International Journal of Disability, Development and

Education

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Tiered Approaches to Rehabilitation Services

in Education Settings: Towards Developing an
Explanatory Programme Theory

Sandra VanderKaay, Leah Dix, Lisa Rivard, Cheryl Missiuna, Stella Ng,
Nancy Pollock, Sandra Sahagian Whalen, Isabel Eisen, Christine Kyte,
Michelle Phoenix, Sheila Bennett, Jacqueline Specht, Jennifer Kennedy,
Dayle McCauley & Wenonah Campbell

To cite this article: Sandra VanderKaay, Leah Dix, Lisa Rivard, Cheryl Missiuna, Stella Ng,
Nancy Pollock, Sandra Sahagian Whalen, Isabel Eisen, Christine Kyte, Michelle Phoenix, Sheila
Bennett, Jacqueline Specht, Jennifer Kennedy, Dayle McCauley & Wenonah Campbell (2021):
Tiered Approaches to Rehabilitation Services in Education Settings: Towards Developing an
Explanatory Programme Theory, International Journal of Disability, Development and Education,
DOI: 10.1080/1034912X.2021.1895975

To link to this article: https://doi.org/10.1080/1034912X.2021.1895975

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INTERNATIONAL JOURNAL OF DISABILITY, DEVELOPMENT AND EDUCATION
https://doi.org/10.1080/1034912X.2021.1895975

Tiered Approaches to Rehabilitation Services in Education

Settings: Towards Developing an Explanatory Programme
Theory
Sandra VanderKaay a, Leah Dix a, Lisa Rivarda, Cheryl Missiuna a, Stella Ng a
,
Nancy Pollocka, Sandra Sahagian Whalen a, Isabel Eisen a, Christine Kyte a,
Michelle Phoenix b, Sheila Bennett a, Jacqueline Specht a,c,
Jennifer Kennedy d,e, Dayle McCauley a and Wenonah Campbell a
a
School of Rehabilitation Science, Institute for Applied Health Sciences, McMaster University, Ringgold
Standard Institution, Hamilton, Canada; bUniversity of Toronto, Ringgold Standard Institution, Toronto,
Canada; cFaculty of Education, Brock University, Ringgold Standard Institution, St. Catharine's, Canada;
d
Canadian Research Centre on Inclusive Education, London, Canada; eJohn George Althouse Faculty of
Education, Western University, Ringgold Standard Institution, London, Canada

ABSTRACT KEYWORDS
Rehabilitation services in education settings are evolving from pull- Education; inclusive;
out interventions focused on remediation for children and youth occupational therapy;
with special education needs to inclusive whole-school tiered physiotherapy; realist
approaches focused on participation. A limited number of disci­ methodology; speech-
language pathology; theory
pline-specific practice models for tiered services currently exist. development; tiered services
However, there is a paucity of explanatory theory. This realist synth­
esis was conducted as a first step towards developing a middle-
range explanatory theory of tiered rehabilitation services in educa­
tion settings. The guiding research question was: What are the
outcomes of successful tiered approaches to rehabilitation services
for children and youth in education settings, in what circumstances
do these services best occur, and how and why? An expert panel
identified assumptions regarding tiered services. Relevant literature
(n = 52) was located through a systematic literature review and was
analysed in three stages. Several important contextual characteris­
tics create optimal environments for implementing tiered
approaches to rehabilitation services via three main mechanisms:
(a) collaborative relationships, (b) authentic service delivery, and (c)
reciprocal capacity building. Positive outcomes were noted at stu­
dent, parent, professional, and systems levels. This first-known
realist synthesis regarding tiered approaches to rehabilitation ser­
vices in education settings advances understanding of the contexts
and mechanisms that support successful outcomes.

Introduction
Across speech-language pathology (SLP), occupational therapy (OT), and physiotherapy
(PT), researchers and practitioners are exploring tiered approaches to delivering rehabi­
litation services in education settings as an alternative to remediation-focused, one-to-

CONTACT Wenonah Campbell campbelw@mcmaster.ca

© 2021 The Author(s). Published by Informa UK Limited, trading as Taylor & Francis Group.
This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives License
(http://creativecommons.org/licenses/by-nc-nd/4.0/), which permits non-commercial re-use, distribution, and reproduction in any med­
ium, provided the original work is properly cited, and is not altered, transformed, or built upon in any way.
2 W. CAMPBELL ET AL.

one, pull-out models (Archibald, 2017; Camden, Leger, Morel, & Missiuna, 2015; Campbell,
Missiuna, Rivard, & Pollock, 2012; Chu, 2017; Ebbels, McCartney, Slonims, Dockrell, &
Norbury, 2019; Hutton, 2009; Kaelin et al., 2019; Mills & Chapparo, 2018). Incorporating
elements of response to intervention (RTI), and several inter-professional and collabora­
tive consultation models, tiered approaches to rehabilitation aim to enhance all students’
participation, and promote the inclusion of children and youth with special education
needs (Campbell, Kennedy, Pollock, & Missiuna, 2016; Gustafson, Svensson, & Fälth, 2014;
Idol, Paolucci-Whitcomb, & Nevin, 2010; Missiuna et al., 2015; Pfeiffer, Pavelko, Hahs-
Vaughn, & Dudding, 2019). Although consensus has not been reached regarding one
cogent definition of inclusion, it is generally understood as providing education to all
students, including students with disabilities, in general, education classrooms, with
needed support embedded therein (Amor et al., 2019; Krischler, Powell, & Pit-Ten Cate,
2019; McCrimmon, 2014; Ritter, Wehner, Lohaus, & Krämer, 2020). Inclusive tiered
approaches to delivering rehabilitation services are most typically provided along
a continuum of three tiers (Chu, 2017). Tier one rehabilitation services are delivered at
a school-wide or classroom-wide level and are beneficial for all (Campbell et al., 2016). In
tier two, targeted rehabilitation services are provided for aggregates of students requiring
additional support for specific issues, and are necessary for some (Law, Reilly, & Snow,
2013). Tier three refers to individualised, intensive rehabilitation services that are essential
for a few (Ebbels et al., 2019). Services are needs-based and can change over time (Ebbels
et al., 2019). Students receiving tier two or tier three services continue to receive tier one
services alongside peers in their classroom (Chu, 2017).
Outcome studies have documented positive results when rehabilitation services in
schools are offered at various tiers. For example, Throneburg, Calvert, Sturm,
Paramboukas, and Paul (2000) found that students with SLP need who received whole-
class and pull-out services made significantly better gains in curricular vocabulary knowl­
edge than students in pull-out intervention only. A randomised controlled trial involving
3- to 6-year-olds indicated that a tier-one SLP reading intervention had a significant
impact on pre-literacy (Bleses et al., 2018), and a pre-test, post-test control group study
indicated that a tier-one OT intervention improved kindergarteners’ motor skills (Ohl et al.,
2013).
Research regarding tiered models of rehabilitation services in education settings has
elucidated several benefits and barriers. Benefits include: (a) enhanced school, home, and
community participation, (b) earlier identification of difficulties, (c) problem prevention,
(d) capacity development among educators/families, (e) responsiveness to unique school/
classroom/student needs, and (f) reduction in service wait times, (Cahill, McGuire,
Krumdick, & Lee, 2014; Camden et al., 2015; Campbell et al., 2016; Ebbels et al., 2019;
Missiuna et al., 2015, 2016; Wilson & Harris, 2018). Barriers include: (a) lack of clarity
regarding rehabilitation professionals’ roles at each tier, (b) insufficient resources, (c)
rehabilitation professionals’ prioritisation of tier three services, (d) variations in profes­
sionals’ skills for each tier, and (e) operational variations among coordinating organisa­
tions (Cahill et al., 2014; Campbell et al., 2012; Ebbels et al., 2019; Wilson & Harris, 2018).
Of the studies cited in the preceding paragraph, several are based on the Partnering for
Change (P4C) tiered model of OT practice (Missiuna et al., 2016; Wilson & Harris, 2018).
Partnering for Change (P4C) was designed to be a more inclusive alternative to decon­
textualised pull-out models for children with developmental coordination disorder by
 INTERNATIONAL JOURNAL OF DISABILITY, DEVELOPMENT AND EDUCATION 3

focusing on ‘building Capacity through Collaboration and Coaching in Context’ (4 Cs)

(Missiuna et al., 2016, p. 146). Camden et al. (2015) proposed an inter-disciplinary model,
the Apollo model, to guide tiered practice in community settings including schools, and
Ebbels et al. (2019) described an evidence-informed untitled tiered practice model of
speech and language service delivery for children with language disorders. The remaining
studies cited above described tiered rehabilitation service within the education system’s
established RTI structure (Bleses et al., 2018; Cahill et al., 2014; Ohl et al., 2013).
Although the importance of practice models in SLP, OT, and PT is well established,
rehabilitation has been broadly criticised for neglecting the role of explanatory theory
(Darrah, Loomis, Manns, Norton, & May, 2006; McColl, Law, & Stewart, 2015; Rodriguez &
Gonzalez Rothi, 2009; Siegert, McPherson, & Dean, 2005). To our knowledge, there are no
current explanatory theories specific to tiered approaches to delivering rehabilitation
services in education settings. Explanatory theory is imperative to guide the development
and empirical testing of programmes and interventions and to inform policy (Jagosh,
2020a; Siegert et al., 2005; Whyte, 2014). Yet research for the purpose of generating
explanatory theory is often not prioritised due to a focus on outcome studies, lack of
funding for research to develop theory, and journal limitations regarding publishing
theoretical manuscripts (Chatterjee, 2005; Siegert et al., 2005). Discussion of what distin­
guishes theories and practice models is beyond the scope of this paper; however, theories
are generally understood as a broad set of analytical principles designed to be explana­
tory whereas models are typically descriptive and have a narrower focus (Nilsen, 2015).
Considering the global interest in, and noted benefits of, tiered approaches to rehabi­
litation services in education settings, along with the paucity of related theory, our
research team’s long-term aim is to develop the first-known middle-range theory of tiered
rehabilitation services in education settings to guide future research and inform policy
and practice. We have adopted the definition of middle-range theory put forth by Merton
(1967, p. 39): ‘theories that lie between the minor but necessary working hypotheses . . . .
and the all inclusive systematic efforts to develop a unified theory that will explain all
observed uniformities . . . ’.

Overview of Research
Realist evaluation (RE) is a theory-driven approach to research that is based on realist
ontology (i.e., a mind-independent reality exists but perception of reality is constructed)
(Waldron et al., 2020; Wong et al., 2016). The goal of RE is to generate middle-range
explanatory program theory by evaluating existing programs and interventions through
asking 'how, why, for whom, to what extent, and in what context complex interventions
work' (Wong et al., 2016, p. 2). Although an extensive process, the use of RE to develop
middle-range programme theory is increasing because of its utility in uncovering how
a programme brings about outcomes (expected and non-expected) as well as identifying
what those outcomes are rather than exclusively focusing on if a programme brings about
a specific set of expected outcomes (Doi, Wason, Malden, & Jepson, 2018; Fick &
Muhajarine, 2019; Jefford, Stockler, & Tattersall, 2003; Pawson, 2006). Furthermore, while
outcome studies aim to reduce complexity by eliminating confounding variables, RE aims
to identify and examine as many variables as possible that may influence the manifesta­
tion and outcomes of a programme (Fick & Muhajarine, 2019). RE is based on the belief
4 W. CAMPBELL ET AL.

that programme outcomes (O) are generated when certain mechanisms (M) are activated
by programmes or interventions delivered in certain contexts (C). For our study, context
was defined as the settings, structures, environments, conditions, and circumstances
within which a programme or intervention occurs (Shaw et al., 2018). Mechanism was
defined as the way in which individuals involved in a programme reason about and
respond to the programme or interventions (i.e., demonstrate agency) in the particular
context in which a programme is delivered (Shaw et al., 2018). Outcome was defined as
the impacts of a programme resulting from the interaction between mechanisms and
contexts (De Souza, 2013).
There are three main steps in the iterative and extensive process of RE to generate
middle-range programme theory: (1) creating an initial programme theory, (2) empirically
testing the initial programme theory, and (3) refining the initial programme theory to
create the tenets of the middle-range programme theory (Fick & Muhajarine, 2019). This
paper reports on research conducted towards realising Step #1, creating an initial pro­
gramme theory.

Step #1: Creating Initial Programme Theory

In RE, the first steps toward creating an initial programme theory involves: (a) identifying
the contexts, mechanisms, and outcomes relevant to a programme or intervention; then
(b) combining and mapping them as a set of context-mechanism-outcome configurations
or CMOCs (i.e., C + M = O) (Pawson, 2006). One of the main ways to identify relevant
contexts, mechanisms, and outcomes (and the avenue adopted for this research study) is
conducting a realist synthesis of relevant literature (Marchal, Kegels, & Van Belle, 2018).
Realist synthesis is a method for literature review that guides the interrogation and
synthesis of existing literature to identify ‘what works for whom in what circumstances
and in what respects’ (Pawson, 2006, p. 74). Unlike meta-analyses and traditional systema­
tic reviews, which favour the inclusion of randomised controlled trials, realist syntheses
expand beyond empirical studies to include other forms of literature while preserving the
requirement for systematic and transparent search and selection processes (Booth,
Wright, & Briscoe, 2018). The research question used to guide this realist synthesis was:
What are the outcomes of successful tiered approaches to rehabilitation services for children
and youth in education settings (O), in what circumstances do these services best occur (C),
and how and why (M)? This study reports on the broad contexts, mechanisms, and
outcomes relevant to tiered rehabilitation services in education settings identified via
the realist synthesis (i.e., part [a] of Step #1). The immediate next step of our research team
(to be reported in a subsequent publication) is to apply an extant theory to guide the
creation of CMOCs (i.e., part [b] of Step #1). Figure 1: Realist Evaluation Process offers
a diagrammatic representation of the whole RE process and indicates which components
are reported herein.

Methods
The Realist and Meta-Narrative Evidence Syntheses: Evolving Standards (RAMESES) (found at
https://bmcmedresmethodol.biomedcentral.com/articles/10.1186/1471-2288-11-115)
 INTERNATIONAL JOURNAL OF DISABILITY, DEVELOPMENT AND EDUCATION 5

Step #1: GOAL: Identify CMOCs

Creating Initial Program
Theory

1. Expert Consultation with Literature Review

Conduct Realist Review
2. Systematic Literature Search
3. Data Analysis to Identify C, M, O
4. Create CMOCs

Step #2
Empirically Testing Initial GOAL: Test Initial Program Theory
Program Theory

Step #3 GOAL: Create Tenets of Middle-Range Program

Refining Initial Program Theory
Theory

Figure 1. Realist Evaluation Process (Created based on Emmel, Greenhalgh, Manzano, Monaghan, &
Dalkin, 2018).

were used to guide and report our realist synthesis (Wong, Greenhalgh, Westhorp,
Buckingham, & Pawson, 2013).

Expert Consultation and Literature Review

Realist syntheses begin with participatory expert consultation and literature review to
identify assumptions about when, how, why, and for whom a programme or intervention
works (Pawson, Greenhalgh, Harvey, & Walshe, 2005). Our multidisciplinary team of
researchers and clinicians with expertise in tiered approaches to school-based rehabilita­
tion functioned as the expert panel. Panel members had both published and reviewed
relevant literature prior to convening for a participatory roundtable discussion (e.g.,
Campbell et al., 2016, 2012; Kennedy et al., 2018; Missiuna et al., 2015, 2012, 2016, 2012;
Pollock, Dix, Whalen, Campbell, & Missiuna, 2017). An impartial experienced independent
researcher (SV), hired to conduct data analysis, facilitated the roundtable discussion to
elicit assumptions related to tiered services. The roundtable discussion was recorded and
transcribed. Contexts (C), mechanisms (M), and outcomes (O) were drawn from the
recorded discussion and later used to guide data analysis. See Supplementary File Part
1: Assumptions Related to Tiered Rehabilitation Services. Ethics approval was not required
6 W. CAMPBELL ET AL.

for the roundtable discussion since our team of experts were not themselves the focus of
the research and the discussion was conducted during the ordinary course of involvement
with the current research team (Government of Canada, 2018). All team members volun­
tarily consented to participation and agreed to be recorded. Hence, ethical principles
outlined in the Tri-Council Policy Statement: Ethical Conduct for Research Involving Humans
were upheld (Government of Canada, 2018).

Searching Process
A member of the team (IE) searched the Cumulative Index to Nursing and Allied Health
Literature (CINAHL), Education Resources Information Center (ERIC), and Web of Science
databases. Recognising ‘there is a limit on what a review can cover’ (Pawson, 2006,
p. 36), we selected these databases because relevant literature could best be located
therein (rehabilitation/education/both). In consultation with the research team, IE and
a library liaison from McMaster University constructed a search strategy comprising 37
terms reflecting three independent concepts: tiered services (n = 9); rehabilitation
services (n = 22); and education settings (n = 6). IE searched terms independently and
then combined terms for the same concept using the Boolean search operator OR.
Next, IE combined searches for the three independent concepts with the Boolean
operator AND to yield articles including all three concepts. Inclusion criteria for the
initial search required that articles be published: (a) from 1996, (b) in English, (c) in
a peer-reviewed source. The literature search began in November 2017 and continued
iteratively until April 2018. See Supplementary File Part 2: Search Strategy Protocol.

Selection and Appraisal of Documents

The search process yielded 4327 citations, reduced to 3403 by removing duplicates
via EndNote (Clarivate Analytics, 2018). The principal investigator (WC) and one
member of the research team (AW) further reduced citations to 3067 using a semi-
automated relevance search conducted in EndNote (Clarivate Analytics, 2018). These
3067 articles proceeded to title and abstract screen (AW/LR) using Covidence (Veritas
Health Information, 2018). To ensure the relevance of articles, we refined inclusion
criteria such that articles had to meet all of the following: (a) services must be
delivered at more than one tier, (b) tier one services must be present, (c) service
delivery must involve one or more rehabilitation professional(s) (OT/PT/SLP), (d)
services must be implemented in an education setting (preschool to end of high
school), (e) students must be 2 to 21 years, and (f) articles must pertain to high-
income economies (The World Bank, 2017) (to permit inclusion of literature applicable
to Canadian context). Records that included relevant terminology but did not contain
enough information to inform decision-making were advanced to full-text review. AW
and LR engaged in dual review for training and confirmed reviewer agreement prior
to single reviewer mode (agreement = 90.7%). Ultimately, 313 articles proceeded to
full-text review plus two identified by WC (these two additional articles were known
to the research team but were not located during the database search).
AW and LR conducted full-text review of 315 articles in consultation with WC. Training
involved dual full-text review of 32 articles (AW/LR) to confirm agreement prior to single
 INTERNATIONAL JOURNAL OF DISABILITY, DEVELOPMENT AND EDUCATION 7

Records identified through database

searching
Identificatio (n = 4327)
Duplicates removed
(n = 924)
Records proceeding to semi-automated
relevance search
(n = 3403)
Records removed
(n = 336)

Records proceeding to title and abstract screen

(n = 3067)
Screening

Inclusion criteria refined Records screened

(n = 3067)

Records excluded
(n = 2754)

Full-text articles proceeding

to full-text review
(n = 313)

Additional records identified (n=2)

Eligibility

Full-text articles proceeding to

full-text review
(n = 315)

Full-text articles excluded

with reasons
(n = 263)
Included

Articles included in realist

synthesis
(n = 52)

Figure 2. PRISMA Flow Diagram of Document Selection Process (Moher, Liberati, Tetzlaff, & Altman,
2009).

reviewer mode (K = 0.904). Problematic articles identified during single review underwent
dual review (n = 8). Fifty-two articles met the inclusion criteria. See Figure 2: PRISMA Flow
Diagram of Document Selection Process.

Data Extraction, Analysis, and Synthesis

Consistent with both qualitative and realist approaches to data analysis, SV completed
data extraction, analysis, and synthesis in three stages: data preparation, coding, and
moving from codes to descriptive categories (Bazeley, 2013; Gilmore, McAuliffe, Power, &
Vallières, 2019; Pawson, 2006). Data preparation involved: (1) uploading the 52 articles to
NVivo (QSR International, 2018), (2) inputting terms (with definitions) related to contexts
(C), mechanisms (M), and outcomes (O) that were drawn from RE methodological
8 W. CAMPBELL ET AL.

literature and the expert panel discussion regarding programme assumptions (thereby
serving as a deductive data extraction matrix), and (3) reviewing all literature for con­
ceptual understanding (Gilmore et al., 2019). Coding involved reading documents in
detail, extracting data relevant to contexts (C), mechanisms (M), and outcomes (O), and
organising extracted data under appropriate matrix terms or nodes. Data were extracted
both deductively (as per terms in the matrix) and inductively using both topic coding
(codes that describe the literal topic of an excerpt) and analytical coding (codes that
interpret or reflect the meaning of an excerpt) (Richards, 2009). Combining deductive and
inductive data extraction and using both topic and analytical inductive coding enhanced
analytical rigour and is compatible with both qualitative data analysis and realist meth­
odology (Fereday & Muir-Cochrane, 2016; Gilmore et al., 2019). Moving from codes to
descriptive categories involved combining and abstracting codes through ‘continuous
dialogue’ with the data to create analytically useful and focused categories (Bazeley,
2013, p. 244; Jagosh, 2020a). Continuous dialogue with the data can be described as
a process of reading (re-reading), analysing, and comparatively interrogating data con­
tained in codes in order to identify common ideas and sort codes into categories with
similar characteristics (Bazeley, 2013). Analytical debriefing with the research team sup­
ported confirmability and triangulation (Lincoln & Guba, 1985). Memo-writing (at all
stages), diagramming, and visual mapping supplemented analysis (Bazeley, 2013).

Results
See Supplementary File Part 3: Document Characteristics for an overview of included
articles. For clarity and consistency, results (descriptive categories) are presented in
response to each sequential component of the research question (i.e., outcomes, con­
texts, and mechanisms). Direct quotes have been used judiciously to illustrate and
support findings (Richards, 2009). A summary of results is presented in Table 1.

What are the Outcomes of Successful Tiered Approaches (O)?

Successful tiered approaches to rehabilitation services in education settings are charac­
terised by several outcomes at the children and youth, parent and professional, and
system level. For children and youth, successful tiered approaches facilitate the achieve­
ment of academic and rehabilitation goals and foster the development of skills needed to
participate in everyday contexts (Ritzman, Sanger, & Coufal, 2006; Throneburg et al.,
2000). Increased participation facilitates positive social outcomes, including a greater
sense of inclusion and belonging. Silliman, Ford, Beasman, and Evans (1999) noted ‘the
greatest growth . . . occurs in the intertwined areas of social development and increased
self-confidence, both of which . . . indirectly influence the motivation to achieve acade­
mically (p. 13).’ Other beneficial child and youth outcomes include earlier and potentially
more accurate identification of needs resulting in an earlier intervention, decreased level
of impairment, and decreased likelihood of labelling (e.g., learning disability) (Brebner,
Attrill, Marsh, & Coles, 2017; Ehren & Nelson, 2005; Elksnin, 1997; Hutton, Tuppeny, &
Hasselbusch, 2016).
For parents and professionals, successful tiered approaches cultivate growth and
development. Increased knowledge and skills gained by parents and professionals led
 INTERNATIONAL JOURNAL OF DISABILITY, DEVELOPMENT AND EDUCATION 9

Table 1. Summary of Results.

What are the outcomes of successful tiered approaches (O)?
Children and Youth Parents and Professionals Systems
● achievement of academic and ● increased knowledge and skills ● earlier, more timely intervention
rehabilitation goals ● deeper understanding of needs ● problem exacerbation prevented
● skill development ● increased confidence applying ● fewer formal diagnoses
● increased participation in every­ knowledge and skill in other ● resource efficient
day contexts contexts ● advancement of knowledge and
● greater sense of inclusion ● increased confidence advocating resources regarding tiered
● earlier and more accurate needs ● greater insight and appreciation approaches and curriculum
identification regarding roles development
● decreased level of impairment
● decreased likelihood of labelling
In what circumstances do these services best occur (C)?
Macro-Level Meso-Level Micro-Level
● broad acceptance that children ● consensus that current service ● acknowledgement that parents,
with disabilities can learn in approaches are problematic and educators, rehabilitation profes­
inclusive general education tiered approaches would be sionals are all equal and integral
classrooms better partners
● legislation mandating inclusive ● clear guidelines for tiered ● rehabilitation professionals with
education approaches strong knowledge and relevant
● high-quality, universally designed ● adequate resource availability skills
curriculum including time allotment
Why and how (M)?
Collaborative Relationships Authentic Services Building Capacity
● commitment of all key players ● services are curriculum relevant ● give and take of ideas
● respect, trust ● goals are student-centred and ● capacity built among all students,
● clear communication curriculum-based rehabilitation professionals, educa­
● shared responsibility, including ● assessment and intervention con­ tors, and parents
assessment, goal setting, and ducted in authentic contexts in
decision-making real-time
● common frameworks ● services are fluid and flexible
● co-teaching

to deeper understanding of the needs of children and youth. Christner (2015) stated ‘[t]he
OT supports the classroom by providing a greater knowledge base to help support all
students . . . .’ (p. 142). Findings indicated that parents and professionals developed
confidence in their ability to carry knowledge and skills forward for use with future
students (professionals) and/or in other contexts (parents/professionals). Parents in
a study by Missiuna et al. (2012), which evaluated the Partnering for Change tiered
approach, reported having more confidence in advocating for their children. One parent
stated, ‘The knowledge I gained absolutely helped my son to be more successful at
school . . . .’ (p. 1449). In addition, education and rehabilitation professionals also devel­
oped greater insight about each other’s role and context. This led to ‘an appreciation of
each individual’s unique contribution’ (Peña & Quinn, 2003, p. 54) and cultivated a culture
of satisfaction, collaboration, and respect.
For systems, tiered approaches facilitated earlier and more timely intervention irre­
spective of formal identification of need. As a result, problem exacerbation may be
prevented, and fewer children obtain formal diagnoses. In a study by Sanger, Mohling,
and Stremlau (2011), SLPs agreed that tiered approaches ‘support a model of prevention
versus “wait until you fail” . . . are preventive and can decrease the number of students
eligible for special education . . . ’ (p. 8). Tiered approaches can be more resource efficient
since more children benefit and fewer children are referred for other (potentially more
costly) services. Justice, McGinty, Guo, and Moore (2009) asserted that ‘every dollar
10 W. CAMPBELL ET AL.

invested . . . will be returned to society in later years through a reduction in special

education and other societal programmes . . . ’ (p. 61). In one study of a tiered approach
aimed at addressing speech-sound errors and disorders, Mire and Montgomery (2008)
stated that the tiered approach ‘significantly improved the efficiency and effectiveness of
SLPs in this district’ (p. 159). A final positive system-level outcome is the ongoing
advancement of knowledge and resources regarding tiered approaches and curriculum
development. As implementation and evaluation occurs, ‘more [is] learned about how
general education and special education supports are integrated throughout the tiers of
intervention to support students . . .’ (Johnson, 2012, p. 325). Both research-based evi­
dence and practice-based expertise are imperative to informing sustainable tiered ser­
vices. Researcher-practitioner partnerships can expand knowledge regarding tiered
approaches as can individual practitioners who ‘lend their expertise to the design of
interventions for students’ (Linan-Thompson & Ortiz, 2009, p. 116).

In what Circumstances do these Services Best Occur (C)?

Several macro-, meso-, and micro-level contextual circumstances for successful tiered
approaches were identified. On a macro-level, there must be broad acceptance that
children with disabilities can learn in inclusive general education classrooms and, there­
fore, should be included therein (Horn & Banerjee, 2009; Linan-Thompson & Ortiz, 2009).
Legislation that mandates inclusive education and aims to ensure success for all students
is also an important macro-level contextual condition (Ohl et al., 2013; Ritzman et al.,
2006). For example, in the United States, the Individuals with Disabilities Education Act
(IDEA) and the No Child Left Behind Act (NCLB) are largely credited for prompting a shift
towards tiered approaches to rehabilitation services in education. Allocation of funds to
adequately support legislation enactment is imperative (Cavallaro, Ballard-Rosa, & Lynch,
1998). Finally, as stated by Horn and Banerjee (2009, p. 407), macro-level contexts must
include a ‘high quality, universally designed curriculum that supports all children’s access
to and participation in the general curriculum’ (p. 407).
On a meso-level, consensus must exist that current approaches to rehabilitation
services are problematic (e.g., ‘wait to fail’) and that tiered approaches would better
meet student need (Christner, 2015; Troia, 2005). School boards and employers of reha­
bilitation professionals should possess clear guidelines (i.e., policies/procedures) explicitly
addressing tiered approaches (Cahill et al., 2014; Paul, Blosser, & Jakubowitz, 2006). For
example, Pollock et al. (2017) reported that ‘education to stakeholders, such as school
boards, principals, other health care professionals, and families, was important to raise
their awareness of the [tiered] model and how it differs from current practice’ (p. 248).
Where appropriate, partnerships could be established with universities or professional
organisations to support guideline development (e.g., American Speech-Language-
Hearing Association) (Bahr, Velleman, & Ziegler, 1999; Reeder, Arnold, Jeffries, &
McEwen, 2011).
Resource availability is also a fundamental meso-level contextual circumstance. Time
must be allotted to enable rehabilitation professionals to have a consistent and ongoing
presence in schools and to adopt a workload orientation that considers direct and indirect
activities across all tiers rather than a caseload orientation focusing on direct activities for
individual students receiving services at tier three (Chu, 2017; Ehren & Nelson, 2005).
 INTERNATIONAL JOURNAL OF DISABILITY, DEVELOPMENT AND EDUCATION 11

Dedicated time to meet with educators and attend school-wide meetings must be an
‘untouchable’ aspect of supporting students (Silliman et al., 1999, p. 13). Administrative
support is closely linked to time provision for rehabilitation professionals (Bose &
Hinojosa, 2008). Supportive administrators are characterised as leaders in inclusive educa­
tion who understand, value, and allot adequate time to tiered approaches (Bose &
Hinojosa, 2008; Silliman et al., 1999). Intervention resources required include documenta­
tion forms and materials appropriate to service delivery in all tiers (Chu, 2017; Johnson,
2012; Paul et al., 2006).
On a micro-level, all school-level stakeholders must acknowledge that parents, educa­
tors, rehabilitation professionals, and others are ‘part of the fabric of the school’ (Campbell
et al., 2012, p. 56) and that all are equal and integral partners in supporting students in
general education classrooms (Brebner et al., 2017; Christner, 2015; Chu, 2017). The
knowledge, skills, and characteristics of rehabilitation professionals are important to the
micro-level context. A strong evidence-informed body of disciplinary knowledge is
imperative combined with knowledge of curriculum (Bose & Hinojosa, 2008; Chu, 2017;
Ehren, 2000). Rehabilitation professionals must possess a clear perspective on their role
within education and understand others’ roles (Ehren & Whitmire, 2009; Paul et al., 2006).
Essential skills include advocacy, effective communication, solution-focused problem
solving, and time management (Barnett & O’shaughnessy, 2015; Bose & Hinojosa, 2008;
Christner, 2015; Sanger et al., 2011). Other important characteristics of rehabilitation
professionals include openness, flexibility, responsivity, and respect (Bose & Hinojosa,
2008; Ritzman et al., 2006; Silliman et al., 1999; Soto Torres, 2018).

Why and How (M)?

Three main mechanisms were identified that operated within the contexts described
above and lead to beneficial outcomes: fostering collaborative relationships, delivering
authentic services, and building capacity for all.

Fostering Collaborative Relationships

Fostering collaborative relationships is an essential mechanism of successful tiered
approaches to rehabilitation in education. Collaboration must include all ‘key players’
(Christner, 2015, p. 141) such as educators, rehabilitation professionals, parents, adminis­
trators, and other related service providers. Key players are respected and trusted co-
equal partners whose unique expertise is understood and valued. Ehren and Whitmire
(2009) emphasised that ‘collaborative efforts are informed and enhanced by the expertise
and experience of others’ (p. 100). Effective collaboration requires commitment (ideally
voluntary) from all key players to the delivery of effective tiered services and to the
collaborative relationship itself. Peña and Quinn (2003) stated that the evolutionary and
dynamic process of effective collaboration ‘takes time, commitment, and nurturing’ (p.
54). Fostering collaborative relationships also requires clear, consistent, constructive, and
open communication that is understandable to all. Embedded within fostering collabora­
tive relationships is a sense of shared responsibility and accountability for the success of all
children and youth including ‘shared ownership of problems among equals’ (Paul et al.,
2006, p. 8). Shared responsibility is reflected in shared assessments, goal setting, and
12 W. CAMPBELL ET AL.

decision-making. Hadley, Simmerman, Long, and Luna (2000) iterated that in fostering
collaborative relationships, key players ‘jointly determine student needs, develop goals,
plan activities to achieve the goals, implement the activities, and evaluate the progress of
the students’ (p. 281). One way to promote shared responsibility is through utilisation of
‘common philosophical framework[s]’ (Paul et al., 2006, p. 8), including theories, models,
and/or terminologies relevant within education. Finally, fostering collaborative relation­
ships also involves varying degrees of shared responsibility for teaching, or co-teaching
(Bahr et al., 1999; Brebner et al., 2017; Justice & Kaderavek, 2004; Ritzman et al., 2006;
Silliman et al., 1999; Soto, Mu Ller, Hunt, & Goetz, 2001; Staskowski & Rivera, 2005). Co-
teaching can take many nuanced and individualised forms including co-planning only,
educator delivering lessons and rehabilitation professional circulating (to tailor content/
provide support as needed), rehabilitation professional delivering lessons (e.g., phonolo­
gical awareness) and educator observing or circulating. Justice (2006) noted ‘improved
outcomes . . . when SLPs and classroom teachers collaboratively plan and co-teach lan­
guage lessons in preschool and elementary classrooms’ (p. 287).

Delivering Authentic Services

In delivering authentic services, all aspects of service delivery including assessment, goal
setting, intervention, and progress monitoring must be curriculum relevant and promote
access to and achievement of curricular content. Jackson, Pretti-Frontczak, Harjusola-
Webb, Grisham-Brown, and Romani (2009) stated:
Assessment practices are considered authentic when they are conducted in familiar or
typical settings, with familiar and interesting toys and materials, and by people who are
familiar to the child (Bagnato & Yeh-Ho, 2006). Further, authentic assessment practices
encourage children to show what they know and can do in the ways in which they would
typically use the concept or skill . . . .(p. 429)
Roth and Troia (2009, p. 77) recommended that ‘goals are authentic, anchored in the
curriculum, and based on student needs and strengths’. Ritzman et al. (2006) stated that
intervention ‘supporting the activities of the classroom without interrupting the flow of
the instructional discourse is essential’ (p. 225). Progress monitoring is ongoing and
contextualised, and data gathered informs dynamic adjustments as needed.
Overall, authentic services are contextualised in the natural and age-appropriate
environments within which children and youth normally participate including classrooms,
playgrounds, gymnasiums, hallways, and cafeterias (Bose & Hinojosa, 2008; Campbell
et al., 2012; Christner, 2015; Hadley et al., 2000). Where possible, services and supports
are provided in real time during engagement in school tasks and activities. Finally, all
aspects of authentic services, including the design of interventions are fluid and flexible.
Flexibility enables rehabilitation professionals to be responsive to the needs of children
and youth as they evolve and change and as the demands of the curriculum change.

Building Capacity for All

Building capacity for all involves ‘sharing of ideas and a spirit of “give and take” rather than
simply one person advising the other’ (Bose & Hinojosa, 2008, p. 292). Providing services in
authentic contexts such as the classroom not only cultivates skill development among
 INTERNATIONAL JOURNAL OF DISABILITY, DEVELOPMENT AND EDUCATION 13

children and youth requiring support (as previously described) but capacity is built
among typically developing students. Grether and Sickman (2008) stated that ‘ . . . typical
peers can support diverse learners . . . These students can be the models and extension of
the classroom teacher and SLP during the interactions with the classroom curriculum’
(p. 161).
Tiered approaches to rehabilitation promote capacity building among rehabilitation
professionals-especially in understanding, developing, and/or adapting curriculum, class­
room and behaviour management, whole-class instruction, classroom transitions, and
other classroom practices (Ehren & Nelson, 2005; Staskowski & Rivera, 2005; Troia, 2005).
Villeneuve (2009) noted the importance for rehabilitation professionals to ‘understand
school board policies, curriculum, and classroom practices of teachers in order to develop
educationally relevant approaches to providing service’ (p. 213). Reciprocally, capacity
also is built among educators. Benefits noted for educators include increased knowledge
and skill in recognising and assessing need, providing educational activities that are
therapeutic, and more consistently carrying over rehabilitation activities within the class­
room (Brebner et al., 2017; Dodge, 2004; Ratzon et al., 2009). Noted benefits can be
achieved incidentally through observation of rehabilitation professionals, discussions,
and/or role modelling and more formally via in-service education or educational materi­
als. Staskowski and Rivera (2005) stated that ‘teachers and administrators learn the nature
of the SLP’s expertise, and the SLP learns about classroom practices and the curriculum’
(p. 145). Finally, capacity building is extended to parents and families. Pollock et al. (2017)
reported that the Partnering for Change tiered approach ‘has been associated with . . .
increased capacity of families . . . to support students’ (p. 250). Reeder et al. (2011) outlined
that physiotherapists promoted capacity building among parents and families via teach­
ing and training.

Discussion
Jagosh, 2020b, 1, p. 28) stated that the main contribution of realist research is ‘cutting
through the complexity of interventions . . . to find the most important aspects of that
complexity . . . ’. Current findings of this realist synthesis clearly cut through the complex­
ity of the included literature to elucidate several important contexts, mechanisms, and
outcomes that are integral to successful tiered approaches to rehabilitation services in
education settings. In their current descriptive form, these findings can be utilised as
a checkpoint for policymakers who may be considering initiating new programmes
involving rehabilitation services in education or reflecting on current models of service
delivery. For example, in the Canadian province within which our team is situated, many
rehabilitation services in schools are delivered using direct, pull-out services via con­
tracted rehabilitation professionals (Deloitte & Touche LLP, 2010). Multiple challenges
were noted in a review of rehabilitation services provided in schools including: (a) lengthy
wait times for contracted services funded by the Ministry of Health, (b) confusion among
educators and families because services are offered by multiple rehabilitation profes­
sionals (some employed by schools and others by contracted health care agencies), and,
(c) uncertainty among educators about how to access and coordinate services on behalf
of students (Deloitte & Touche LLP, 2010). One main recommendation emerging from the
review was to ‘establish alternate models of service delivery across the province to
14 W. CAMPBELL ET AL.

improve access and wait times’ (Deloitte & Touche LLP, 2010, p. 8). Given that realist
syntheses aim to inform policy regarding the delivery of social services (Pawson, 2006),
tiered services could be considered one such ‘alternate model’ based on findings of earlier
and more timely access to services, increased knowledge and understanding among
parents and professionals, deeper insight and clarity among professionals regarding
their roles, and improved service coordination.
Two fundamental macro-level contextual circumstances upon which successful tiered
approaches are built both relate to inclusive education: (1) the belief that children and
youth with special needs can and should learn in inclusive environments, and (2) the need
for a high-quality, universally designed general curriculum that promotes access and
participation for all students. These macro-level contextual circumstances are consistent
with Article 24 of the United Nations Convention of the Rights of Persons with Disabilities,
which mandates that people with disabilities be included in general education, have
access to quality education in their communities, and be provided with accommodations
and support to facilitate participation (United Nations, 2006). As previously stated, inclu­
sive education is generally understood as providing education to all students, including
students with disabilities, in general education classrooms, with needed support (Amor
et al., 2019; Krischler et al., 2019; McCrimmon, 2014; Ritter et al., 2020). Although inclusive
education is a global imperative with many noted benefits, barriers to implementation
persist (Ahmad, 2012; Heyder, Südkamp, & Steinmayr, 2020; Klang et al., 2019; Krischler
et al., 2019; Reid et al., 2018; Soto Torres, 2018). Types of barriers include epistemological,
systemic, attitudinal, and practical (Ahmad, 2012; Heyder et al., 2020; Krischler et al., 2019;
McCrimmon, 2014; Page, Mavropoulou, & Harrington, 2020). Several recent studies
describe persistent barriers to inclusive education; for example, educators’ perceived or
actual level of competence in supporting students with special education needs, if low,
can be a barrier (Klang et al., 2019; Lavin, Francis, Mason, & LeSueur, 2020; Li & Cheung,
2019). Lavin et al. (2020) reported lack of support for educators as a barrier and Klang et al.
(2019) noted barriers to social participation for children with special education needs in
inclusive settings. Results of this realist synthesis explicitly extend knowledge regarding
the implementation of inclusive education by indicating that tiered approaches to reha­
bilitation in education settings could address several of these barriers by building the
capacity of educators, providing authentic support directly in classrooms in real time, and
promoting positive social outcomes for students with special education needs.
Our review identified three main mechanisms for successful tiered services: fostering
collaborative relationships, building capacity for all, and delivering authentic services. These
mechanisms reflect three distinct ways in which rehabilitation professionals take rea­
soned action within their context to effect positive outcomes. Jagosh et al. (2012) stated
that each mechanism is a ‘generative force that leads to outcomes’ (p. 317). Literature
regarding rehabilitation service delivery in schools has largely focused on collaboration
between rehabilitation professionals and educators to promote student outcomes (Borg
& Drange, 2019; Wintle, Krupa, Cramm, & DeLuca, 2017). Our findings regarding collabora­
tion are consistent with existing literature in: (a) reinforcing the importance of collabora­
tion, (b) reporting on essential features of collaborative relationships, (c) acknowledging
the need for coordination among complex interfacing systems, and, (d) acknowledging
that collaboration is situated within existing global, governmental, and professional
discourses (Archibald, 2017; Flynn & Power-defur, 2013; Regan, Orchard, Khalili, Brunton,
 INTERNATIONAL JOURNAL OF DISABILITY, DEVELOPMENT AND EDUCATION 15

& Leslie, 2015; Villeneuve & Shulha, 2012; World Health Organization, 2010). However,
despite broad acceptance of the importance of collaboration, research specific to inter-
professional collaboration in schools indicates a lack of knowledge about how inter-
professional collaboration meets the needs of educators and students, and how it
includes students’ families (Kennedy et al., 2019). There is also a significant body of
research indicating several persistent barriers to inter-professional collaboration (Borg &
Drange, 2019; Pfeiffer et al., 2019; Wintle et al., 2017). For example, findings from a scoping
review of inter-professional collaboration among OTs and educators suggested that OTs
visiting schools from outside agencies, OT caseload size and educators’ busy schedules
may constrain collaborative service delivery (Wintle et al., 2017). Similarly, Pfeiffer et al.
(2019) cite time constraints/scheduling and lack of administrative supports as barriers to
collaboration for SLPs working in schools.
Our study extends current knowledge in two important ways. First, our findings not
only confirm the importance of collaboration but situate it within a detailed consideration
of the contexts that facilitate effective collaboration. Previous authors have identified
contextual barriers to collaboration, but our research outlines the macro-, meso-, and
micro-level contextual factors important to successful collaboration and, as such, provides
a pragmatic checklist for considering contexts. Second, realist approaches posit that
mechanisms may have interactive effects (Lacouture, Breton, Guichard, & Ridde, 2015).
Much of the literature regarding rehabilitation services in schools has focused on a siloed
understanding of collaboration. Some authors have suggested that inter-professional
collaboration is the main construct in effectively supporting children with special educa­
tion needs within education (Edwards, 2012; Knackendoffel, Dettmer, & Thurston, 2018).
Research regarding the importance of capacity building for all stakeholders and delivery
of authentic services is much sparser although it is explicitly addressed in the Partnering
for Change research (Campbell et al., 2016; Missiuna et al., 2012). To some extent, an
implicit assumption may exist that collaboration among rehabilitation professionals and
educators necessarily begets capacity building (Kerins, 2018). However, our analysis
elucidated three discreet but equally important mechanisms. Each mechanism possesses
its own attributes and influences, yet undoubtedly interacts with other mechanisms
within the described contexts to bring about successful student, parent and professional,
and systems outcomes (Lacouture et al., 2015; Shaw et al., 2018). Our finding regarding
mechanisms calls for a more robust understanding of delivery of rehabilitation services in
education settings. The finding also sets the stage for advancing research and knowledge
in a new way: moving from studying siloed constructs with a focus on collaboration to
a more nuanced exploration of several potential mechanisms, how they are intercon­
nected, and how they may work together symbiotically in context to promote successful
outcomes.

Limitations
Although our search for literature focused on three highly relevant databases, it is possible
that we did not locate all articles relevant to our research question. Additionally, as outlined
by Pawson et al. (2005), we acknowledge that our findings do not provide directive or
generalisable formulae for programme implementation. Finally, similar to other kinds of
qualitative research, we acknowledge that readers intending to implement or improve
16 W. CAMPBELL ET AL.

tiered approaches to rehabilitation services will need to use their judgement in interpreting
and applying our findings in a manner that is aligned with their context.

Conclusion
This realist synthesis was conducted as part of the first step in a realist evaluation aimed at
developing a middle-range explanatory programme theory of tiered rehabilitation services
in education settings. More specifically this study answered the question: What are the
outcomes of successful tiered approaches to rehabilitation services for children and youth in
education settings, in what circumstances do these services best occur, and how and why?
Findings advance our understanding of successful tiered approaches by clearly explicating
and describing several macro-, meso-, and micro-level contextual factors and three main
mechanisms (fostering collaborative relationships, delivering authentic services, and building
capacity for all) that lead to positive outcomes for children, youth, parents, professionals,
and systems. Findings also contribute to extending knowledge regarding inclusive educa­
tion and inter-professional collaboration. Despite the limitations, our findings may be
useful to those considering new programme development for delivering tiered rehabilita­
tion services in education settings or to (re)assess existing programmes. Next steps in our
programme of research involve using extant theory to guide the development of CMOCs,
which will subsequently be tested through primary empirical research.

Data Availability
A list of the literature included as data can be found in Supplementary File Part 3: Document
Characteristics.

Disclosure Statement
No financial interests or benefits have arisen from this research.

Funding
This work was supported by the Ontario Ministry of Education.

ORCID
Sandra VanderKaay http://orcid.org/0000-0002-1797-5096
Leah Dix http://orcid.org/0000-0003-0439-7538
Cheryl Missiuna http://orcid.org/0000-0001-7582-6411
Stella Ng http://orcid.org/0000-0003-1433-6851
Sandra Sahagian Whalen http://orcid.org/0000-0001-8760-3979
Isabel Eisen http://orcid.org/0000-0001-9086-9890
Christine Kyte http://orcid.org/0000-0002-8370-426X
Michelle Phoenix http://orcid.org/0000-0002-6190-3997
Sheila Bennett http://orcid.org/0000-0002-0119-8595
Jacqueline Specht http://orcid.org/0000-0002-6536-1232
Jennifer Kennedy http://orcid.org/0000-0003-4162-9705
 INTERNATIONAL JOURNAL OF DISABILITY, DEVELOPMENT AND EDUCATION 17

Dayle McCauley http://orcid.org/0000-0003-3863-7229

Wenonah Campbell http://orcid.org/0000-0003-1579-0271

References
Ahmad, W. (2012). Barriers of inclusive education for children with intellectual disability. Indian
Streams Research Journal, 2(11), 1–4. https://www.researchgate.net/publication/325757581_
Barriers_of_Inclusive_Education_for_Children_with_Intellectual_Disability
Amor, A. M., Hagiwara, M., Shogren, K. A., Thompson, J. R., Verdugo, M. A., Burke, K. M., & Aguayo, V.
(2019). International perspectives and trends in research on inclusive education: A systematic
review. International Journal of Inclusive Education, 23(12), 1277–1295.
Archibald, L. M. D. (2017). SLP-educator classroom collaboration: A review to inform reason-based
practice. Autism & Developmental Language Impairments, 2, 1–17.
Bagnato, S. J., & Yeh-Ho, H. (2006). High-stakes testing with preschool children: Violation of profes­
sional standards for evidence-based practice in early childhood intervention. KEDI International
Journal of Educational Policy, 3(1), 23–43.
Bahr, R. H., Velleman, S. L., & Ziegler, M. A. (1999). Meeting the challenge of suspected develop­
mental apraxia of speech through inclusion. Topics in Language Disorders, 19(3), 19–35. https://
journals.lww.com/topicsinlanguagedisorders/Fulltext/1999/05000/Meeting_the_Challenge_of_
Suspected_Developmental.4.aspx
Barnett, J. E., & O’shaughnessy, K. (2015). Enhancing collaboration between occupational therapists
and early childhood educators working with children on the autism spectrum. Early Childhood
Education Journal, 43(6), 467–472.
Bazeley, P. (2013). Qualitative data analysis. London, UK: SAGE.
Bleses, D., Hojen, A., Justice, L. M., Dale, P. S., Dybdal, L., Piasta, S. B., . . . Haghish, E. F. (2018). The
effectiveness of a large-scale language and preliteracy intervention: The spell randomized con­
trolled trial in Denmark. Child Development, 89(4), e342–e363.
Booth, A., Wright, J., & Briscoe, S. (2018). Scoping and searching to support realist approaches. In
N. Emmel, J. Greenhalgh, A. Manzano, M. Monaghan, & S. Dalkin (Eds.), Doing realist research (pp.
147–165). London, UK: SAGE.
Borg, E., & Drange, I. (2019). Interprofessional collaboration in school: Effects on teaching and
learning. Improving Schools, 22(3), 251–266.
Bose, P., & Hinojosa, J. (2008). Reported experiences from occupational therapists interacting with
teachers in inclusive early childhood classrooms. American Journal of Occupational Therapy, 62(3),
289–297.
Brebner, C., Attrill, S., Marsh, C., & Coles, L. (2017). Facilitating children’s speech, language and
communication development: An exploration of an embedded, service-based professional devel­
opment program. Child Language Teaching and Therapy, 33(3), 223–240.
Cahill, S. M., McGuire, B., Krumdick, N. D., & Lee, M. M. (2014). National survey of occupational
therapy practitioners’ involvement in response to intervention. American Journal of Occupational
Therapy, 68(6), 234–240.
Camden, C., Leger, F., Morel, J., & Missiuna, C. (2015). A service delivery model for children with
DCD based on principles of best practice. Physical & Occupational Therapy in Pediatrics, 35(4),
412–425.
Campbell, W., Kennedy, J., Pollock, N., & Missiuna, C. (2016). Screening children through response to
intervention and dynamic performance analysis: The example of partnering for change. Current
Developmental Disorders Reports, 3(3), 200–205.
Campbell, W. N., Missiuna, C. A., Rivard, L. M., & Pollock, N. A. (2012). “Support for everyone”:
Experiences of occupational therapists delivering a new model of school-based service.
Canadian Journal of Occupational Therapy. Revue Canadienne D’Ergothérapie, 79(1), 51–59.
Cavallaro, C. C., Ballard-Rosa, M., & Lynch, E. W. (1998). A preliminary study of inclusive special
education services for infants, toddlers, and preschool-age children in California. Topics in Early
Childhood Special Education, 18(3), 169–182.
18 W. CAMPBELL ET AL.

Chatterjee, N. (2005). Theory for all and rehabilitation for the few (with money): Who does our theory
serve? Disability and Rehabilitation, 27(24), 1503–1508.
Christner, A. (2015). Promoting the role of occupational therapy in school-based collaboration:
Outcome project. Journal of Occupational Therapy, Schools, & Early Intervention, 8(2), 136–148.
Chu, S. (2017). Supporting children with special educational needs (SEN): An introduction to a
3-tiered school-based occupational therapy model of service delivery in the United Kingdom.
World Federation of Occupational Therapists Bulletin, 73(2), 107–116.
Clarivate Analytics. (2018). EndNote. https://endnote.com/buy/
Darrah, J., Loomis, J., Manns, P., Norton, B., & May, L. (2006). Role of conceptual models in a physical
therapy curriculum: Application of an integrated model of theory, research, and clinical practice.
Physiotherapy Theory and Practice, 22(5), 239–250.
De Souza, D. E. (2013). Elaborating the context-mechanism-outcome configuration (CMOc) in realist
evaluation: A critical realist perspective. Evaluation, 19(2), 141–154.
Deloitte & Touche LLP. (2010). Review of School Health Support Services: Final report. http://www.
health.gov.on.ca/en/common/system/services/lhin/docs/deloitte_shss_review_report.pdf
Dodge, E. P. (2004). Communication skills: The foundation for meaningful group intervention in
school-based programs. Topics in Language Disorders, 24(2), 141–150.
Doi, L., Wason, D., Malden, S., & Jepson, R. (2018). Supporting the health and well-being of
school-aged children through a school nurse programme: A realist evaluation. BMC Health
Services Research, 18(1), 664.
Ebbels, S. H., McCartney, E., Slonims, V., Dockrell, J. E., & Norbury, C. F. (2019). Evidence-based
pathways to intervention for children with language disorders. International Journal of Language
and Communication Disorders, 54(1), 3–19.
Edwards, A. (2012). The role of common knowledge in achieving collaboration across practices.
Learning, Culture and Social Interaction, 1(1), 22–32.
Ehren, B. J. (2000). Maintaining a therapeutic focus and sharing responsibility for student success:
Keys to in-classroom speech-language services. Language, Speech, and Hearing Services in Schools,
31(3), 219–229.
Ehren, B. J., & Nelson, N. W. (2005). The responsiveness to intervention approach and language
impairment. Topics in Language Disorders, 25(2), 120–131. https://journals.lww.com/topicsinlangua
gedisorders/Fulltext/2005/04000/The_Responsiveness_to_Intervention_Approach_and.5.aspx
Ehren, B. J., & Whitmire, K. (2009). Speech-language pathologists as primary contributors to response
to intervention at the secondary level. Seminars in Speech and Language, 30(2), 90–104.
Elksnin, L. K. (1997). Collaborative speech and language services for students with learning
disabilities. Journal of Learning Disabilities, 30(4), 414–426.
Emmel, N., Greenhalgh, J., Manzano, A., Monaghan, M., & Dalkin, S. (Eds.). (2018). Doing realist
research. London, UK: SAGE.
Fereday, J., & Muir-Cochrane, E. (2016). Demonstrating rigor using thematic analysis: A hybrid
approach of inductive and deductive coding and theme development. International Journal of
Qualitative Methods, 5(1), 80–92.
Fick, F., & Muhajarine, N. (2019). First steps: Creating an initial program theory for a realist evaluation
of healthy start-départ santé intervention in childcare centres. International Journal of Social
Research Methodology, 22(6), 545–556.
Flynn, P., & Power-defur, L. (2013, November 14-16). Collaboration in schools: Let the magic begin!
ASHA Convention, Chicago, IL.
Gilmore, B., McAuliffe, E., Power, J., & Vallières, F. (2019). Data analysis and synthesis within a realist
evaluation: Toward more transparent methodological approaches. International Journal of
Qualitative Methods, 18, 1609406919859754.
Government of Canada. (2018). Tri-Council Policy Statement: Ethical Conduct for Research Involving
Humans-TCPS 2. https://ethics.gc.ca/eng/policy-politique_tcps2-eptc2_2018.html
Grether, S. M., & Sickman, L. S. (2008). AAC and RTI: Building classroom-based strategies for every
child in the classroom. Seminars in Speech and Language, 29(2), 155–163.
 INTERNATIONAL JOURNAL OF DISABILITY, DEVELOPMENT AND EDUCATION 19

Gustafson, S., Svensson, I., & Fälth, L. (2014). Response to intervention and dynamic assessment:
Implementing systematic, dynamic and individualised interventions in primary school.
International Journal of Disability, Development and Education, 61(1), 27–43.
Hadley, P. A., Simmerman, A., Long, M., & Luna, M. (2000). Facilitating language development for
inner-city children: Experimental evaluation of a collaborative, classroom-based intervention.
Language, Speech, and Hearing Services in Schools, 31(3), 280–295.
Heyder, A., Südkamp, A., & Steinmayr, R. (2020). How are teachers’ attitudes toward inclusion related
to the social-emotional school experiences of students with and without special educational
needs? Learning and Individual Differences, 77, 101776.
Horn, E., & Banerjee, R. (2009). Understanding curriculum modifications and embedded learning
opportunities in the context of supporting all children’s success. Language, Speech, and Hearing
Services in Schools, 40(4), 406–415.
Hutton, E. (2009). Occupational therapy in mainstream primary schools: An evaluation of a pilot
project. British Journal of Occupational Therapy, 72(7), 308–313.
Hutton, E., Tuppeny, S., & Hasselbusch, A. (2016). Making a case for universal and targeted children’s
occupational therapy in the United Kingdom. British Journal of Occupational Therapy, 79(7),
450–453.
Idol, L., Paolucci-Whitcomb, P., & Nevin, A. (2010). The collaborative consultation model. Journal of
Educational and Psychological Consultation, 6(4), 329–346.
Jackson, S., Pretti-Frontczak, K., Harjusola-Webb, S., Grisham-Brown, J., & Romani, J. M. (2009).
Response to intervention: Implications for early childhood professionals. Language, Speech, and
Hearing Services in Schools, 40(4), 424–434.
Jagosh, J. (2020a). Retroductive theorizing in Pawson and Tilley’s applied scientific realism. Journal
of Critical Realism, 19(2), 121–130.
Jagosh, J. (2020b, May 16). Public health architecture and realist methodology [Video]. YouTube.
https://www.youtube.com/watch?v=3rqyrS1NVSs&feature=youtu.be
Jagosh, J., Macaulay, A. C., Pluye, P., Salsberg, J., Bush, P. L., Henderson, J., . . . Greenhalgh, T. (2012).
Uncovering the benefits of participatory research: Implications of a realist review for health
research and practice. Milbank Quarterly, 90(2), 311–346.
Jefford, M., Stockler, M. R., & Tattersall, M. H. (2003). Outcomes research: What is it and why does it
matter? Internal Medicine Journal, 33(3), 110–118.
Johnson, C. D. (2012). Classroom listening assessment: Strategies for speech-language pathologists.
Seminars in Speech and Language, 33(4), 322–339.
Justice, L. M. (2006). Evidence-based practice, response to intervention, and the prevention of
reading difficulties. Language, Speech, and Hearing Services in Schools, 37(4), 284–297.
Justice, L. M., & Kaderavek, J. N. (2004). Embedded-explicit emergent literacy intervention I:
Background and description of approach. Language, Speech, and Hearing Services in Schools, 35
(3), 201–211.
Justice, L. M., McGinty, A., Guo, Y., & Moore, D. (2009). Implementation of responsiveness to
intervention in early education settings. Seminars in Speech and Language, 30(2), 59–74.
Kaelin, V. C., Ray-Kaeser, S., Moioli, S., Kocher Stalder, C., Santinelli, L., Echsel, A., & Schulze, C. (2019).
Occupational therapy practice in mainstream schools: Results from an online survey in
Switzerland. Occupational Therapy International, 2019, 3647397.
Kennedy, J., Missiuna, C., Pollock, N., Wu, S., Yost, J., & Campbell, W. (2018). A scoping review to
explore how universal design for learning is described and implemented by rehabilitation health
professionals in school settings. Child: Care, Health and Development, 44(5), 670–688.
Kennedy, J. N., Missiuna, C. A., Pollock, N. A., Sahagian Whalen, S., Dix, L., & Campbell, W. N. (2019).
Making connections between school and home: Exploring therapists’ perceptions of their relation­
ships with families in partnering for change. British Journal of Occupational Therapy, 83(2), 98–106.
Kerins, M. (2018). Promoting interprofessional practice in schools. The ASHA Leader, 23, 12.
Klang, N., Göransson, K., Lindqvist, G., Nilholm, C., Hansson, S., & Bengtsson, K. (2019). Instructional
practices for pupils with an intellectual disability in mainstream and special educational settings.
International Journal of Disability, Development and Education, 67(2), 151–166.
20 W. CAMPBELL ET AL.

Knackendoffel, A., Dettmer, P., & Thurston, L. P. (2018). Collaboration, consultation, and teamwork for
students with special needs (8th ed.). New York, NY: Pearson.
Krischler, M., Powell, J. J. W., & Pit-Ten Cate, I. M. (2019). What is meant by inclusion? On the effects of
different definitions on attitudes toward inclusive education. European Journal of Special Needs
Education, 34(5), 632–648.
Lacouture, A., Breton, E., Guichard, A., & Ridde, V. (2015). The concept of mechanism from a realist
approach: A scoping review to facilitate its operationalization in public health program
evaluation. Implementation Science, 10(1), 153.
Lavin, C. E., Francis, G. L., Mason, L. H., & LeSueur, R. F. (2020). Perceptions of inclusive education in
Mexico City: An exploratory study. International Journal of Disability, Development and Education,
1–15. doi:10.1080/1034912x.2020.1749572
Law, J., Reilly, S., & Snow, P. C. (2013). Child speech, language and communication need re-examined
in a public health context: A new direction for the speech and language therapy profession.
International Journal of Language and Communication Disorders, 48(5), 486–496.
Li, K. M., & Cheung, R. Y. M. (2019). Pre-service teachers’ self-efficacy in implementing inclusive
education in Hong Kong: The roles of attitudes, sentiments, and concerns. International Journal of
Disability, Development and Education, 1–11. doi:10.1080/1034912x.2019.1678743
Linan-Thompson, S., & Ortiz, A. A. (2009). Response to intervention and english-language lear­
ners: Instructional and assessment considerations. Seminars in Speech and Language, 30(2),
105–120.
Lincoln, Y. S., & Guba, E. G. (1985). Naturalistic inquiry. Newbury Park, CA: SAGE.
Marchal, B., Kegels, G., & Van Belle, S. (2018). Theory and realist methods. In N. Emmel, J. Greenhalgh,
A. Manzano, M. Monaghan, & S. Dalkin (Eds.), Doing realist research (pp. 79–89). London, UK: SAGE.
McColl, M. A., Law, M. C., & Stewart, D. (2015). Theoretical basis of occupational therapy (3rd ed.).
Thorofare, NJ: SLACK.
McCrimmon, A. W. (2014). Inclusive education in Canada. Intervention in School and Clinic, 50(4),
234–237.
Merton, R. K. (1967). On theoretical sociology: Five essays, old and new. New York, NY: he Free Press.
Mills, C., & Chapparo, C. (2018). Listening to teachers: Views on delivery of a classroom based sensory
intervention for students with autism. Australian Occupational Therapy Journal, 65(1), 15–24.
Mire, S. P., & Montgomery, J. K. (2008). Early intervening for students with speech sound disorders.
Communication Disorders Quarterly, 30(3), 155–166.
Missiuna, C., Campbell, W., Dix, L., Pollock, N., Bennett, S., Stewart, D., . . . Cairney, J. (2015). Partnering
for change: An innovative service for integrated rehabilitation services [Webinar]. CanChild. https://
srs-mcmaster.ca/library/p4c_webinar/presentation_html5.html
Missiuna, C., Hecimovich, C. A., Pollock, N., Bennett, S., Campbell, W., Camden, C., . . . Song, K. (2015).
Partnering for change. www.partneringforchange.ca
Missiuna, C., Pollock, N., Campbell, W., DeCola, C., Hecimovich, C., Sahagian Whalen, S., . . .
Camden, C. (2016). Using an innovative model of service delivery to identify children who are
struggling in school. British Journal of Occupational Therapy, 80(3), 145–154.
Missiuna, C., Pollock, N., Campbell, W. N., Bennett, S., Hecimovich, C., Gaines, R., . . . Molinaro, E.
(2012). Use of the medical research council framework to develop a complex intervention in
pediatric occupational therapy: Assessing feasibility. Research in Developmental Disabilities, 33(5),
1443–1452.
Missiuna, C., Pollock, N., Levac, D., Campbell, W., Whalen, S., Bennett, S., . . . Russell, D. (2012).
Partnering for change: An innovative school-based occupational therapy service delivery
model for children with developmental coordination disorder. Canadian Journal of
Occupational Therapy. Revue Canadienne D’Ergothérapie, 79(1), 41–50.
Moher, D., Liberati, A., Tetzlaff, J., & Altman, D. G.; PRISMA Group. (2009). Preferred reporting items
for systematic reviews and meta-analyses: The PRISMA statement. BMJ, 339, b2535.
Nilsen, P. (2015). Making sense of implementation theories, models and frameworks. Implementation
Science, 10, 53.
Ohl, A. M., Graze, H., Weber, K., Kenny, S., Salvatore, C., & Wagreich, S. (2013). Effectiveness of a
10-week tier-1 response to intervention program in improving fine motor and visual-motor skills
 INTERNATIONAL JOURNAL OF DISABILITY, DEVELOPMENT AND EDUCATION 21

in general education kindergarten students. American Journal of Occupational Therapy, 67(5),

507–514.
Page, A., Mavropoulou, S., & Harrington, I. (2020). Culturally responsive inclusive education: The
value of the local context. International Journal of Disability, Development and Education, 1–14.
doi:10.1080/1034912x.2020.1757627
Paul, D. R., Blosser, J., & Jakubowitz, M. D. (2006). Principles and challenges for forming successful
literacy partnerships. Topics in Language Disorders, 26(1), 5–23.
Pawson, R. (2006). Evidence-based policy: A realist perspective. London, UK: SAGE.
Pawson, R., Greenhalgh, T., Harvey, G., & Walshe, K. (2005). Realist review: A new method of
systematic review designed for complex policy interventions. Journal of Health Services
Research & Policy, 10(1), 21–34.
Peña, E. D., & Quinn, R. (2003). Developing effective collaboration teams in speech-language
pathology. Communication Disorders Quarterly, 24(2), 53–63.
Pfeiffer, D. L., Pavelko, S. L., Hahs-Vaughn, D. L., & Dudding, C. C. (2019). A national survey of speech-
language pathologists’ engagement in interprofessional collaborative practice in schools:
Identifying predictive factors and barriers to implementation. Language, Speech, and Hearing
Services in Schools, 50(4), 639–655.
Pollock, N. A., Dix, L., Whalen, S. S., Campbell, W. N., & Missiuna, C. A. (2017). Supporting occupational
therapists implementing a capacity-building model in schools. Canadian Journal of Occupational
Therapy. Revue Canadienne D’Ergothérapie, 84(4–5), 242–252.
QSR International. (2018). NVivo 11. https: //www.qsrinternational.com/.
Ratzon, N. Z., Lahav, O., Cohen-Hamsi, S., Metzger, Y., Efraim, D., & Bart, O. (2009). Comparing
different short-term service delivery methods of visual-motor treatment for first grade students
in mainstream schools. Research in Developmental Disabilities, 30(6), 1168–1176.
Reeder, D. L., Arnold, S. H., Jeffries, L. M., & McEwen, I. R. (2011). The role of occupational therapists
and physical therapists in elementary school system early intervening services and response to
intervention: A case report. Physical & Occupational Therapy in Pediatrics, 31(1), 44–57.
Regan, S., Orchard, C., Khalili, H., Brunton, L., & Leslie, K. (2015). Legislating interprofessional
collaboration: A policy analysis of health professions regulatory legislation in Ontario, Canada.
Journal of Interprofessional Care, 29(4), 359–364.
Reid, L., Bennett, S., Specht, J., White, R., Somma, M., Li, X., . . . Patel, A. (2018). If inclusion means
everyone, why not me? https://www.inclusiveeducationresearch.ca/docs/why-not-me.pdf
Richards, L. (2009). Handling qualitative data. London, UK: SAGE.
Ritter, R., Wehner, A., Lohaus, G., & Krämer, P. (2020). Effect of same-discipline compared to different-
discipline collaboration on teacher trainees’ attitudes towards inclusive education and their
collaboration skills. Teaching and Teacher Education, 87, 102955.
Ritzman, M. J., Sanger, D., & Coufal, K. L. (2006). A case study of a collaborative speech-language
pathologist. Communication Disorders Quarterly, 27(4), 221–231.
Rodriguez, A. D., & Gonzalez Rothi, L. J. (2009). Even broken clocks are right twice a day: The utility
of models in the clinical reasoning process. Advances in Speech Language Pathology, 8(2),
120–123.
Roth, F. P., & Troia, G. A. (2009). Applications of responsiveness to intervention and the
speech-language pathologist in elementary school settings. Seminars in Speech and Language,
30(2), 75–89.
Sanger, D., Mohling, S., & Stremlau, A. (2011). Speech-language pathologists’ opinions on response
to intervention. Communication Disorders Quarterly, 34(1), 3–16.
Shaw, J., Gray, C. S., Baker, G. R., Denis, J. L., Breton, M., Gutberg, J., . . . Wodchis, W. (2018).
Mechanisms, contexts and points of contention: Operationalizing realist-informed research for
complex health interventions. BMC Medical Research Methodology, 18(1), 178.
Siegert, R. J., McPherson, K. M., & Dean, S. G. (2005). Theory development and a science of
rehabilitation. Disability and Rehabilitation, 27(24), 1493–1501.
Silliman, E. R., Ford, C. S., Beasman, J., & Evans, D. (1999). An inclusion model for children with
language learning disabilities: Building classroom partnerships. Topics in Language Disorders, 19
(3), 1–18.
22 W. CAMPBELL ET AL.

Soto, G., Mu Ller, E., Hunt, P., & Goetz, L. (2001). Professional skills for serving students who use AAC
in general education classrooms: A team perspective. Language, Speech, and Hearing Services in
Schools, 32(1), 51–56.
Soto Torres, Y. (2018). Safe and inclusive schools: Inclusive values found in Chilean teachers’
practices. International Journal of Inclusive Education, 24(1), 89–102.
Staskowski, M., & Rivera, E. A. (2005). Speech-language pathologists’ involvement in responsiveness
to intervention activities: A complement to curriculum-relevant practice. Topics in Language
Disorders, 25(2), 132–147.
The World Bank. (2017). World Bank country and lending groups. https://datahelpdesk.worldbank.
org/knowledgebase/articles/906519-world-bank-country-and-lending-groups
Throneburg, R. N., Calvert, L. K., Sturm, J. J., Paramboukas, A. A., & Paul, P. J. (2000). A comparison of
service delivery models: Effects on curricular vocabulary skills in the school setting. American
Journal of Speech-Language Pathology, 9(1), 10–20.
Troia, G. A. (2005). Responsiveness to intervention: Roles for speech-language pathologists in the
prevention and identification of learning disabilities. Topics in Language Disorders, 25(2),
106–119.
United Nations. (2006). Convention on the rights of persons with disabilities. https://www.un.org/
development/desa/disabilities/convention-on-the-rights-of-persons-with-disabilities.html
Veritas Health Information. (2018). Covidence systematic review software. http://www.covidence.org/
Villeneuve, M. (2009). A critical examination of school-based occupational therapy collaborative
consultation. Canadian Journal of Occupational Therapy. Revue Canadienne D’Ergothérapie, 76,
206–218.
Villeneuve, M. A., & Shulha, L. M. (2012). Learning together for effective collaboration in
school-based occupational therapy practice. Canadian Journal of Occupational Therapy. Revue
Canadienne D’Ergothérapie, 79(5), 293–302.
Waldron, T., Carr, T., McMullen, L., Westhorp, G., Duncan, V., Neufeld, S. M., . . . Groot, G. (2020).
Development of a program theory for shared decision-making: A realist synthesis. BMC Health
Services Research, 20(1), 59.
Whyte, J. (2014). Contributions of treatment theory and enablement theory to rehabilitation
research and practice. Archives of Physical Medicine and Rehabilitation, 95(1 Suppl), S17–23 e12.
Wilson, A. L., & Harris, S. R. (2018). Collaborative occupational therapy: Teachers’ impressions of the
Partnering for Change (P4C) model. Physical & Occupational Therapy in Pediatrics, 38(2), 130–142.
Wintle, J., Krupa, T., Cramm, H., & DeLuca, C. (2017). A scoping review of the tensions in OT-teacher
collaborations. Journal of Occupational Therapy, Schools, & Early Intervention, 10(4), 327–345.
Wong, G., Greenhalgh, T., Westhorp, G., Buckingham, J., & Pawson, R. (2013). RAMESES publication
standards: Realist syntheses. BMC Medicine, 11(1), 21.
Wong, G., Westhorp, G., Manzano, A., Greenhalgh, J., Jagosh, J., & Greenhalgh, T. (2016). RAMESES II
reporting standards for realist evaluations. BMC Medicine, 14(1), 96.
World Health Organization. (2010). Framework for action on interprofessional education and colla­
borative practice. https://www.who.int/hrh/resources/framework_action/en/