Disability and Rehabilitation

ISSN: 0963-8288 (Print) 1464-5165 (Online) Journal homepage: http://www.tandfonline.com/loi/idre20

Community participation interventions

for children and adolescents with a
neurodevelopmental intellectual disability: a
systematic review

Jaimi Andrews, Marita Falkmer & Sonya Girdler

To cite this article: Jaimi Andrews, Marita Falkmer & Sonya Girdler (2015) Community
participation interventions for children and adolescents with a neurodevelopmental
intellectual disability: a systematic review, Disability and Rehabilitation, 37:10, 825-833, DOI:
10.3109/09638288.2014.944625

To link to this article: http://dx.doi.org/10.3109/09638288.2014.944625

Published online: 29 Jul 2014.

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ISSN 0963-8288 print/ISSN 1464-5165 online

Disabil Rehabil, 2015; 37(10): 825–833

! 2014 Informa UK Ltd. DOI: 10.3109/09638288.2014.944625

REVIEW

Community participation interventions for children and adolescents

with a neurodevelopmental intellectual disability: a systematic review
Jaimi Andrews1, Marita Falkmer2,3, and Sonya Girdler1,2
1
School of Exercise and Health Sciences, Edith Cowan University, Perth, Western Australia, Australia, 2School of Occupational Therapy and Social
Work, Curtin University, Perth, Western Australia, Australia, and 3School of Education and Communication, CHILD Programme, Institute of Disability
Research, Jönköping University, Jönköping, Sweden
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Abstract Keywords
Purpose: The purpose of this review was to examine the effectiveness of community integration Adolescence, children, community
interventions in facilitating the community participation, self-esteem, and quality of life of participation and quality of life,
children and adolescent’s with a neurodevelopmental intellectual disability. Methods: Electronic intellectual disability,
searches of five databases and manual searches of reference lists were conducted. Community neurodevelopmental disorder
integration interventions which targeted friendship development, recreation participation,
quality of life, and self-esteem were included. Results: Thirteen studies were included in this
History
review. A variety of study designs and interventions were used. All but one study reported
significantly increased friendships, five studies reported increased recreation participation and Received 7 October 2013
one study reported increased quality of life and self-esteem. Methodological quality of the Revised 3 July 2014
studies ranged from adequate to strong. Conclusions: Community integration interventions Accepted 10 July 2014
appear to be effective in enhancing the inclusion of children and adolescents with a Published online 29 July 2014
neurodevelopmental intellectual disability. In particular, findings from this review highlight that
there are potentially many ways to continue to improve the effectiveness of community
participation interventions for this group. These include the need for the development of
programmes which facilitate friendships alongside recreational participation, include typically
developing peers, consider the activity preferences of children and adolescents in developing
programmes, and accommodate individual impairments and needs through grading and
adaptive leisure activities. Future interventions should use the International Classification of
Functioning, Disability and Health as a measurement framework and consider the role of factors
such as impairment, personal and environmental factors in facilitating community participation.

ä Implications for Rehabilitation

 Community participation interventions appear to be effective in enhancing the inclusion of
children and adolescents with neurodevelopmental intellectual disability.
 Future community integration interventions should facilitate friendships alongside recre-
ational participation, include typically developing peers, consider the activity preferences of
children and adolescents in developing programme, and accommodate individual impair-
ments and needs through grading and adaptive leisure activities.
 The International Classification of Functioning, Disability and Health should be used as a
measurement framework and consider the role of factors such as impairment, personal and
environmental factors in facilitating community participation.

Introduction intellectual disability, behavioural problems, impaired speech,

The prevalence of neurodevelopmental intellectual disability
in Western Australia is 14.3 per 1000 people [1].
Neurodevelopmental disability refers to a condition or disorder
which begins in the early stages of development (conception,
birth, infancy, and childhood) [2]. It can result in mild to profound
Address for correspondence: Dr. Sonya Girdler, PhD, School of
Occupational Therapy and Social Work, Curtin University, Perth 6102,
Western Australia, Australia. Tel: +61 08 9266 3630. E-mail: sonya.gird-
ler@curtin.edu.au
social withdrawal, and poor gross motor functioning [3]. Causes
of neurodevelopmental disability include Rett syndrome, autism,
cerebral palsy, Down syndrome, Asperger’s syndrome, and
Fragile X syndrome. These conditions often have a profound
influence on daily life [2]. A clear example of this includes
limitations in the ability to participate in community activities
such as recreation and friendships [2].
For children and adolescents with an intellectual disability,
community participation can enhance physical and mental
wellbeing, promote social inclusion, improve independence, and
increase self-worth, life satisfaction and quality of life [4–7].
 826 J. Andrews et al.
Although the importance of community participation has been
identified, current research suggests that people living with an
intellectual disability participate in fewer recreational activities
than their peers [8].
Interventions and programmes targeted at community par-
ticipation play a key role in facilitating the inclusion of people
with a disability. However to date, few community participation
interventions have been developed for children and adolescents
with an intellectual disability. Instead, research has focus on
the child’s health needs such as medical care [3]. However,
interventions and programmes which target recreational partici-
pation and friendships are reported to be more valued by the
families of children with an intellectual disability than interven-
tions focused on health care [3]. Among children with disability,
targeted community participation programmes have been shown
to increase sports participation and social interaction between
children with and without a disability, as well as improve
academic performance and functional skills [9,10]. In addition,
interventions set in the community provide typically developing
children with an opportunity to gain an understanding of
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disability [11,12].
When designing a community participation intervention for
children and adolescents with a neurodevelopmental intellectual
disability, several factors should be considered. The International
Classification of Functioning, Disability and Health (ICF) is a
holistic, theoretical framework which is often used to describe the
relationship between impairment, activity and participation, and
personal and environmental factors [13].
Impairment factors which may impede community participa-
tion interventions include cognitive and language ability [14] and
severity of intellectual disability [15,16]. Current literature
suggests that young people with a more severe impairment are
less likely to participate in community activities [17,18]. Clinical
symptoms also have the ability to impact the frequency and
intensity at which a child can participate in recreational activities
and friendships [19,20].
Personal factors which may impact on engagement in
programmes targeting community participation include age and
gender [14]. Depending on the age of the child or adolescent,
activity preference and availability of leisure activities may vary.
It has been suggested that as a child with a disability ages, activity
preferences change and activities become less available [17].
Gender may also influence participation as research suggests that
males prefer more physical activities, whilst girls prefer sedentary
activities [21].
For children and adolescents with an intellectual disability,
disability results from the interaction between their intellectual
impairment and the environment, with environmental factors
acting as either a barrier or facilitator to participation [13].
Environmental factors which may influence participation in
community interventions for this group include accessibility,
family socio-demographics, and available community sup-
ports [14,15,22]. Family financial resources can impact
on a young person’s ability to attend programmes due to the
cost of attendance fees or specialised equipment [15]. The
needs of siblings or prior commitments may also need to
be considered [23]. Negative and discriminatory attitudes of the
community can also restrict participation in community
programmes [24].
Therefore, the objective of this systematic review was to
review the effectiveness of community integration interventions
in facilitating the community participation, self-esteem and
quality of life for children and adolescent’s with a neurodevelop-
mental intellectual disability. Community integration interven-
tions for the purposes of this review were those targeting
community, civic and social life and peer friendships [13].
Disabil Rehabil, 2015; 37(10): 825–833
Methods
Search strategy
A search of the COCHRANE database failed to identify a previous
review addressing the objective of this review. Four electronic
databases were then searched for this review. Each database was
searched from its earliest electronic record (Cumulative Index of
Nursing and Allied Health Literature – CINAHL from 1982,
MEDLINE from 1966, PsycINFO from 1685, and SPORTDiscus
from 1381) until April 2012. The main search terms were grouped
into four concepts. The first concept had the following keywords
with intervention and programme added to the end: community-
based, friendship, social skills, group, and peer support. The
second concept included Rett syndrome, Down syndrome, autis*
(autism, autism spectrum disorder), cerebral palsy, neurodevelop-
mental disability, intellectual disability, and mental retardation.
The third concept included outcome key words including
community participation, activity participation, friend* (friend-
ship, friends), leisure, recreation, social interaction, interpersonal,
self-esteem, and quality of life. The fourth concept included
children, adolescent, teenager, and young. With assistance from
the librarian, all terms were adjusted, exploded and truncated in
order to match the database being searched. Forward citation
searching using an electronic database, Web of Science, was
completed on included articles. Manual searches were conducted
on all reference lists of retrieved studies; however, conference
proceedings and grey literature were not searched.
Inclusion and exclusion criteria
A priori criteria for inclusion of studies were applied initially to
titles and abstracts and then full-text articles if the abstract did not
provide sufficient information. Studies were included if the
community integration intervention was delivered in a group and
were aimed at targeting community participation, self-esteem,
and/or quality of life. Interventions were also not limited to being
delivered by a specific health profession or discipline. Participants
in the studies were restricted to children and adolescents aged 5–18
years with a neurodevelopmental disorder resulting in intellectual
disability such as Rett syndrome, Down syndrome, cerebral palsy,
and autism (for the remainder of this review, neurodevelopmental
intellectual disability will be referred to as intellectual disability).
Studies were excluded if the interventions were delivered
individually, during school hours (except during recess and
lunch) or were primarily targeted at parents. Participants which
had an acquired neurodevelopmental disability or physical
disability only were also excluded for this review. Quantitative,
qualitative, and mixed-method studies were included in this
review, and articles were limited to those published in English.
Assessment of methodological quality
Two reviewers independently assessed the quality of each study
using the Standard Quality Assessment Criteria for Evaluating
Primary Research Papers developed by Kmet et al. [25]. This
quality assessment form contains a 14-item quantitative and a 10-
item qualitative checklist. Guidelines and instructions have been
provided to assist reviewers in undertaking quality assessment of
research and calculating a summative quality score. The quality of
assessed research was described as strong (score of 480%), good
(70–80%), adequate (50–70%), or limited (550%) [26]. Any
discrepancies between reviewers were resolved through discussion.
Data extraction
Data were independently extracted from selected studies using the
following headings: study objective, study design, participant and
 DOI: 10.3109/09638288.2014.944625
sample size, intervention used, data collection method, outcome
measures, results, discussion, and limitations. Once data were
extracted, the level of evidence was determined according to the
criteria described in the National Health and Medical Research
Council guidelines [27].
Results
Search strategy and selection criteria
Electronic searches located a total of 396 articles using the key
terms (see Figure 1). The titles and abstracts were reviewed with
325 articles not meeting the inclusion criteria and 16 articles were
unable to be obtained. The full-text of the remaining 55 articles
was reviewed and nine were found to meet inclusion criteria.
Reference lists and citations from web of science were manually
searched resulting in the further inclusion of four articles.
Therefore, 13 studies were included in this systematic review.
An overview of the study designs of the 13 articles included in
this review are presented in Table 1: four were randomised control
trial’s (RCT) [6,28–30], one was a true experimental design (one-
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way repeated measures) [31], seven were quasi-experimental
designs (time series, multiple baseline, pretest–post-test)
[11,12,23,32–35], and one was a mixed methods study [22].
Within the 13 articles, a variety of interventions were reported.
Three were recreation programmes [12,23,31], two were friend-
ship clubs/groups [11,33], two were community art programmes
[22,35], two were social skills groups [32,34], two were friendship
training groups [6,29], one was a Peer-mediated group [30] and
one was a community skills group [28]. Overall, 468 young people
participated in these interventions, 277 with an intellectual
disability including 214 with an autism spectrum disorder
(autism, Asperger’s syndrome) [6,11,12,23,28–30,32–35], one
child with Down syndrome [22], 62 with a non-specified
intellectual disability [28,31,33], and 191 were typically develop-
ing peers [12,22,30–33,35] (see Table 1). All but one study [28],
reported on the impact of interventions on outcomes relating to
friendships, five reported on recreational and activity participation
[12,22,23,31,35], five reported on social skills [6,30,32–34], and
one reported on quality of life and self-esteem/confidence [22].
Figure 1. Flow chart on different phases of
the systematic review.
Studies obtained from Web
of Science n = 2
Studies identified from
reference list n = 2
Community participation interventions 827
Quality of studies
The methodological quality of selected studies is presented in
Table 1. Overall, methodological quality of the 13 included
studies ranged from adequate to strong. There appeared to be no
relationship between the type of intervention protocol and the
quality of the article. For most articles, the study design,
objective, method of participant selection, participant/comparison
characteristics, and outcome measures were clearly described.
Random allocation of participants and blinding of investigators
varied, depending on the study design. Due to the nature of the
interventions, it was impossible to blind participants. Very few
articles reported effect sizes, confounding variables, and variance.
Other shortcomings included poorly reported sample sizes, with
readers left to make their own conclusions. Generally, the
analytical methods were justified appropriately and the results
and conclusion sections were reported in detail.
Interventions
The intention of this review was to examine the effectiveness of
interventions targeting community participation of young people
with a neurodevelopmental intellectual disability, however, the
majority of the interventions identified targeted friendships rather
than recreational or leisure participation. Even though it has been
reported that both friendship and leisure participation are
important in promoting quality of life and health and well-being
for children with an intellectual disability [36], only four of the 13
studies incorporated both friendship facilitation and recreational
participation into their programmes [11,12,23,31].
Of the 13 included articles, seven were specifically targeted at
facilitating friendships [6,11,29,30,32–34]. The aim of these
interventions was to develop friendships, teach appropriate social
skills for friendship development (conversation and initiation
skills), and promote inclusion in peer groups. Three studies
[12,23,31] undertook a recreational programme aimed at
promoting participation in well-known sports and preferred
activities, while also encouraging friendship development.
Finally, two studies were described as community art programmes
[22,35]. These aimed to enhance basic art skills, encourage
Titles and abstracts
identified screened
n = 396
Excluded n = 325
Unable to obtain/ further
information required to make
assessment n = 16
Full copies retrieved and
assessed for eligibility
n = 55
Excluded n = 46
Age n = 15
No intervention n = 3
Outcomes not relevant n = 8
Individual/paired interventions
n = 11
ABI or physical disability n = 4
Foreign language n = 3
Systematic review n = 2
Publications meeting
inclusion criteria and
included in review n = 13
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828
Table 1. Findings of the included studies.

Author, year, Design/number of Intervention

J. Andrews et al.
a
country participants Participants group Control group Outcome measures Results Methodological quality

Frankel 2010 USA RCT (n ¼ 68) Children with high Children’s friendship training Delayed interven- Friendships Friendships Strong quality (score ¼ 24/28)
functioning ASD group (n ¼ 35) tion group  The loneliness scale (child) Significant change (p40.05) " Investigators and participants
and their parents Aim: develop friendships (n ¼ 33)  Piers self-concept scale in play dates (number, not blinded. Large sample size,
7–11 y 12 weekly sessions (child) behaviour), child’s self-con- analytical and variance
Classroom (after-hours)  Quality of play questionnaire trol and assertiveness described, random allocation,
Children and parents (parent) Significant change (p50.025) study design evident, and
(separated)  The Pupil Evaluation # loneliness, " popularity results/conclusion sufficiently
Inventory (teacher) reported
Social skills
 Social Skills Rating System
(parent)
Mackay 2007 UK Quasi-experimental Children with high Social skills group – Friendships Friendships Good quality (score ¼ 20/26).
time series functioning ASD Aim: friendship skills  Informal interviews (parent) " social participation and Sample size and confounding
(n ¼ 46) 6–16 y 12–16 weekly sessions 8 per Social skills appropriate conversation variables partially reported.
group  Spence social skills and (p50. 001) Investigators blinded, no
6 groups: 3  6–11 yo; 3  12– social competence with Social skills random allocation and variance
16 yo Classroom (after- peers questionnaires " social skills and competence not reported. Random alloca-
hours) & community (parent/child) (turn-taking, personal space, tion, and results/conclusion suf-
outings  The three things – key social body language) (p50.01) ficiently reported
skills (parent)
Laugeson 2008 RCT (n ¼ 33) Teenagers with ASD Parent assisted social skills Delayed interven- Friendship Friendships Good quality (score ¼ 20/28).
USA 13–17 y group (n ¼ 17) tion group  Friendship quality scale  " hosted get togethers, better Investigators and participants
Aim: develop friendships (n ¼ 16)  The quality of play ques- quality friendships not blinded, variance not
12 weekly sessions 7 per group tionnaire (parent/teen) (p50.05) reported, sample size and con-
Classroom (after hours) Social skills Social skills founding variables partially
Children and parents  Social skills training scale  " knowledge of social skills reported. Random allocation,
(separated) (parent/teacher) compared to delayed inter- and results/conclusion suffi-
 Test of adolescent social vention group (p50.05) ciently reported.
skills knowledge (teen)
Kasari 2012 USA RCT (n ¼ 75) Children with high Peer-mediated group (n ¼ 60) No intervention Friendships Friendships Good quality (score ¼ 21/28).
functioning ASD Aim: develop friendships Children with high  Social network survey (child)  " no. Friendships and social Blinding of participants not
(n ¼ 30) 2 sessions/wk for 6 wk functioning  Playground observations network (p ¼ 0.02) reported, sample size and con-
Children without ASD Recess and lunch at school ASD (n ¼ 15) (assessor)  Reciprocal friendships were founding variables partially
(n ¼ 45)  Self, peer and teacher reports non-significant reported. Investigators blinded,
6–11 y Social skills  # isolation on the playground random allocation, and results/
 Teachers report Social skills conclusion sufficiently reported.
 " social skills (p ¼ 0.01)

Disabil Rehabil, 2015; 37(10): 825–833

Becker 2010 USA Case report Girl with Down syn- Performing arts group – Quality of life  " QOL and self-confidence Adequate quality (score ¼ 13/20).
(n ¼ 1) drome (11 y, mild Aim: participation in dance,  PedsQL (parent)  " interaction and engagement Poorly described study. Data
cognitive impair- voice, acting 14 weekly Friendships, Self-confidence, with peers collection and analysis not
ment) sessions Engagement  " motivation for other com- clearly described. No verifica-
Children without Down Community performing arts  Observations munity programmes tion procedures to establish
syndrome (8–14 y) centre  Parent report credibility or reflexivity of
account.
Haring 1992 USA Multiple baseline Adolescent’s with Social network group – Social interaction/friendships Friendships Adequate quality (score ¼ 15/22).
(n ¼ 11) autism (n ¼ 1) & Aim: facilitate social inter-  Observations (assessor)  " friendships (quality, quan- Sample size not identified.
intellectual disabil- action and inclusion  Qualitative - satisfaction, tity, interactions) Confounding variables, variance
ity (n ¼ 1) Weekly sessions  " peer interaction outside of and analytical methods partially
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DOI: 10.3109/09638288.2014.944625
Adolescent’s without 2 Groups: 1 (n ¼ 5), 2 (n ¼ 6) peer interaction/relationship school and continued peer described. Blinding and random
autism & intellec- Recess, lunch and classroom (child and peers) network allocation N/A.
tual disability (after-hours) Social skills
(n ¼ 9)  " knowledge of social skills
12–13 y
Barry 2003 USA One-group pretest– Children with high Social skills group – Social skills Social Skills Good quality (score ¼ 18/24) Small
post-test functioning autism Aim: Social skills and friend-  SSRS- social skills compe-  Significant " Greeting skills sample size, confounding vari-
(n ¼ 11) (n ¼ 4) ships tence (parent) (p50.03) ables not considered, and study
Children without 8 weekly sessions  Social skills observations –  Trend for " conversation design not clearly identified.
autism (n ¼ 7) (only Out-patient university psych- play (investigators) skills (p50.10) Investigators blinded, results/
used for assessment ology clinic (community)  Social skills interview – was  " Greeting skills outside conclusion sufficiently reported,
period) the child using the skills in clinic and analytical methods justified.
6–9 y community setting (parent) Friendships/Social Support
Friendship/Social Support  Significant " in perceived
 Social support scale (child) social support from peers
 Loneliness scale (child) (p50.05), play (p50.03)
 " meaningful peer relation-
ships between children with
and without autism
 # perceived loneliness
Siperstein 2009 One-way repeated Children with mild Summer recreational pro- – Friendships Friendships Good quality (score ¼ 17/22)
USA measures intellectual disabil- gramme  Peer hang-out-with and  Children with ID made new Blinding and random allocation
(n ¼ 67) ity (n ¼ 29) Aim: participation in swim- friendship inventory (child) friends and more accepted N/A. Study design, confounding
Children without intel- ming, basketball, soccer, Recreational participation by peers variable and variance not clearly
lectual disability free play, arts & crafts  Adapted sports skills assess- Recreational participation identified. Large sample size
(n ¼ 38) 5 sessions/wk for 4 wk ment (investigators)  Significant " in swimming and analytical methods
8–13yo 12 per group and soccer skills for chil- described.
Leisure centre dren with ID (p50.001)
 Strong relationship between
sports skills and building
relationships (p50.01)
Drysdale 2008 RCT (n ¼ 40) Children with moderate Community skills group No intervention ! Community skills (shopping Community skills (shopping Good quality (score ¼ 22/28)
Ireland intellectual disabil- Aim: participation in games, normal class- and telephone) and telephone) Participants not blinded.
ity (8 autism and 32 learning shopping and tele- room activities  Observations  Intervention group " under- Confounding variables con-
non-specified) phone skills (n ¼ 16)  Task analysis standing of required shop- sidered, small sample size ana-

Community participation interventions

9–11 yo 2 sessions/wk for 8 wk ping skills (p ¼ 0.007) lytical methods described,
6 per group  No change in handling of random allocation, blinded
2 groups: 1 - classroom and money, making telephone investigators, study design evi-
community training call dent, and results/conclusion
(n ¼ 12); 2 - classroom  No difference between sufficiently reported.
training (n ¼ 12) classroom and community
Classroom (after hours) and based training
community outings
Fennick 2003 USA Two-group pre- Children with mild to Recreation group – Recreational participation/ Recreational participation Adequate quality (score ¼ 11/20).
test–post-test (n severe autism Aim: participation in swim- Friendships  Positive feedback on pro- Random allocation and blinding
¼ not specified) (n ¼ 5) ming, gymnastics, develop  Observations ! participa- grammes N/A. Analytical methods,
Children without friendships tion, attendance and enjoy- Friendships results and conclusion partially
autism 2 groups: 1 - swimming (n ¼ 3); ment  No improvement in friend- described. Small sample size
6–13 yo 2 - gymnastics (n ¼ 2)  Parent survey ships and confounding variables not
Leisure centre  " participation in group considered
community programmes
(continued )

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830
Table 1. Continued

Author, year, Design/number of Intervention

J. Andrews et al.
a
country participants Participants group Control group Outcome measures Results Methodological quality

Schleien 1995 USA Multiple baseline Children with mild to Community art programme – Friendships Friendships Strong quality (score ¼ 18/22)
(n ¼ 32) severe autism Aim: develop friendships, learn  Observations – positive  Significant " in positive Random allocation and blinding
(n ¼ 7) art skills interactions, appropriate and interactions initiated by N/A. Sample size is large.
Children without 7 monthly sessions inappropriate behaviour children without autism Confounding variables and
autism (n ¼ 25) Community museum towards children with variance partially described
7–11 yo autism: younger group
(p ¼ 0.012); older group
(p ¼ 0.007)
 No change in initiation or
conversation by children
with autism
Schleien 1987 USA One-group pretest– Children with severe Summer recreation programme – Friendships Play/participation Strong quality (score ¼ 18/22)
post-test autism (n ¼ 2) Aim: participation in badmin-  Attitude acceptance scale  Appropriate play signifi- Random allocation and blinding
(n ¼ 69) Children without ton, basketball, volleyball, (peers) cantly " in recreational N/A. Sample size, variance and
autism (n ¼ 67) gymnastics, swimming, Play/participation activities confounding variables not men-
7–12yo tennis, squash, free time  Behavioural observations –  " depending of participants tioned. Analytical methods and
5 sessions/wk for 3 wk in play and with peers preferred activity results/conclusions sufficiently
3 age groups: 7–8 yo; 9–10 yo; (children and peers) Friendships described.
11–12 yo  " in appropriate peer
University campus interaction
(community)
Carter 2004 USA Two-groups pre- Children with Friendship club – Friendships, enjoyment, Friendships Adequate quality (score ¼ 13/22).
test–post-test Asperger’s syn- Aim: develop friendships and activity participation  Most children had " friend- Random allocations and blind-
(n ¼ 10) drome skills.  Observations ships ing N/A. Study design, outcome
8–15 yo 6 weekly sessions  Verbal and written feedback Activity participation measures, analytical methods
2 age groups: 8–10 y (n ¼ 6); from children and parents  " activity participation and and results not sufficiently
11–15 yo (n ¼ 4) enjoyment described. Variance and con-
Classroom (after hours) and founding variables not described
community
a
N.B. – Scoring for methodological quality ¼ total sum (‘‘yes’’  2 + ‘‘partial’’  2)/total possible score (28 – number of N/A  2).

Disabil Rehabil, 2015; 37(10): 825–833

 DOI: 10.3109/09638288.2014.944625
friendship development, and promote participation in art activities
such as dancing, singing, acting, and arts and crafts.
Intervention settings included two held in a school classroom
(after-hours) [6,29], and two at school during recess and lunch
breaks [30,33]. Six were conducted in a community setting (leisure
centre, museum, performing arts centre, university campus)
[12,22,23,31,32,35] and three were held both in a classroom and
community setting [11,28,34]. Controversy exists in relation to the
most appropriate setting for delivery of interventions. While some
research has found that skills learnt in the classroom were
transferred to the playground and not the community [30], other
research has reported that skills learnt in both the classroom and
community were generalised to the community setting [11,34]. In
comparison, Drysdale et al. [28] found no difference between the
classroom setting and the community setting in skill transfer,
however the results from this study should be interpreted with
caution due to limitations in the study methodology which included
the small size of study groups and the fact that the community
training comprised of only two outings.
Several studies found that engaging in programmes and
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interventions with typically developing peers as well as children
with an intellectual disability was more beneficial than an
intervention with just children with an intellectual disability.
Participation in community activities with typically developing
peers was important for children with an intellectual disability as it
enhanced normalisation, increased recreational opportunities and
encouraged positive friendships [11,12,22,23,30,31,33]. In studies
which only involved children and adolescents with an intellectual
disability [6,11,29,32], both researchers and parents reflected that
future programmes should include typically developing peers.
Studies included in this review also highlighted the importance
of considering activity preferences in the development of
programmes. Three studies [11,12,23] identified that incorporat-
ing the activity preferences of children and adolescents with an
intellectual disability significantly increased participation and
engagement in recreational activities.
Comparison groups varied for all four RCT’s. The two
friendship training groups [6,29] were evaluated against a 12-
week delayed treatment group. The peer-mediated group [30] was
compared against a no-treatment group. Finally, the community
skills programme [28] evaluated the difference between three
groups: classroom training, classroom training, and community
outings, and a no-treatment group.
Outcomes
Four broad outcomes; friendships, recreational participation,
community participation skills, and quality of life were evaluated
for this systematic literature review (Table 1).
Friendships
Despite using a variety of outcomes measures, all but one study
measuring friendships as an outcome reported significant positive
changes. Friendships interventions were evaluated in three RCT
studies [6,29,30], with two studies comparing intervention groups
with delayed treatment groups [6,29], and one with a no-treatment
group [30]. Significant improvements in friendships (quality,
quantity) and play dates were found using friendship measures
including the Friendship Quality Scale [6], the Quality of Play
Questionnaire [6,29], the Social Network Survey and via obser-
vations and interviews [30]. A significant decrease in loneliness
was also reported using social inclusion scales including the
Loneliness Scale, Piers Self-concept Scale, and the Pupil
Evaluation Inventory [29]. Of the four pretest–post-test studies
evaluating friendship interventions [11,12,23,32], three studies
reported significant increases in friendship quality, quantity, and
Community participation interventions 831
interactions [11,12,32]. While Fennick et al. [23] reported no
observed improvement in friendships through observations, Carter
et al. [11] reported qualitative improvements and two studies
reported significant friendship improvement in friendship on
measures of social inclusion [12] social support, and a decrease in
loneliness [32]. A significant increase in positive friendships and
interactions outside of school was reported following friendship
interventions in two multiple baseline designs [33,35], one time
series design [34], one repeated measures design [31] and case
report [22] when measured using observations [22,33,35], infor-
mal interviews [34], and the Peer Hang-out-with and Friendship
Inventory [31].
Recreational participation
Five studies reported on the effectiveness of interventions
aimed at facilitating participation in recreational activities
[12,22,23,31,35]. Two pretest–post-test studies evaluating recre-
ational programmes [12,23] reported a significant increase in
sports participation using observations as an outcome measure,
however only the study by Schleien et al. [12] was assessed as
strong methodologically. One repeated measures [31] and one
mixed methods study [22] yielded similar results to the pretest–
post-test studies assessing participation in recreation activities
through observation [22] and the Adapted Sports Skills
Assessment [31]. In addition, Siperstien et al. found a strong
relationship between sports skills and building friendships
(p50.01) and Becker et al. reported that following a recreation
intervention, a girl with Down syndrome had increased motiv-
ation to attend other community programmes. Carter et al. [11]
also reported increased participation among participants in
informal leisure activities following a friendship club, even
though the stated aim on the intervention was to promote
friendships.
Community participation skills
Only one study examined the effectiveness of an 8-week
community skills intervention in facilitating community partici-
pation skills in 40 children with an intellectual disability [28].
This study also evaluated if classroom training supplemented by
community-based training resulted in better outcomes for par-
ticipants in comparison to classroom training only. Following a
three-armed RCT, significant differences were found between
both intervention groups and the control group in a shopping task
(p ¼ 0.007); however, there was no significant difference between
the intervention groups. Participants improved in their perform-
ance on a shopping task regardless of whether they had received
community skills training in the classroom only or classroom
training supplemented by community-based training. The meth-
odological quality of this RCT was rated as good; however, the
small sample size across the three intervention groups is likely to
have resulted in the study being underpowered (Table 1).
Quality of life
Only one study, a case report, examined the impact of
participating in a community performing arts programme on the
quality of life and self-esteem of an 11-year-old girl with Down
syndrome and mild cognitive impairment [22]. Following
participation in a 14-week performing arts session the girl’s
mother reported that her quality of life increased in all subsets of
the Paediatric Quality of Life Inventory (PedsQL) [37] except for
emotional function, with a total scales score increasing from 51 to
57. Qualitative improvements were also observed in relation to the
girls motor and social abilities. The methodological quality of this
study was assessed as adequate (Table 1).
 832 J. Andrews et al.
Discussion
This systematic review found adequate to strong evidence that
community integration interventions appear to be effective in
promoting the successful inclusion of children and adolescents
with an intellectual disability. However, findings from this review
also highlight that there are potentially many ways to continue to
improve the effectiveness of community participation interven-
tions for this group. These include the need for the development
of programmes which facilitate friendships alongside recreational
participation, include typically developing peers, consider the
activity preferences of children and adolescents in developing
programmes, and accommodate individual impairments and needs
through grading and adaptive leisure activities.
This review found that the majority of reported interventions
targeted friendships rather than recreational participation. This is
despite evidence which suggests that cooperatively structured
integrated recreation programmes, which include both children
with and without disabilities promote both social inclusion and
friendships [31,38]. While accommodating the competitive nature
Downloaded by [Curtin University Library] at 00:00 30 August 2017
of sports and individual abilities in an integrated setting can pose
many challenges to programme leaders, successfully balancing
these aspects can result in benefits for children both with and
without intellectual disabilities [31,39]. There is a clear need for
future research to explore ways in which recreation programmes
can enhance the community participation of children and
adolescents with intellectual disability, because as concluded by
Siperstein et al. [31], ‘‘One thing is clear: When the focus is on
recreation and having fun together, the social inclusion of children
with intellectual disabilities is possible’’ (p. 105).
This review found evidence to suggest that interventions that
included typically developing peers with children with intellectual
disability are a more effective model for delivering community
integration interventions than those that only include children with
intellectual disabilities. A recurring theme throughout previous
research has been the finding that children and adolescents with
intellectual disability have few friends [20] and engage in social
and recreational activities more often on their own and with family
members than their typically developing peers [20,40]. Parents
report that the social aspects of group interventions can be
motivating for adolescents with intellectual disability [39].
Collectively, these findings suggest that future community inte-
gration interventions should focus on facilitating engagement with
typically developing peers as a means of enhancing friendship
outcomes and fostering community inclusion.
Participation in community integration interventions was also
enhanced for children and adolescents with intellectual disability
as a result of including individual preferences in programmes.
Individual preferences are linked to the subjective aspects of
participation, captured in ICFs definition of participation as
‘‘involvement in a life situation’’ [13]. Clearly, the level of
engagement and involvement is an important factor in successful
interventions aimed at enhancing societal inclusion. Incorporating
individual preferences in interventions can only serve to facilitate
engagement. Information about an individual’s engagement and
subjective feelings of belonging while involved in community
integration interventions could be taken into account and
measured in relation to future interventions.
Accommodating individual impairments and needs through
grading and adapting leisure activities has the potential to
facilitate the community participation of children and adolescents
with intellectual disabilities [20]. This approach is consistent with
the associations between impairment and participation described
in the ICF. Further, succeeding in leisure and recreational
activities motivates further participation [40], and while there
are obvious challenges in delivering community integration
Disabil Rehabil, 2015; 37(10): 825–833
interventions in a group setting which meet individual needs,
interventions that can balance these tension will ultimately be the
most effective in maximising the community integration of
children and adolescents with intellectual disability.
In considering the impact of factors which may influence
participation in community integration interventions for young
people, the research suggests that both individual and environ-
mental factors were important. Impairment factors such as the
impact of clinical symptoms and severity of disability participation
was discussed in several studies. Fennick et al. [23] reported that a
limited ability to communicate negatively affected participants’
ability to form friendships. A number of studies also reported that
children and adolescents with a more severe intellectual disability
were less likely to recognise friendships [30,34], improve in their
community living skills [28], or engage in the programme as a
whole [31]. Both age and gender were examined as potential
personal factors which may impact on participation in pro-
grammes. Four studies [6,12,31,34] purposefully formed similar
age and sex groups to facilitate similar age and sex friendships.
Potential environmental factors which were identified included
family social demographics, accessibility, and community sup-
ports. Several strategies were described in relation to minimising
the impact of family socio-demographic circumstances on
participation and attendance in interventions including incentives
such as paid parking and minimising the cost of programmes
[6,31,34]. Other strategies included grouping children according
to parents’ and childs’ availability, prior commitments and
geographic location [23,34]. Several of the interventions
described strategies to accommodate for the needs of children
and adolescents with an intellectual disability including assistive
equipment, individualised programmes, and modifications to
sporting activities [6,11,12,22,23,34,35]. Community supports
were targeted in four studies with teachers and typically
developing peers learning strategies to promote the inclusion of
children with an intellectual disability [23,30,32,35].
The overarching and preferred outcome in the ICF is health
defined as the outcome of functioning in the domains of the body,
activity, and participation [13]. Restrictions in any of the
components affect an individual’s functioning and influences
health. The results from this review support the notion that
facilitating community participation for children and adolescents
with an intellectual disability is complex, and therefore interven-
tions need to target multiple factors as described by the ICF. The
use of the ICF framework in future research could be helpful as it
supports an interdisciplinary approach, offers a common language
for researchers, and supports measurement of functioning and
disability as well as contextual factors. Research based on the ICF
can help to develop our understanding of how the performance of
activities is influenced by body functions and structures which, in
turn, may affect activities and/or participation.
Limitations from this systematic review should be clarified.
First, only four electronic databases were used to search the
literature. However, these databases were those most likely to
identify research examining the objective of this review. Second,
very few studies reported effect sizes, making it difficult to
compare to retaliative effectiveness of the individual interventions.
Third, parent proxy reporting was used in several studies of young
people with a moderate to severe disability. This could potentially
affect the findings from these studies as it may be difficult for
parents to accurately report on their child’s quality of life. Finally,
assessment of the methodological quality revealed that four studies
[11,22,23,33] were of adequate quality. This highlights the need for
more robust methodologies in this area of research.
Overall, this systematic literature review highlights the need
for more research examining the effectiveness of interventions
which aim to increase leisure participation, friendships, and
 DOI: 10.3109/09638288.2014.944625
quality of life of young people with intellectual disability. When
planning interventions, impairment, personal and environmental
factors should be considered. Programmes should also aim to be
flexible, promote activity preference, encourage active participa-
tion, and provide enjoyment for all young people [15,22]. Only 13
articles met the inclusion criteria for this systematic review,
indicating that further research is required in this area. Being a
full and active member of the community is important in the
development of all young people, and while limited by the
available research this review has highlighted some of the key
factors in enhancing the effectiveness of community participation
interventions for children and adolescents with an intellectual
disability.
Declaration of interest
The authors declare no conflicts of interests. The authors alone
are responsible for the content and writing of this article.
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