Participation Patterns of Israeli Children with and without Autism, and the Impact of Environment

Abstract

Aims

Participation is vital to children’s quality of life, yet it is often limited for those with autism spectrum disorder (ASD). An improved understanding of the factors that may support or hinder their participation is important. This study aims to explore the participation patterns of children with and without ASD in the home, school, and community settings, as well as to explore the impact of environmental factors on the participation of children with ASD.

Methods

78 parents of children aged 6–12, attending mainstream educational settings (30 with ASD; 48 without ASD) completed the Participation and Environment Measure for Children and Youth and a demographic questionnaire.

Results

Children with ASD were rated significantly lower than children without ASD in participation, and their parents expressed a greater desire to change their participation while reporting lower overall environmental support. Among the ASD group, significant differences in participation were found across the three settings, with the highest participation scores at home. Environmental factors that support or limit children’s participation were identified.

Conclusions

The results highlight the importance of environmental factors in children’s participation. It is essential to evaluate different environmental settings; identifying the supportive and limiting environmental factors will enhance interventions for children with ASD.

Keywords:

• Autism
• children
• environment
• involvement
• participation frequency

The International Classification of Functioning, Disability and Health for Children and Youth (ICF-CY; WHO, 2007) defines participation as “involvement in a life situation.” This represents involvement in many areas, including learning, communication, and self-care activities (Chien et al., 2014). Participation is recognized as a significant factor affecting health, well-being, and overall quality of life (Law, 2002). Participation is important for children’s development (Dahan-Oliel et al., 2012) in motor, cognitive, and communication skills; relationships with others; and adaptive behaviors (Anaby et al., 2014; Askari et al., 2015). Participation has been conceptualized as a multidimensional action includes the dimensions of frequency and involvement. Participation “frequency” is regarded as an objective, measurable aspect (the number of times), while “involvement” is a qualitative description of personal feelings during participation, including motivation, adherence, satisfaction, and emotional engagement (Granlund, 2013; Imms et al., 2017).

Children’s participation involves engagement in formal activities with structure, rules, and clear goals, during school and extra-curricular programs; and in informal self-initiated activities, alone or with family and friends (Anaby et al., 2012; Rosenberg et al., 2011). Simpson et al. (2018) indicated that the prevailing assumption—that frequent participation among children is preferable—does not distinguish between its positive and negative effects on the children, or examine whether children desire to change their participation in certain activities.

Children’s participation is influenced by health status, personal factors (e.g. age and sex), and environment (Chien et al., 2014; Yee et al., 2017). Participation in diverse environments is vital to a child’s development and well-being (Askari et al., 2015). Rosenberg et al. (2011) found that while personal factors affect the children’s range of activities, environmental factors (home, family habits, and routines) affect their participation frequency.

Children with disabilities who participate in activities can learn new skills, develop playing skills, and create social connections that may increase their satisfaction in life (Di Marino et al., 2018). Studies have indicated lower participation frequency among children with disabilities, compared to typically developing (TD) children (Bedell et al., 2013). Although the limited participation of children with disabilities is often attributed to their medical diagnosis, environmental factors should also be considered. The environment creates opportunities or barriers that can allow or limit participation, affecting both the frequency and involvement of children in activities (Anaby et al., 2014; Pfeiffer et al., 2017). Parents of children with disabilities, such as autism spectrum disorder (ASD), report that the environment often limits their children’s participation, due to a lack of accessibility to buildings, services not tailored to their needs, and social prejudice (Egilson et al., 2017). Children with disabilities often rely on parental support in participation. For example, parental and family involvement was found to allow greater participation of children with acquired brain injury, especially in organized activities (Anaby et al., 2012). Killeen et al. (2019) found that supportive strategies used by parents of youth with disabilities featured collaboration, advocacy, and other involvement in the school setting. The strategies used by parents to support younger children’s participation should likewise be examined.

ASD is one of the most prevalent childhood conditions extending into adulthood, characterized by impaired communication and social interaction, repetitive and stereotypical behavior, and limited interests not explained by intellectual factors (Mukherjee, 2017). The disorder has a wide, heterogeneous range of disabilities. According to the Diagnostic and Statistical Manual of Mental Disorders (DSM-5; APA, 2013), there are three degrees of support required: Level 1, “assistance required”; Level 2, “extensive assistance required”; and Level 3, “very extensive assistance required” (Mazurek et al., 2019). Children and adolescents with ASD report lower participation in activities, compared to their TD peers (Askari et al., 2015; Little et al., 2015), reflected in lower participation frequency, less involvement, and parental dissatisfaction with their children’s participation in community activities (Egilson et al., 2017). Specific factors associated with core ASD symptoms, such as difficulty in social communication and interpersonal relationships, often result in less participation in activities involving social interaction, and a preference for activities performed alone or with adults (Askari et al., 2015; Egilson et al., 2018; Werkman et al., 2020).

The environment heavily influences the participation of children and adolescents with ASD. Supportive or restrictive factors can include sensory aspects (e.g. noise and lighting), physical space, cognitive and social demands, and the availability of supporting resources (Egilson et al., 2018; Krieger et al., 2018). Piller et al. (2017) noted that the response to various sensory stimuli in the school setting directly affects these children’s participation in daily activities. Egilson et al. (2018) found that cognitive, social, and physical activity demands, along with peer relationships, were greater barriers to community-based participation of children with ASD than to TD children. Similar findings were reported for home settings (Egilson et al., 2017). While participation frequency was lower in the community than at home, parental desire for change at home was reportedly higher than for the community (Egilson et al., 2018).

Although the participation behavior of children with ASD is distinct and varied, most studies have focused on children with lower support needs (Egilson et al., 2018; Lamash et al., 2020). Only a few compared the participation of children with different levels of support needs, and/or identified the environmental supports required for their participation. Most studies assessed participation only in the home/community (Egilson et al., 2017, 2018), or omitted comparisons with peers (Simpson et al., 2018, 2019), or studied preschool children only (Avrech-Bar et al., 2016; Khalifa et al., 2020). Others focused on specific environmental aspects and not on general participation (Pfeiffer et al., 2017; Piller et al., 2017). Assessing the participation of children with ASD should include the opportunities made possible by a specific context, in a variety of daily-life situations (Lami et al., 2018; Piller et al., 2017; Yee et al., 2017).

School is a significant environment in children’s lives. Israel’s educational policy offers children with ASD the option to either integrate in a mainstream (inclusive) education setting or attend a non-inclusive special educational setting (Golos et al., 2022). Our study aimed to explore the participation patterns of children aged 6–12 with ASD across the range of support required, who attended special classes in the mainstream educational setting; compared with peers without ASD across three environmental settings: home, school, and community.

Our objectives were to: (a) compare the participation characteristics and environmental factors that support or limit children with and without ASD; (b) explore and contrast the participation frequency, involvement, and desire for change among children with ASD in all three settings; and (c) explore the environmental factors that support and limit the participation of children with ASD, along with the main strategies used by parents to promote their children’s participation.

Methods

Study Design

A quantitative descriptive and comparative (case-controlled) cross-sectional design was used, along with qualitative descriptive information, which was used to better understand parental participation support strategies.

Participants

Parents of 78 children (aged 6–12) were recruited using a convenience sample: 30 children with ASD, attending special classes in mainstream educational settings; and 48 children without ASD, attending mainstream educational settings.

Inclusion in the ASD group required a diagnosis of ASD by a qualified professional (psychiatric or developmental physician) based on the DSM-5 criteria (APA, 2013). Children attending exclusively special educational settings (e.g. not specialized classrooms within a mainstream school) were excluded, since they may receive different supports. In the group without ASD, exclusion criteria included a diagnosis of neurodevelopmental disabilities by a qualified medical professional. For both groups, exclusion criteria were a diagnosis of Tourette syndrome, epilepsy, cerebral palsy, brain injury, psychiatric disorder, and/or intellectual disability, and autism for the non-ASD group.

In the ASD group (see Table 1), most children were boys (86.7%), similar to the literature on ASD (Mukherjee, 2017). Most children (over 60%) were described as having social, emotional, and behavioral difficulties requiring Level 2 assistance. Of the children without ASD, 66.7% were boys. A few children without ASD (2.0–6.2%) were described by parents as having difficulties in attention, learning, speech, and/or communication. In both groups, most parents (over 70%) were married, with professional or academic education, family income was average or higher, and they all resided in different regions of Israel. No significant differences (p > .05) were found between groups in age (t₍₇₆₎ = 0.74), family education, or family income (χ²₍₁₎ = 0.47), with borderline differences (p = 0.05) in sex (χ²₍₁₎ = 3.87).

Table 1. Demographic characteristics of the participants.

		Children with ASD		Children without ASD
		n	Mean (SD)	n	Mean (SD)
Child’s age		30	8.95 (1.96)	48	8.61 (2.01)
		n	%	n	%
Child’s sex	Boys	26	86.7	32	66.7
	Girls	4	13.3	16	33.3
ASD support required	Level 1	5	16.7	----	----
	Level 2	18	60.0	----	----
	Level 3	7	23.3	----	----
Child’s difficulties	Attention	11	36.6	2	4.17
	Learning	8	26.6	1	2.0
	Speech and communication	13	43.3	3	6.2
	Motor	6	20	----	----
	sensory	11	36.6	----	----
	Emotional and behavioral	18	60	----	----
	Social	19	63.3	----	----
Parents’ marital status	married	21	70.0	43	89.6
	Divorced/single parents	9	30.0	5	10.4
Family income	Below average	4	13.3	0	0
	Average	14	46.7	25	52.1
	Above average	12	40.0	23	47.9
Father’s education	high school education	2	6.7	2	4.2
	Professional education	6	26.7	1	2.1
	Academic education	22	73.3	45	93.7
Mother’s education	high school education	3	10.0	4	8.3
	Professional education	8	26.7	2	4.2
	Academic education	19	63.3	42	87.5

ASD support required determined by the support needed for functioning and adaptation as reported, according to the definition of the qualified professional based on the DSM-5: Level 1 – “assistance required”, Level 2 – “extensive assistance required”, Level 3 – “very extensive assistance required”; Child’s main difficulties as reported by parents.

Measures

Demographic Questionnaire

The questionnaire developed for this study enabled parents to provide demographic information: the child’s age, sex, specific difficulties, ASD support required, parents’ education, and family income.

Participation and Environment Measure for Children and Youth (PEM-CY; Coster et al., 2010)

The PEM-CY is a parent-report instrument assessing the participation of schoolchildren aged 5–17 years across three settings, along with environmental factors affecting their participation. The PEM-CY categories represent broad types of activities typically performed in each setting: home (10 activities), school (5 activities), and community (10 activities). For each activity type, the parents rate: (a) how frequently their child participates (“never” = 0; “daily” = 7); (b) how involved their child is while participating (“minimally” = 1; “very” = 5); and (c) whether they desire change in their child’s participation (“no” or “yes”). If “yes,” parents identify the type of change desired (“frequency,” “involvement,” and/or “variety”). Parents are then asked whether certain environmental features help or hinder their child’s participation in activities (“not an issue,” “usually helps,” “sometimes helps/makes harder,” “usually makes harder”). They also report perceived adequacy/availability of supporting resources (“not needed,” “usually yes,” “sometimes yes/no,” “usually no”). Qualitative information is likewise collected about parental strategies (up to 3 strategies in each setting) used to promote their child’s successful participation in activities. The PEM-CY was found to have moderate-to-good internal consistency (Cronbach’s = 0.59–0.83) in the participation scales. Its test–retest reliability was found to be moderate at school (r = 0.58), high at home (r = 0.84), and high in the community (r = 0.79). High reliability was found in the environment scale (r > 0.76). This measure identifies significant differences in participation patterns and environmental factors between children with and without disabilities (Coster et al., 2011), supporting its construct validity. The Hebrew version of the PEM-CY, effectively used in Israel, was employed in this study.

Procedure

The study was approved by the University Ethics Committee (No.2703-2018), and the Ministry of Education (No.10105). The research team approached school principals and staff in different educational settings (including schools with special classes for children with ASD) in different regions and explained the research. Collaborating school principals and teachers sent information letters to the parents of both groups. Parents interested in participating in the study contacted the researcher and screening was performed based on the exclusion/inclusion criteria. After written and oral explanations, parents’ consent was obtained, and they completed the questionnaires manually or electronically via email. The data were collected without identifying details.

Data Analysis

Statistical analysis was performed using SPSS version 26.0 (IBM Corp, 2016). Descriptive statistics were used to describe the study population, data distribution, and environmental factors, together with the percentage of parents reporting each item as either supporting or limiting their child’s participation. Parametric statistics were used when assumptions of normality were met, and nonparametric statistics were used when these were violated. Differences between the groups in sex and family income were examined using the chi-squared test for independence, and an independent-sample t-test was used for the age variable. To compare the scores of the three levels of required assistance among the ASD group, a one-way MANOVA was used. A significance level of 0.05 was used.

For each setting, the participation patterns were measured using mean variables. Parental desire for change in their child’s participation was measured as the percent of activities for which the parents indicated that desire. Following the PEM-CY guidelines, a score was calculated for “overall environmental support” in each setting separately, and all environment-related questions were recoded into 3-point scales by merging “not an issue/not needed” with “usually helps/usually yes.” The total for all environment ratings was divided by the maximum possible score within a setting, and multiplied by 100. Higher scores indicated more support for children’s participation or more availability of supporting resources.

To compare frequency, involvement, desire for change, and overall environmental support between the groups, a one-way MANOVA was used. Effect-size calculation was conducted using eta squared: η² > 0.14 = large effect, 0.06 < η² < 0.13 = medium, and 0.01 < η² < 0.05 = small (Stevens, 2002). As no significant relationship was found between the demographic variables and participation patterns, they were not considered mediating variables.

To compare supporting/limiting environmental factors between the groups, a Mann-Whitney test was used. Dichotomous variables were assigned to the supporting factors (1 = usually helpful/usually yes, 0 = other answers) and the limiting factors (1 = usually limiting/usually no, 0 = other answers); the average and median scores were then calculated for each participant. The effect size was also calculated using partial eta squared.

To investigate specific participation patterns of children with ASD, one-way ANOVA for repeated measures and post-hoc tests with Bonferroni correction were used to examine the differences in mean scores of frequency and involvement across the three settings. The effect size was also calculated using partial eta squared.

The initial qualitative information provided by the parents of children with ASD, concerning strategies for supporting their child’s participation, was analyzed by the principles of content analysis using the inductive approach (Hsieh & Shannon 2005; Vaismoradi et al., 2016). This is a process of describing qualitative data that results in clusters of responses; it involves establishing categories that refer to the manifested content. In order to identify parents’ main strategies, their written responses were gathered and organized. Then a list of codes and categories emerged and were discussed. Data triangulation was performed by the research team, one of whom was an occupational therapist with expertise in ASD populations; the others had expertise in participation. Following agreement among the research team, the five main categories were formulated, and sample quotes were selected. This process enhanced the credibility of the findings.

Results

Comparison between Groups: Participation Patterns

The differences in participation patterns and desire for change between the groups in the combined dependent variables were statistically significant, with large effect sizes for participation frequency (F_(3,72 = 11.80, p < .001; η² = 0.33) and involvement (F_(3,72) = 25.09, p < .001; η² = 0.51). Follow-up univariate ANOVAs showed significant differences, with medium-to-large effect sizes in frequency and involvement in all three settings (see Table 2). The ASD group was found to participate less frequently and was less involved in all settings, compared to the non-ASD group.

Table 2. Comparison of participation patterns (frequency, involvement), desire for change and overall environmental support in the different settings between the two groups.

		Children with ASD (n = 30)	Children without ASD (n = 45–47)
Measure	Setting	Mean (SD)	Mean (SD)	F(1,74)	η²
Frequency (8-point scale)	Home	5.05 (.91)	5.98 (.53)	32.06***	0.30
	School	3.56 (1.32)	4.46 (1.02)	8.80**	0.11
	Community	2.51 (1.16)	3.50 (.89)	17.44***	0.19
Involvement (5-point scale)	Home	3.47 (.58)	4.26 (.34)	53.91***	0.42
	School	3.43 (.79)	4.34 (.59)	33.50***	0.31
	Community	3.38 (.83)	4.20 (.61)	26.39***	0.26
		Percentage (SD)	Percentage (SD)	F(1,75)	η²
Desire for change	Home	82 (17.50)	49.86 (24.90)	37.94***	0.34
	School	75.33 (28.13)	32.41 (31.15)	37.44***	0.33
	Community	64.10 (28.50)	27.87 (23.14)	37.42***	0.33
		Mean (SD)	Mean (SD)	F(1,73)	η²
Overall environmental support	Home	82.41 (11.86)	90.74 (11.98)	8.78**	0.11
	School	80.72 (12.32)	92.81 (9.17)	23.73***	0.25
	Community	78.33 (13.96)	91.35 (11.31)	19.44***	0.21

**p < .01, ***p < .001.

The combined dependent variable of the desire for change significantly differed between the groups (F_(3,73) = 252.65, p < .001, η² = 0.91). In follow-up univariate ANOVAs, significant differences were found, with large effect sizes in all three settings, indicating that the parents in the ASD group were more interested in overall change than were the parents in the non-ASD group.

A significant difference between groups was found in overall environmental support for the three settings (F_(3,71) = 9.67, p < .001, η² = 0.29), and also in each setting, with medium-to-large effects sizes. The ASD group reported lower overall environmental support, indicating that either the environmental factors were less supportive of participation by children with ASD, or the existing support was less available when needed.

Comparison between Groups: Supporting or Limiting Environmental Factors

As seen in Table 3, children with ASD scored significantly higher than children without ASD in reported limiting environmental factors in each setting, with moderate-to-large effect sizes (p < .05; η² = 0.08–0.14). Children with ASD also scored higher than children without ASD in overall supporting environmental factors, but no significant differences (p > .05) were found between groups in each setting.

Table 3. Comparison of environmental factors that support or limit participation between the two groups.

		Children with ASD (n = 30)		Children without ASD (n = 46–48)
		Mean (SD)	Median	Mean (SD)	Median	z	η²
Limiting environmental factors	Home	0.13 (0.19)	0.08	0.04 (0.10)	0.00	−2.83*	0.08
	School	0.15 (0.17)	0.11	0.04 (0.08)	0.00	−3.42***	0.13
	Community	0.17 (0.17)	0.12	0.07 (0.13)	0.00	−3.49***	0.14
Supporting environmental factors	Home	0.36 (0.20)	0.33	0.29 (0.19)	0.25	−1.48	0.03
	School	0.40 (0.21)	0.41	0.32 (0.19)	0.35	−1.51	0.03
	Community	0.33 (0.17)	0.25	0.29 (0.21)	0.25	−0.89	0.01

*p < .05, ***p < .001.

Children with ASD: Participation Patterns and Desire for Change

Among the ASD group, no significant differences were found in the three levels of required support relating to the frequency of participation, involvement, desire for change, or overall environmental support (F_(6,50) = 0.39, 2.11, 1.01, 0.99; p > .05, respectively). The results of examining the differences in participation patterns (frequency, involvement) and desire for change among children with ASD across the home, school, and community settings showed that the frequency of participation significantly changed with the setting (F_(2,58) = 72.40, p < .001, η² = 0.71). Pairwise comparisons with Bonferroni correction showed that all three settings significantly differed from one another (p < .001). The frequency of participation was highest at home (M = 5.05, SD = 0.91), followed by school, and then the community (School: M = 3.56, SD = 1.32, Community: M = 2.51, SD = 1.16). Involvement did not significantly change with the setting (F_(2,58) = 0.15, p > .05, η² = 0.005). Again, involvement was highest at home (M = 3.47, SD = 0.58), next-highest in school, and lowest in the community (School: M = 3.43, SD = 0.79, Community: M = 3.38, SD = 0.83); but these differences were not significant. The desire for change changed significantly with the setting (F_(2,58) = 6.29, p < .01, η² = 0.18). Pairwise comparisons with Bonferroni correction showed that the desire for change was once again highest at home (M = 82, SD = 17.50), followed by the school (M = 75.33, SD = 28.13), and then the community (M = 64.10, SD = 28.50). However, significant differences were found only between home and community (p < .05); with close-to-significant differences (p = .05) between school and community.

Children with ASD: Supporting and Limiting Environmental Factors

The environmental factors that support or limit the participation of children with ASD in each setting were represented by a higher percentage of supporting (or limiting) environmental factors indicated by more parents who believed that the item in question supports (or hinders) their child’s participation. As seen in Table 4, the most supportive factors in the home setting (53–70%) were “money,” “supplies,” “other people’s attitudes,” and “time”; followed by “relationships with family members,” “information,” and “adequate services within the home” (40–46%). Regarding barriers at home, “cognitive demands,” followed by “social demands,” were the most commonly reported inhibitors (30–40%). In the school setting, “personal transportation,” “money,” “supplies,” “time,” “attitudes of educational staff,” “information,” “school policies and procedures,” and “programs and services” were the most reported supportive factors (41–76%). “Cognitive demands” and sensory qualities” were reportedly the most common inhibitors (46–48%), followed by “physical and social demands” (23–26%). In the community setting, “money,” “personal transportation,” “information,” “time,” and “supplies” were the most reported supportive factors (55–75%); followed by “programs and services” and “other people’s attitudes and actions” (40–41%). “Sensory qualities” was the most commonly reported inhibiting factor (46%), followed by “social demands,” “relationships with peers,” and “cognitive and physical demands” (23–36%).

Table 4. Percentage of environmental factors reported by parents as supports and inhibits the participation of children with ASD in all settings.

Item	Home (%)		School (%)		Community (%)
	Supports	Inhibits	Supports	Inhibitors	Supports	Inhibitors
Physical layout	13.3	3.3	26.7	0.0	16.7	16.7
Sensory qualities	16.7	10.0	6.7	46.7	6.7	46.7
Physical demands	10	16.7	6.7	26.7	10	23.3
Cognitive demands	10	40.0	13.8	48.3	13.3	33.3
Social demands	16.7	30.0	13.3	23.3	10	36.7
Relationships	46.7	13.3	33.3	13.3	16.7	36.7
Attitudes of others	55.2	3.4	66.7	6.7	40	10.0
Adequate services	40	13.3
Supplies	63.3	6.7	70	6.7	55.2	10.3
Safety			40	3.3	16.7	6.7
Information	44.8	13.8	60	6.7	62.1	6.9
Personal transportation			76.7	6.7	72.4	3.4
Public transportation			26.7	6.7	34.5	0.0
Time	53.3	6.7	70	13.3	57.1	7.1
Money	70	0.0	73.3	3.3	75.9	3.4
School policies and procedures			53.3	16.7
Programs and services			41.4	17.2	41.4	13.8
Weather			6.7	20.0	7.1	10.7

Relationships – Home: Relationships with family members; School and Community: Relationships with peers;

Attitudes – Home: Attitudes of others and professionals; School: Attitudes of educational staff; Community: Attitudes and actions of others.

Children with ASD: Strategies to Promote Participation

Qualitative information was collected from the responses of the parents of children with ASD to the open-ended question, which related to the strategies they used to promote their children’s successful participation in activities. As seen in Table 5, five main categories were identified from 105 supporting strategies. The first category was planning and maintaining a regular daily schedule; parents noted that maintaining a daily schedule of habits and routines helped to promote the participation of their children at home. The second category was providing reinforcement and support; parents noted that when they provided mediation, guidance, and positive feedback, their children participated better in daily activities. The third category was encouraging activities that include social interactions; parents encouraged and initiated the participation of their children in social activities with others. The fourth category was adapting the sensory environment; parents reported that using appropriate levels of sensory stimuli adapted to their children’s needs promoted their participation. The last category was communication with educators and professionals; continuous exchange of information with school staff to promote children’s participation.

Table 5. Categories and example of strategies to promote participation of children with ASD by parent’s report.

Category	Explanation	Examples
(a) Planning and maintaining a regular daily schedule	Maintaining a well-known daily schedule of habits and routines, with appropriate preparation for activities, helped promote the children’s home participation	“We maintain regular habits, such as a family dinner every Friday or a shopping list at the supermarket”; “We prepare for school activities so that the child knows in advance what to expect.”
(b) Providing reinforcement and support	Children participated better in activities when they were provided with mediation, guidance, and positive feedback (encouragement and reinforcement of success).	“We give him clear and concise instructions, and reinforce him when he is functioning well and remembering to do things on his own”; “We mediate the incident for our child, and we are with him if he needs us.”
(c) Encouraging activities that include social interactions	Parental initiation and encouragement helped the child to participate in varied activities with others.	“If there is an appropriate activity, we take him along with all his siblings”; “We encourage him to attend classes such as art, basketball, and bicycling along with his peers.”
(d) Adapting the sensory environment.	An appropriate level of sensory stimuli was reported as more inviting to promote child participation	“We walk outside in the evening when the light is not too strong”; “We try to get to school early when it is not yet crowded with children.”
(e) Communication with educators and professionals	Maintaining continuous communication with school staff (educators and professionals), and sharing information, promoted child participation	“I am in contact with the teacher regarding difficulties in the child’s school and providing appropriate support”; “We attend all parent-teacher meetings and other meetings with the educational staff.”

Discussion

This study explored the environmental factors influencing participation patterns among children with ASD aged 6–12 attending special classes in the mainstream educational setting, compared to their peers, across three different environmental settings. We also explored the specific environmental factors that supported or inhibited participation among children with ASD, as well as support strategies identified as useful by their parents.

Participation of Children with and without ASD

Comparison between the groups indicated significant differences in participation patterns in all three settings. Children with ASD were rated significantly lower than children without ASD in frequency and involvement; and parents of children with ASD expressed greater desire to change their participation. These findings support previous studies also indicating that children with ASD participate to a limited extent in social and leisure activities, and in unstructured play (Ratcliff et al., 2018). Lamash et al. (2020) studied adolescents aged 11–19 with and without ASD, and found no significant differences between groups in participation at home; but they did find lower participation levels among the ASD group in some school and community activities. These findings, which differed from ours, may be explained by the differences in the study populations. Ours included younger children with ASD at varied levels of support needs, with most requiring extensive assistance (Level 2) but not significantly differing from other levels in participation. Lamash et al. (2020) studied adolescents, all identified with lower support needs (Level 1) but at an age when social interaction outside the home becomes more challenging.

It is not surprising that low participation of children with ASD prompted their parents to express a greater desire for change in all three settings, compared to parents of children without ASD. However, the wide distribution of desire for change in both groups may indicate great variability. This emphasizes the need to examine each child’s personal participation profile along with the parental desire for change.

Among children with ASD, all results indicated differences between environments. The frequency of participation and desire for change were higher at home than in school and the community. A possible explanation for these findings was given by Simpson et al. (2018), whose study indicated that the high participation frequency in-home activities among children with ASD includes video screen-watching. Additionally, a high desire for change in home activities may be explained by high parental involvement there, compared to other settings (Egilson et al., 2018). Our findings also indicated that even when children frequently participate in activities, parents may desire to change the specific activities. The finding of lower community participation frequency supports other studies indicating limited participation of children with ASD in extracurricular and school activities, especially leisure activities with social components. These findings may reflect the preference of children with ASD to stay near home, and play alone or with their parents (Askari et al., 2015; Khalifa et al., 2020).

The involvement of children with ASD was not significantly different among the three settings. This finding may reflect the difference between reporting frequency and involvement (Granlund, 2013; Imms et al., 2017). Parents may find it easier to report quantitative frequency, compared to qualitative involvement. Likewise, participation differences among settings may be more noticeable with frequency than with involvement. Additionally, children with ASD may need more support, compared to children without ASD, in order to be involved in different settings.

Environmental Factors Supporting or Limiting Participation

A significant difference between groups emerged in overall environmental support, with medium-to-large effect sizes in all three settings. The overall environmental support reported by the ASD group was lower than that of the non-ASD group, indicating that environmental factors in general were less supportive of the participation of children with ASD, or the supports were less available. Parents of children with ASD reported environmental factors as significantly more limiting, compared to children without ASD; whereas the supporting environmental factors were not significantly different between the groups. These findings support other studies suggesting that environmental factors can directly impact participation among the ASD population (Krieger et al., 2018; Simpson et al., 2018). However, the few studies focusing on home and community indicated environmental support differences in those settings between children with and without ASD (Egilson et al., 2017, 2018).

Possible explanations for our different findings can include the differences in study designs, sample sizes, and needed levels of environmental support. In our study, the sample was smaller, with varying levels of support needs, but mostly children at Level 2. Previous studies included only Level-1 children, who presumably faced fewer limiting environmental factors than the children in our study. This explanation is supported by Anaby et al. (2014), who also found that limiting factors have a greater impact on participation by children with greater numbers of functional challenges.

Regarding the environmental factors that impact participation in all settings, two main limiting factors were reported by many parents of children with ASD: social and cognitive activity demands. The social factor was not surprising, since the core symptoms of ASD include social and communication difficulties, resulting in avoidance of activities involving social interaction and a preference for activities alone or with adults (Askari et al., 2015; Egilson et al., 2018). The report of cognitive demands as another limiting factor supports other studies highlighting the everyday cognitive difficulties even among children with lower support needs (Egilson et al., 2017, 2018; Lamash et al., 2020). This finding was consistent with parents’ reports of specific attention and learning difficulties. Additionally, parents described strategies to promote their children’s participation which involved cognitive aspects, such as planning and maintaining a regular daily schedule. Clinical observations are needed to examine how the cognitive and social activity demands on children with ASD might be modified in various settings.

Another environmental factor that many parents reported as limiting participation was sensory intensity. The sensory domain is addressed in the DSM-V when discussing the ASD population (APA, 2013). Sensory processing often impairs the functioning and social participation of individuals with ASD (McCormick et al., 2016; Werkman et al., 2020). Our findings support previous studies, including Bagby et al. (2012), who described how sensory aspects of the environment (volume, touch, lighting, and crowding) impact indoor and outdoor participation among children with ASD. Others noted the effect of sensory environments on children’s participation in the community and home (Pfeiffer et al., 2017, 2019). In our study, sensory stimuli were reported as barriers to participation primarily in the school and community, and less at home. This might be explained by parental awareness of their child’s sensory difficulties, resulting in efforts to adapt the home setting to the child’s needs (Egilson et al., 2018; Khalifa et al., 2020). Further support is found in our parents reporting strategies to promote participation by ensuring appropriate sensory levels at home. The fact that community and school settings were reportedly less supportive of their children may be explained by our study’s focus on children attending special classes designed for them within the mainstream educational setting. This inclusive arrangement is integrated with the general school environment, which is not adapted to the needs of children with ASD.

Regarding supporting environmental factors, the literature reports that parents of children with disabilities have more difficulty identifying supporting factors than limiting factors (Anaby et al., 2014; Bedell et al., 2013). In our study, certain environmental factors were seen by parents as supporting their child’s participation in all three settings: money, time, equipment, other people’s attitudes, and information. Our findings support other studies indicating that these factors encourage children’s participation and improve their functioning (Khalifa et al., 2020; Lamash et al., 2020). Additional factors (appropriate programs and services, and use of personal transportation) were also seen as supports in the school and community. Parents generally expressed support for adapted programs and services in the school and community, indicating that parental partnership with educational and therapeutic staff promoted children’s successful participation.

In social relationships, many parents reported that family members were supporting factors in the child’s participation at home. However, relationships with peers were a weaker supporting factor in school and a limiting factor in the community setting. Parents who described support strategies included the need to encourage the child to participate in varied activities with others. Given that children with ASD have more difficulty with communication skills, the varied influence of relationships in different settings can be explained by the specific partners. Individuals who can meet the needs of the child with ASD can assist in participation. This is supported by a study that examined interpersonal play among children with ASD and found that playmates had a positive effect on children’s performance (Vousden et al., 2019).

In the home and school settings, relationships with encouraging family members and educational staff can promote participation. Parental strategies to promote participation included collaboration with caregivers and educators to support the child together, as well as parental mediation and emotional support. Other studies indicating the value of social support for this population include Avrech-Bar et al. (2016), who found that mothers of children with ASD significantly contributed to their children’s participation. Krieger et al. (2021) explored how adolescents with ASD perceive their need for social engagement, and how they benefit from trusted individuals who facilitate their participation. Our findings on supporting environmental factors are also confirmed by the ICF model (WHO, 2007), which identifies attitudes and supportive relationships with others among the environmental factors positively influencing participation in daily life.

Clinical Implications

Our study reinforces existing findings on how environmental factors impact the participation of children in general and children with ASD in particular. Environmental factors must be considered when planning intervention for children with ASD, including adapting social and cognitive activity demands, as well as moderating sensory stimuli to promote their participation. It should also include steps to change the attitudes of others in the child’s environment, to strengthen supportive relationships, and to develop appropriate services in the school and community. Furthermore, addressing parental desires for change in the child’s participation, and receiving feedback on effective resources and strategies, can promote more family-centered intervention, as well as inform educators and caregivers in the child’s wider settings.

Limitations and Recommendations for Further Research

This study, focused on children aged 6-12 diagnosed with ASD, attending special classes in a mainstream educational setting, was limited in scope. First, although we uncovered significant results, further studies are needed among larger samples of children with ASD: at varied levels of support needs, and with co-occurring intellectual disability in both inclusive and non-inclusive educational settings, and from diverse families and socioeconomic backgrounds. Participation assessment is also recommended from other perspectives (educators, caregivers other than the parents, and children themselves). Secondly, the PEM-CY, our primary research tool, provides in-depth information but is somewhat time-consuming to complete, making parent recruitment through educational settings challenging. Thirdly, this study focused on participation patterns and environmental factors; other components (such as sensory, cognitive, verbal, and communication abilities) should be considered in further research. Acquiring additional information about parents’ strategies in different environments is also recommended.

Conclusions

This study explored participation patterns and environmental factors of children with ASD, aged 6–12, attending special classes in the mainstream educational setting, compared to their peers without ASD, in the home, school, and community. We found that children with ASD participated less than children without ASD in all three settings. Parents in the ASD group expressed a greater desire to see change in their children’s participation, and they identified limiting environmental factors: demands for social and cognitive activities, and sensory stimuli. They also noted supportive environmental factors: information, other people’s attitudes, time, and money; and they outlined strategies they used to promote their child’s participation: regular daily schedules, parental mediation, positive reinforcement, and emotional support. Our findings highlight the importance of assessing participation frequency, involvement, and desire for change; along with identifying supportive and limiting environmental factors that may impact these children’s participation. This information can help set goals and construct intervention programs while providing guidance to caregivers of children with ASD. Further studies are needed to expand this knowledge.

Authors contributions

Anat Golos is the primary investigator (PI) and the corresponding author. All authors were the researchers and contributed to this paper.

Ethics statement

This study was approved by the Ethics Committee of the Hebrew University of Jerusalem (No. 27032018) and the Israeli Ministry of Education (No. 10105).

Consent form

Informed consent was obtained from all subjects involved in the study.

Acknowledgements

We are grateful to the schools’ principals and teachers for their support and to the parents of the children who participated in this study, as well as to Ms. Haya Fogel-Grinvald for the statistical consultation.

Disclosure statement

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

Data availability statement

Not applicable.

Additional information

Funding

This research received no specific support.

Notes on contributors

Anat Golos

Dr. Anat Golos is the Head of Environment, Culture, and Participation in the Community Laboratory in the School of Occupational Therapy, Faculty of Medicine at the Hebrew University, Israel. The topics of her research interests are participation, quality of life, and environmental factors in diverse populations in the community.

Shira Vidislavski

Shira Vidislavski was a master's student in the School of Occupational Therapy, Faculty of Medicine at the Hebrew University, Israel. She is an occupational therapist in the area of autism.

Dana Anaby

Dr. Dana Anaby is associate professor in the School of Physical and Occupational Therapy at the McGill University, Canada. The topics of her research interests are participation and well-being among children and youth with physical disabilities, with a special focus on leisure participation and the impact of the environment.