Qualitative
•  environment design data were gathered on 49 participants: 14 students, 17 parents, and 18 teachers. Data analysis was based
on grounded-theory procedures. Quantitative data were gathered on 32 students using the School Function
•  socialization
Assessment.
•  task performance and analysis
RESULTS. The characteristics of each school setting influenced students’ participation. Some settings
presented more challenges than others, particularly those with open spaces and limited structures such as the
school playground and field trips. Possibilities of student participation decreased with increasing numbers of
risk factors, but the interaction between factors was equally important.
CONCLUSION. To promote school participation of students with disabilities, occupational therapists should
consider a confluence of child, environmental, and task factors rather than focusing on individual aspects.

Egilson, S. T., & Traustadottir, R. (2009). Participation of students with physical disabilities in the school environment.
American Journal of Occupational Therapy, 63, 264–272.

Snaefridur Thora Egilson, MSc OT, PhD, is
Associate Professor, Faculty of Health Sciences,
Occupational Therapy Program, University of Akureyri,
Akureyri, Iceland; sne@unak.is
Rannveig Traustadottir, PhD, is Professor, Center of
Disability Studies, Faculty of Social Sciences, University of
Iceland, Reykjavik.
264
S
everal studies have revealed that students with physical disabilities often have
difficulties with participation in school activities (Eriksson, Welander, &
Granlund, 2007; Hemmingsson & Borell, 2000, 2002; Mancini, Coster, Trombly,
& Heeren, 2000; Pivik, McComas, & LaFlamme, 2002; Prellwitz & Tamm, 2000;
Schenker, Coster, & Parush, 2005). It is often difficult, however, to establish the
extent to which the challenges that students encounter are related to individual
factors or the inability of the environment to accommodate students’ needs. Several
environmental issues have been found to affect the participation of students with
physical disabilities (Hammal, Jarvis, & Colver, 2004; Hemmingsson & Borell,
2000, 2002; Hemmingsson, Borell, & Gustavsson, 1999, 2003; Law et al., 1999;
Simeonsson, Carlson, Huntington, McMillen, & Brent, 2001). Although inclusion
of students with disabilities has been advocated for years, the construction and archi­
tectural design of most school buildings is still aimed to fit the population of students
without disabilities. Physical barriers most often noted include distances; heavy doors;
steep ramps; and rough surfaces, such as uncut curbs and thresholds (Hemmingsson
& Borell, 2000; Palisano et al., 2003; Tieman, Palisano, Gracely, Rosenbaum, et
al., 2004). Settings characterized by unpredictable movement, speed, and distances
typically create difficulties for students with physical disabilities (Palisano et al.,
2003; Tieman, Palisano, Gracely, & Rosenbaum, 2004). Natural spaces are also a
challenge in areas with uneven terrain and unstable weather conditions.
Despite international agreements on inclusion—such as the Salamanca State­
ment (U.N. Educational, Scientific, and Cultural Organization, 1994), which
May/June 2009, Volume 63, Number 3
highlights the importance of providing education for all
within the regular education system—the main hindrances
to school participation are sometimes found in factors
­connected to rights and government administration.
Organizational issues affecting accessibility, such as failure
to plan or seek advice about access when constructing or
renovating school buildings, reveal the influence that insti­
tutional aspects may have on the physical environment
(Lightfoot, Wright, & Sloper, 1999; Pivik et al., 2002). A
successful inclusive school climate depends on a supportive
school community and efforts by school staff regarding
accommodation and instructional needs (Destefano, Shriner,
& Lloyd, 2001; Flavell, 2001; Pivik et al., 2002). Cultural
and attitudinal barriers may entail a lack of understanding
by teachers and support staff and result in assigning assis­
tance to students instead of adapting or equalizing curricu­
lum or settings (Giangreco & Broer, 2005).
Several attributes of the child also have an impact on
educational participation. These may include physical, cog­
nitive, and communicative skills; emotional, behavioral, and
social function; activity preferences; sense of control; self-
efficacy; and age and gender (King et al., 2003; Law, 2002).
Impairment can restrict activity considerably (Battaglia et
al., 2004; Beckung & Hagberg, 2002; Coster & Haltiwanger,
2004; Mancini & Coster, 2004; Mancini et al., 2000;
Richardson, 2002; Schenker et al., 2005; Simeonsson et al.,
2001). Although a direct correlation between the type and
severity of impairment and the skill a child will demonstrate
cannot be assumed, impairments related to limitations of
movement, sensation, cognition, and pain or fatigue may
bring about challenges that can affect school participation.
Thus, characteristics of the school environment and
the tasks performed in different educational contexts affect
the possibilities of students with disabilities to apply their
skills consistently across school settings. Various attributes
of the child may also influence the extent to which adapta­
tions in the school environment can accommodate his or
her needs. Within occupational therapy it has been recog­
nized that behavior is influenced by and cannot be sepa­
rated from contextual influences. The Person–Environment–
Occupation (PEO) model (Law et al., 1996) reflects the
perspective that problems in occupational performance are
produced in the relationship among people, the environment
in which they live, and the daily tasks that they perform. It
is, however, difficult to find empirical data to describe this
interaction in detail in the literature. A limitation in some of
the research on participation of students with disabilities
concerns a lack of examination of the confluence of factors
that may affect school participation.
The purpose of this study was to explore the participa­
tion of Icelandic students with physical disabilities in main­
The American Journal of Occupational Therapy
streamed schools and, in particular, to identify the major
influences on student participation. The study examined
these concerns by posing the following research question:
How do environment, task, and student characteristics inter­
act to facilitate or hinder school participation?
Method
The study was conducted using a mixed-methods design
incorporating qualitative and quantitative data. The qualita­
tive and quantitative data were collected simultaneously,
although the qualitative inquiry guided the project. The
quantitative data played a supportive role to augment and
provide additional sources of information. This embedded
design provided the study with information from different
types of data and from different levels within the study. The
collection of both descriptive data and numeric information
was an attempt to produce well-validated findings and shed
light on the complexities of the subject under study (Creswell,
2003, 2008; Tashakkori & Teddlie, 1998).
The qualitative inquiry was informed by a grounded
theory approach, in which the analyses of action and process
are completed through the constant comparative method of
inquiry (Bogdan & Biklen, 2003; Strauss & Corbin, 1998).
Qualitative data were collected through participant observa­
tions and semistructured interviews exploring the views and
experiences of students, teachers, and parents. Longitudinal
data were obtained to gain an understanding of variations
over time and across environments. Much of the data, how­
ever, were cross-sectional and focused on a student while at
a certain grade level. The School Function Assessment (SFA;
Coster, Deeney, Haltiwanger, & Haley, 1998) was used to
gather quantitative data on students reflecting the character­
istics of the key participants in the qualitative part of the
study. The instrument provides detailed information that
could not be obtained through interviews or during school
observations. The data collected from the two methods were
compared and contrasted for similarities and differences
during the analysis and interpretation phase. The study was
carried out by Snaefridur Thora Egilson and approved by
the Icelandic National Bioethics Committee.
Qualitative Data
Study Participants. A total of 49 participants were in the
qualitative arm of the study: 14 students with physical dis­
abilities (defined as key participants), 17 parents, and 18
teachers. Participants were recruited from the disability
records of the Icelandic State Diagnostic and Counseling
Center and selected through a purposeful sample designed
to reflect major variations in the student group and the
school environment. The students were 6 to 12 years old,
265
two in each grade from 1 to 7; all had physical impairments Quantitative Data
caused by medical conditions such as cerebral palsy, myelo­
Study Participants. Participants were selected by a pur­
meningocele, or neuromuscular disorders. Children with
posive national sample according to the same criteria as the
co-occurring intellectual disabilities were excluded, but seven
key participants in the qualitative arm. A list of 40 potential
students had secondary impairments such as attention deficit
participants with movement impairments was compiled.
disorders or mild learning impairments or used alternative
The children’s parents were contacted and informed about
communication. The participating children came from 11
the study. Once a parent had signed a consent form, the
schools located in different parts of Iceland. The demo­
child’s teacher was contacted and asked to provide informa­
graphic characteristics of the study participants are summa­
tion about the student by completing the SFA. Thirty-five
rized in Table 1.
SFA forms were returned. Three were excluded because they
Procedure. The parents were contacted by phone and
did not fulfill the criteria on students’ functional character­
informed about the study. When a signed consent form had
istics, leaving 32 forms for analysis, 14 for boys and 18 for
been obtained, the student’s teacher was contacted and
girls (see Table 1). All students had a primary physical
asked to participate. With one exception, all contacted fami­
impairment, and 47% had an additional impairment such
lies agreed to participate. The time to visit each school was
as attention deficit disorder or expressive-language limita­
set in cooperation with parents and teachers. Before inter­
tions; those characteristics are consistent with those of the
views and observations, guides were developed to list issues
students in the qualitative arm. SFA data were obtained on
to be explored and discussed. Participants were asked about
11 of the 14 students in the qualitative component.
a typical school day, how the child was faring at school,
Instrument. The SFA (Coster et al., 1998) is a criterion-
whether or not she or he actively participated in different
referenced instrument designed to measure a student’s par­
school settings, how the school accommodated the child’s
ticipation in and performance of school-related functional
needs, and the communications and relationships between
home and school.
On average, each student was observed for 4 hr in one Table 1. Characteristics of the Participating Students in the Study
session; the focus was on his or her participation in relation
Qualitative Quantitative
to events occurring in the setting, the interaction within peer Sample Sample
groups, and the interaction between students and adults. A (N = 14) (N = 32)
total of 13 school observations were made. Interviews with Fre- Fre-
quency quency
teachers and students took place at school; interviews with n % n %
parents occurred in their homes. The interviews lasted 40 to Gender
80 min and were conducted in a conversational manner,   Boys 9 64 14 44
encouraging respondents to tell their stories in their own   Girls 5 36 18 56
way. Interviews were conducted with 17 parents, 18 teachers, Grade level
  First, second 4 29 11 34
and 9 students. Two children did not want to be inter­
  Third, fourth 4 29 12 38
viewed, and 3 were either considered to be too young or had
  Fifth, sixth, seventh 6 43 9 28
problems with verbal expression. The parents of these chil­ Diagnosis
dren were asked about their child’s perspective on his or her   Cerebral palsy 8 57 16 50
school participation. The School Setting Interview   Myelomeningocele 2 14 6 19
(Hemmingsson, Egilson, Hoffman, & Kielhofner, 2005),   Neuromuscular disorders 3 21 8 25
which considers students’ opportunities for participating in   Musculoskeletal disorder 1 7 2 6
school activities and environments, was used as an interview   Specific learning needs 7 50 15 47
  Alternative communication 2 14 2 6
guide in the student interviews. Questions were occasionally
Student’s primary means of mobility
added to follow up on issues that emerged from participant
  Walks on own 3 22 10 31
observations or interviews with parents or teachers. All inter­   Crutches, cane, or walker 3 22 7 22
views were tape recorded and later transcribed verbatim for   Manual wheelchair 1 7 4 13
analysis. In addition to the formal interviews, informal dis­   Electric wheelchair 1 7 2 6
cussions with students, teachers, and assistants took place   Other (braces, walks with assistance) 3 22 5 16
during fieldwork and were included in the field notes.   Transferred by others 3 22 4 13
Follow-up telephone interviews were conducted with all School location
  Capital area 8 57 19 59
parents 1 year after the initial data gathering to gain a longi­
  Other 6 43 13 41
tudinal perspective.
266 May/June 2009, Volume 63, Number 3
tasks and activities. It was constructed with the needs and
situations of elementary school children in mind and focuses
on areas that typically are challenging for students with
physical disabilities. The instrument is completed by one or
more school professionals who know the students’ everyday
performance on the activities being assessed. The SFA con­
sists of three parts. Part I, Participation, is used to examine
the student’s level of participation in six different school
environments: regular or special education classroom, play­
ground or recess, transportation to and from school, bath­
room and toileting activities, transitions to and from class,
and mealtime or snack time. In each setting, a 6-point rating
scale is used to indicate whether the student’s participation
is similar to that of same-age or -grade peers. Part II, Task
Supports, measures the assistance and adaptations provided
to the student in school-related functional tasks. Part III,
Activity Performance, examines the student’s performance
in common school activities, such as moving around the
classroom, using school materials, and communicating
needs. The SFA yields a comprehensive description of a stu­
dent’s participation, support needs, and functional perfor­
mance in school. It can help identify areas of limitation not
previously recognized, prioritize among areas in need of
program planning, and assist in documenting progress and
the effects of intervention (Coster et al., 1998).
Procedure. Consistent with the standard method of scor­
ing the instrument, the informants (typically classroom
teachers) were asked to follow the written instructions and
use the criteria offered in the SFA Record Form to complete
the assessment. Occasionally, Snaefridur Thora Egilson pro­
vided explanations to ensure that teachers would complete
the forms correctly and within the time frame required.
Mixed-Methods Analysis. Originally, qualitative field notes
and interviews were analyzed separately for each student.
Then categories from students, parents, and teachers were
compared and analyzed separately for each group. The coding
and analysis was conducted in alignment with the grounded
theory method as outlined by Strauss and Corbin (1998). The
analyses consisted of careful line-by-line examination of infor­
mation reported by participants and observations during
school visits. Open coding was used initially to separate data
into categories and to see processes connected to the question
of the study. The open codes were then compared and con­
trasted to detect similarities and differences across cases. Next,
categories were formed, and larger segments of the data were
connected through axial coding. Comparing the data to these
categories helped to refine them and acknowledge their inten­
sity and impact. The recurring categories were continuously
compared with the data to ensure that they were based on the
observations and interviews. In the quantitative arm, the stu­
dents’ raw score totals were used for a descriptive inspection
The American Journal of Occupational Therapy
of the scales. Percentages of ratings at scale values in Part I,
Participation, also were examined to further reflect variations
among Icelandic students.
The information from the qualitative and quantitative
data was then combined to seek convergence among the
results (Creswell, 2003). After examining the information
acquired in terms of competing theories, the adapted PEO
model (Law et al., 1996) was used to provide an analytic
structure for the organization of the findings.
Results
Some contexts within the school environment facilitated
involvement, whereas others were more challenging to chil­
dren with physical disabilities. Changes in participation
occurred as a consequence of the interaction between the
child and the environmental aspects and educational tasks
characterizing each context. The following sections address
these three dimensions in more detail and then focus on their
interaction.
Environmental Characteristics
Various aspects in the natural and constructed school envi­
ronments were essential for student performance. Most
school buildings were only partly accessible to students with
physical disabilities. Distances within school premises com­
plicated the situation, and cluttered hallways and classrooms
were often a challenge. Natural conditions reflecting the
Icelandic climate hampered access to the school playground,
especially during winter, as Egilson witnessed in one school
observation:
The school grounds are covered in snow, but there is
a path made along the building. The other students all
disappear onto the piles of snow, where they play tag and
have snowball fights. Tor manages to push his wheelchair
back and forth along the path while he watches the others
play from a distance. In the end, he looks for one of the
adults on duty and starts chatting with her.
Adaptations of educational tools and assignments
allowed many students to work successfully on school activi­
ties. The use of assistive devices enabled some students to
maintain an adequate posture to promote optimal perfor­
mance, concentration, and endurance within the classroom
and to travel within school. However, lack of time and
knowledge about how to use the devices occasionally resulted
in limited benefit. Although most students had problems
with written work, use of computers was generally limited
and contributed to increased need for adult support.
Some of the hindrances in the physical environment were
related to school traditions and routines, which had an influ­
ence on the organization of operations. When asked why a
267
student with physical impairment was placed in a classroom
on the second floor, one teacher answered, “But third grade
has always been in this classroom.” Design of school schedules
was critical when the child had to transfer between classes and
settings. The mother of one sixth grader said,
There are no breaks in school between classes, so there is
little time to transfer from the second floor to the first.
As a result, he is always the last one out and the last one
into the classes. One needs immense organizational skills
for a child like this.
The extent to which the school administration sup­
ported and advocated inclusive practices was important, but
a lack of distinctive rules and regulations often made the situ­
ation fragile. Some of the solutions used by the school, such
as assigning many assistants to a student to minimize the
burden on staff, were inadequate for the children and their
families. Lack of directives and support from the school
organization often resulted in teachers’ concerns about vast
responsibilities placed on themselves. Several teachers had
difficulties adjusting activities for the child with disability
while attending to other students. The smooth-running
classroom was both the means and the ends for many
teachers.
The teacher played a key role in whether a child was an
active participant in class. Accordingly, change in personnel
often altered the situation considerably, for better or worse.
Despite the teachers’ concerns regarding the practical issues
of inclusion, a majority expressed that the presence of the
child with disability contributed to growth and tolerance
among their peers.
Variation was found in the extent to which a school
environment respected individual needs and allowed for
flexibility and adjustment. Differences between rural and
urban areas were also observed. Smaller communities were
generally more flexible than bigger ones, but limited formali­
ties and lack of professional knowledge complicated matters
in challenging situations and occasionally hampered transfer
of decisions.
In essence, physical accessibility had a major influence
on whether students were able to fully participate in the
school environment. Laws and regulations determined what
resources and services were made available, which in turn
influenced student involvement in different contexts. Each
school’s culture, values, and attitudes influenced methods of
problem solving and how resources were used.
Child Characteristics
The personal and social competencies of each student were
of critical importance for his or her participation in different
contexts. Will, motivation, and capacity and knowledge
about how to perform and interact also affected other factors.
268
These characteristics, together with social skills, problem-
solving skills, and resilience often compensated for physical
limitations. Thus, strengths or weaknesses in specific areas
affected the use of the students’ other capacities. Despite
individual variations, many students in the study demon­
strated strengths in cognitive, social, or behavioral skills.
Impairment effects were also striking, and involvement
in many school activities was complicated by excessive effort,
fatigue, and pain, occasionally leading to disengagement or
withdrawal. Although the type and extent of physical involve­
ment repeatedly led to activity limitations, the data did not
indicate that these aspects had more overall effect on school
participation than did other child attributes. The likelihood
and level of functional problems increased as extent and
severity of motor impairment increased, but capacities such
as will or motivation sometimes outweighed the challenges
students faced because of their disabilities, as Egilson reflected
in one school observation:
The teacher asks Helga and two boys to distribute books.
The boys take a bunch of books, but Helga can only take
three at a time. She presses the books tightly against her
chest with her arms twisted and both wrists tightly bent.
Helga walks around the classroom with extraneous, ran­
dom movements. However, she is quick and concentrates
while the boys drag their feet.
The nature of students’ impairments occasionally
affected the extent to which environmental and task accom­
modations were available, and some impairments caused
restrictions that would remain regardless of arrangements
made. In general, children who had a combination of limited
manipulation skills, lack of verbal expression, and restricted
mobility were least likely to participate in most settings.
Those children who were well adjusted and bright and
who had a cheerful and positive disposition were more often
considered to be full participants by their peers and teachers.
Interestingly, the difficulties faced by these students in par­
ticular settings were sometimes underestimated because of
those same characteristics, as if these happy and well-adjusted
children could not have any problem at all. The finding may
reflect the common practice of perceiving personality char­
acteristics out of context. This study revealed that many child
attributes were of importance only when seen in a specific
context. Hence, capacity was not enough. Without an
opportunity, students’ strengths were of limited value in
ensuring participation. One fifth grader, who used a walker
for travel, participated actively in many settings. Conversely,
on the playground he could not keep up with his peers,
contributing to a monotonous and nonrewarding role. In
the interview he said,
The hardest thing is that I can hardly participate dur­
ing recess. Mostly it is soccer, but the school ground is
May/June 2009, Volume 63, Number 3
 graveled so I can hardly play. And then recess is over.
Sometimes the kids come, and at times there are games
that I can partake in. But that hardly occurs. And when it
is snowing some kids come and play with me; they throw
snow at me and I am supposed to try to escape.
If a child could not physically participate in a particular
setting, strengths such as social skills were often of limited
value. The extent to which each child’s strengths contributed
to increased involvement was situational.
Task Characteristics
The characteristics of distinctive school activities, opportuni­
ties for flexibility of implementation, and modification of
the traditional ways of execution and performance also
affected the students’ participation. As expected, activities
that primarily required motor skills were much more difficult
for students than those that primarily depended on cogni­
tive, social, and behavioral skills. Although the children’s
overall performance varied, relative strengths were found on
several tasks with primarily cognitive and behavioral
demands.
Numerous positive incidents were observed in which
teachers enabled students to participate in educational activi­
ties by modifying either the curriculum or the instructional
methods. However, there appeared to be less flexibility in
adapting the physical aspects of the educational activities
than in accommodating the cognitive and behavioral
demands, to which several teachers responded with flexibility
and ease. Thus it appeared that space and structure of tradi­
tional tools and materials often influenced working proce­
dures by school staff. One teacher provided one of many
similar comments when she said,
There is this discussion about adaptable teaching meth­
ods, but it is a fact that you follow a certain line in
teaching. You cannot have a fleeting schedule in a class
of 20 children if it is to be realistic or significant. There is
always a fixed agenda.
Lack of adaptability and alternative strategies enhanced
reliance on physical capacities by the students in this study.
The academic endeavors were emphasized by school person­
nel, and although students were expected to participate in
traditional educational tasks, they were not always expected
to join in physically challenging activities. Most students
participated actively in the majority of the undertakings in
the classroom but did so much less in settings where physical
space, movement, and speed were in focus, such as during
breaks. Then students were often alone or passively observ­
ing their classmates engaged in play.
Analysis of the SFA activity scale scores revealed more
substantial performance difficulties in some areas for stu­
dents with physical disabilities than in others. Greatest chal­
The American Journal of Occupational Therapy
lenges were observed on the following scales: Up/Down
Stairs, Recreational Movement, Travel, Maintaining and
Changing Positions, Eating and Drinking, and Manipulation
With Movement, all in the physical tasks category. Relative
strengths for these children were found in Functional
Communication, Following Social Conventions, Behavior
Regulation, Memory, and Safety, all in the cognitive–behav­
ioral tasks category. A detailed description of the students’
results on the SFA activity scales is available elsewhere
(Egilson, 2005).
School Setting
Building on the PEO model (Law et al., 1996), the findings
from this study add a new dimension, “school setting,”
which consists of distinct tasks and environmental factors.
Figure 1 illustrates the participation of students with physical
disabilities within typical settings in school. The adapted
model allows for participation and nonparticipation, depend­
ing on the type and strength of relationships between and
within the dimensions. Changes in setting participation
occur as a consequence of interaction between and within
the child and the environmental aspects and educational
tasks characterizing each particular setting.
Most participation occurred during mealtimes, whereas
major challenges were found during recess, field trips, and
transportation. The related subject settings, such as physical
education and swimming, were also a problem for many
students. The lowest SFA participation scores occurred in
playground/recess and transportation, as illustrated in Table
2. A substantial number of students had extensive problems
in these areas, reflected in low mean and median ratings.
Relative strengths were found in mealtime/snack time, and
the standard deviation for mealtime/snack time reflected less
difference in participation than in other school settings.
Participation scores in the classroom were relatively evenly
spread out, indicating variations in performance.
For each child, particular features of the school setting
and individual attributes were essential at a given time,
whereas others were not imperative. Occasionally, the child’s
cognitive, fine motor, and social skills were most important,
typically in the educational activities in the main classroom.
In other instances, positive attitudes of the school organiza­
tion, cooperation between the school and home, and use of
assistive devices were critical in whether students in this
study were able to participate within a setting. Often, par­
ticipation was contingent on adaptations of important school
tasks. If a setting, such as the gym or the playground, was
not physically accessible, the student had limited use of
strengths that were a great asset in other circumstances. Such
instances were repeatedly observed, typically in a challenging
physical environment with limited resources, such as lack of
269
 tion. Setting structures to promote participation were gener­
ally limited or inconsistently applied. Where applied with
success, it was often on an informal or even subconscious
basis, such as when sensitive and engaged teachers used their
tacit practical knowledge to make decisions they could not
articulate. Their knowledge and basis for action, however,
were difficult to relay to other people or situations, contribut­
ing to the instability and fluctuations found in the schools.
Hence, successful participation often happened by chance
rather than by design. The factors that contributed to success
included shared philosophies and goals within school, exten­
sive communication between the school and the family, and
support from administrators and outside agencies.

Figure 1. Model of student participation in various school settings.
Note. From Law, M., Cooper, B., Strong, S., Rigby, P., & Letts, L. (1996).
“The person–environment–occupation model: A transactive approach to
occupational performance,” Canadian Journal of Occupational Therapy, 63,
p. 18. Copyright © 1996 by the CAOT Publications ACE. Adapted
with permission.
guidelines, knowledge, experience, or imagination by staff.
The tasks performed within these settings often required
physical capacities the student did not possess. Lack of
accommodation in the form of an alternative activity,
instructional modification, or different criteria for success
also restricted students. Such situations occurred most nota­
bly in open spaces with limited structures, such as during
breaks and in the gym, although similar instances were
observed in all school settings.
Social expectations on performance, physical features
(e.g., surfaces, distances), and institutional aspects (e.g., time
constraints for practical and educational tasks) influenced
each student’s possibilities for use of his or her capacities.
Similarly, a strict educational structure or lack of expectations
negatively affected a student’s possibilities for active participa­
Discussion
In this study, the students’ participation varied to a large
extent as a function of the characteristics of the child, his or
her educational and social tasks, and environmental contexts
during different time periods. Thus, participation was an
outcome of a complex and changing interaction between the
child and his or her settings. The importance of the various
features for each child commonly evolved over time and
settings, redefining the influences and relationships among
factors. This is consistent with the findings of Eriksson and
colleagues (2007) that school participation differs depending
on occasion and type of activity.
Some settings were typically harder than others for stu­
dents with physical disabilities, and setting structures on
occasion contributed to children’s problems, isolation, and
failure. In general, rigid adherence to traditional curricula
and methods of instruction and lack of accommodations
decreased opportunities for student participation. Contextual
features thus provided an understanding of the differences
between students’ capacities and variations in performance.
Students’ use of distinctive skills, such as their interaction
strategies, appeared to be closely connected to whether or
not necessary opportunities were provided within the school
environment.

Table 2. SFA Participation Scores in Six Different School Settings

Standard % of Ratings at Each Scale Value

Settings Mean Median Deviation 1 2 3 4 5 6
Regular classroom 4.1 4 1.5 6 9 16 28 16 25
Playground/recess 3.4 3.5 1.9 22 22 6 12 16 22
Transportation 3.6 4 1.9 25 6 13 25 3 28
Bathroom/toileting 4.2 4.5 1.9 9 19 6 16 6 44
Transitions 4.5 5 1.4 3 3 22 13 31 28
Mealtime/snack time 4.9 5.5 1.3 0 9.5 0 31 9.5 50
Note. Raw scores are reported. Scale values: 1 = Participation extremely limited, 2 = Participation in a few activities, 3 = Participation in all aspects with constant
supervision, 4 = Participation in all aspects with occasional assistance, 5 = Modified full participation, 6 = Full participation.

270 May/June 2009, Volume 63, Number 3

 The attitudes and abilities of individual teachers to
modify the curriculum and instruction were most important
to whether students were able to participate in settings such
as the general classroom, cafeteria, and gym. Several teachers
reported difficulties in varying from the standard curriculum
and traditional approaches to instruction. This finding is
consistent with research suggesting that the average teacher
feels unprepared to serve students with disabilities, has little
time available to collaborate with others, and makes few
accommodations for students with special needs (Burstein,
Sears, Wilcoxen, Cabello, & Spagna, 2004; Pivik et al.,
2002). Similar to the findings of Hemmingsson, Gustavsson,
and Townsend (2007), many teachers in this study appeared
to interpret participation in school as taking part in the col­
lective activities in the classroom, whereas students and par­
ents stressed the social aspect of participation in various
school settings.
In promoting the participation of students with physical
disabilities in schools, occupational therapists need to focus
extensively on the child in his or her setting. The challenge
with the PEO model, originally presented by Law et al.
(1996) and adapted by the findings of this study to include
the concept of setting, relates to its use in practice. If every­
thing is potentially relevant to the understanding of students’
participation, then where does one begin to focus attention?
For practical purposes, it is generally easier to alter either the
environment or the task than the child, because the majority
of this particular group of students had disabling conditions
that were not amenable to considerable change. In addition
to highlighting opportunities that already exist within the
school setting, occupational therapists should closely study
and emphasize setting characteristics for necessary adjust­
ments. Delineation of a child’s strengths and abilities must
also be stressed to enable identification of helpful strategies
for the child to facilitate participation. The findings signify
that occupational therapists must align with important stake­
holders, such as parents and the educational system, to facili­
tate increased participation outcomes for children with dis­
abilities in school as well as in other areas of their lives.
Study Strengths and Limitations
Although the study participants were selected for their rep­
resentativeness in terms of age, grade, school location, and
impairments, the sample size was small and each child was
unique. The findings pertain to the Icelandic context; nev­
ertheless, the rich descriptions provide support of study
transfer to other contexts. The literature clearly suggests that
many of the aspects may be of relevance in other countries
working toward the inclusion of students with disabilities.
Commonalities were found with recent studies (Coster &
The American Journal of Occupational Therapy
Haltiwanger, 2004; Eriksson & Granlund, 2004a, 2004b;
Eriksson et al., 2007; Hemmingsson & Borell, 2002; Mancini
& Coster, 2004; Schenker et al., 2005, Schenker, Coster, &
Parush, 2006). Many studies in the area focus only on a few
aspects or use one frame of reference. Although the results
cannot be generalized, this mixed-methods study adds to the
literature by making visible the interaction of child, environ­
mental, and task factors that affect participation of students
with physical disabilities. In future studies, it would be impor­
tant to further examine the confluence of factors that are most
important for high degrees of participation and the effect of
environmental and task modifications in promoting school
participation of students with disabilities.  s
Acknowledgments
This article was based on an unpublished PhD dissertation
study by Snaefridur Thora Egilson (2005). We gratefully
acknowledge the comments of Jon Torfi Jonasson, Ingvar
Sigurgeirsson, Wendy Coster, and Michael Giangreco on
the dissertation study. The study was supported by a grant
from the University of Akureyri Research Fund.
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