Participation in school is crucial for children’s learning, development, health, and well-being. Participation and engagement in learning processes has been linked to better academic, social-emotional, and behavioral outcomes, while poor engagement is associated with difficulties in schoolwork, relationships, and increased health problems (Reschly & Christenson, 2022). In Sweden, several reports have identified challenges related to children’s participation at school and the insufficient support provided, especially for children with neurodevelopmental disabilities and mental health problems (Attention, 2023; Swedish Inspectorate, 2022). These reports actualize the need for creating inclusive learning environments and providing targeted interventions that enhance engagement, participation, and overall well-being.

Viewing inclusion as ensuring all children’s right to adequate support in school, rather than merely integrating those in need of special support into mainstream settings (Ainscow, 2020; Nilholm & Göransson, 2017), requires innovative support models. These models should support teachers in creating inclusive learning environments that benefit all children, rather than focusing on individual students. This study evaluated Partnering for Change (P4C), a service delivery model designed to create inclusive learning environments through interventions at the class, group, and individual levels (Missiuna et al., 2012; Missiuna, 2015) in Sweden.

P4C emphasizes capacity development through the partnership between occupational therapists (OT) and teachers, focusing on collaborative real-time interventions without formal diagnosis (Campbell et al., 2023). The partnership is characterized by interprofessional collaboration and joint problem-solving, in which both teachers and OTs collaborate on equal terms to promote children’s participation and engagement at school. This service delivery model includes three tiers of interventions in the learning environment—universal design for learning (UDL) for the entire class, group interventions, and individual support—tailored to the specific needs of students and adjusted over time based on their responses.

Previous studies in Canada have demonstrated that P4C increases the knowledge and capacity of teachers, OTs, as well as parents to create support that is adapted to children’s varying needs (Missiuna et al., 2012; Missiuna, 2015). Furthermore, P4C has proven effective in delivering class-level interventions that benefit the entire educational setting (Camden et al., 2021). However, research about the impact of P4C on children’s engagement and participation in school remains limited. In addition, little is known about how the collaboration within P4C can be structured to enhance teachers’ and OTs’ capacity to foster inclusive learning environments.

The aim of this study was to evaluate the effect of P4C for children’s participation and engagement, as well as school professionals’ capacity development for inclusion. Additionally, it explored school professionals’ perceptions of interprofessional collaboration within P4C.

The study was conducted in elementary school classes from preschool class to grade six in Sweden (6-12 y.o.). Participants included nine intervention classes (213 students, 13 teachers and five OTs) and nine control classes (231 pupils and 9 teachers). To recruit participants, information about the project was distributed through social media and in direct contact with municipalities and schools. The participants received information about the project and had time to consider their participation. Informed consent was obtained from principals, teachers, and parents prior to participation. The intervention followed P4C in which a three-tiered approach, Universal Design for Learning targeting the entire class rather than individual students is applied first. Group and individual levels (tier 2 and 3) are collaboratively planned only after implementing and evaluating the first universal tier. Before implementing P4C, OTs completed an online training course, developed by the CanChild research group and adapted for Swedish conditions. At the start of the intervention, Dynamic Performance Analysis (DPA) was used to identify performance breakdowns in the classroom as teachers and OTs jointly analyzed the performance breakdowns and set performance goals and interventions to prevent low engagement in learning. During the intervention, the OTs collaborated with teachers through regular planning and follow-up meetings. Control classes followed standard practice in accordance with the Swedish Education Law (SFS 2010:800), which mandates a three-tiered support system (i.e. universal supports to all pupils, extra adaptations and special support). Data collection was conducted at three time points: (a) baseline, before the P4C was implemented; (b) post-test, immediately after the P4C (4 months); (c) follow-up, 11 months after at the end of the following semester. Data on children’s engagement in school was collected using Engagement versus Disaffection with Learning, Teacher Report (EEL) (Ritosa et al., 2020). Students completed the Swedish Child Health Utility 9D (CHU9D) (Stevens, 2009), measuring health-related quality of life, and How I Feel About My School (HIFAMS) questionnaire (Ford, 2016). Additionally, OTs observed occupational performance in school-based activities and their findings were documented digitally (Campbell et al., 2016). They also rated the attainment of occupational performance goals. Teachers’ and OTs’ self-rated capacity development for inclusion using the Knowledge, Skill and Experience questionnaire (Missiuna et al., 2014). Three focus group interviews were conducted with school professionals in the intervention group to explore their perceptions of capacity development in interprofessional collaboration within the P4C.

Preliminary results indicate that 85% of the performance goals for children in the intervention group were partly or fully achieved, and there was a significant increase in occupational performance in intervention classes before and after P4C. Furthermore, the intervention group reported higher amount of supports focused on the universal level (i.e. directed to all the pupils) compared to the control group (89 vs. 16 documented supports). However, the results indicate relatively high student engagement and well-being in both groups both before and after P4C. Regarding capacity development, school professionals in both intervention and control group reported increased capability to create inclusive school environments over time. However, teachers in the intervention group showed greater improvements in their ratings. The interviews with school professionals complemented the quantitative results and explored their perceptions of capacity development while participating in the study. The results show that participants developed greater awareness of children’s diverse ways of participating in the lessons. They provided multiple examples of class-wide adaptations and reported using differentiated teaching strategies designed for whole class rather than for individual students. Additionally, the professionals reflected on key aspects of interprofessional collaboration for inclusion, such as valuing each other’s roles and perspectives, resolving differences through open communication, setting common goals, and adapting collaboration to specific educational contexts. Furthermore, a crucial factor in fostering collaboration and enhancing the capacity to create inclusive learning environments was that the collaboration took place in the students' natural setting — the classroom. Teachers highlighted this as a key difference compared to other professional development initiatives, which often involved theoretical lectures without practical tools for application. In P4C, collaboration was grounded in addressing real-time problems, allowing teachers to apply their knowledge, develop new insights, and create solutions together.

Ainscow, M. (2020). Promoting inclusion and equity in education: lessons from international experiences. Nordic Journal of Studies in Educational Policy, 6(1), 7–16. https://doi.org/10.1080/20020317.2020.1729587 Attention (2023). Om vi bara hade fått hjälp tidigare. [If we just got the supports earlier]. https://attention.se/2023/02/22/ny-rapport-om-vard-och-stod-till-unga-med-npf/ Camden, C., Campbell, W., Missiuna, C., Berbari, J., Héguy, L., Gauvin, C., Dostie, R., Ianni, L., Rivard, L., & Anaby, D. (2021). Implementing Partnering for Change in Québec: Occupational Therapy Activities and Stakeholders’ Perceptions. Canadian Journal of Occupational Therapy (1939), 88(1), 71–82. https://doi.org/10.1177/0008417421994368 Campbell, W., Missiuna, C., Dix, L., & Whalen, S. S. (2023). Partnering for Change: collaborating to transform occupational therapy services that support inclusive education. Frontiers in Public Health, 11, 1275920–1275920. https://doi.org/10.3389/fpubh.2023.1275920 Ford T. (2026). How I feel about my school: the construction and validation of a measure of wellbeing at school for primary school children. Journal of the American Academy of Child & Adolescent Psychiatry, 55(10):S156-S. Missiuna, C. A., Pollock, N. A., Levac, D. E., Campbell, W. N., Whalen, S. D. S., Bennett, S. M., Hecimovich, C. A., Gaines, B. R., Cairney, J., & Russell, D. J. (2012). Partnering for Change: An Innovative School-Based Occupational Therapy Service Delivery Model for Children with Developmental Coordination Disorder. Canadian Journal of Occupational Therapy (1939), 79(1), 41–50. https://doi.org/10.2182/cjot.2012.79.1.6 Missiuna C. Partnering for change: embedding universal design into school-based occupational therapy. Occup Ther Now. 2015;17:13–5. Nilholm, C., & Göransson, K. (2017). What is meant by inclusion? An analysis of European and North American journal articles with high impact. European Journal of Special Needs Education, 32(3), 437–451. https://doi.org/10.1080/08856257.2017.1295638 Reschly, A. L., & Christenson, S. (Eds.). (2022). Handbook of research on student engagement (Second edition.). Springer. Ritoša A, Danielsson H, Sjöman M, Almqvist L, Granlund M. Assessing school engagement: Adaptation and validation of “Engagement Versus Disaffection With Learning: Teacher Report” in the Swedish educational context. Frontiers in Education. 2020;5. Stevens K. Developing a descriptive system for a new preference-based measure of health-related quality of life for children. Qual Life Res. 2009;18(8):1105-13. Swedish Educational Law (SFS 2010:800). Swedish Inspectorate (2022). Skolors arbete för en tillgänglig lärmiljö för elever med neuropsykiatriska svårigheter. [Schools’ work for accessible environment for pupils with neurodevelopmental disorders]. https://www.skolinspektionen.se/beslut-rapporter/publikationer/kvalitetsgranskning/2023/skolors-arbete-for-en-tillganglig-larmiljo-for-elever-med-neuropsykiatriska-svarigheter/