Environmental factors play a vital role in either supporting or hindering participation of young children in home, preschool, and community contexts [1
]. Environmental factors refer to the physical, social, and attitudinal features that surround a child, as defined in the International Classification of Functioning, Health, and Disability (ICF) [4
]. The five domains of environmental factors framed by the ICF include “Products and technology”, “Natural and human-made changes”, “Support and relationship”, “Attitude”, and “Services, systems and policies” [4
]. For young children who have or are at risk for developmental disabilities, the Division for Early Childhood (DEC) Recommended Practices (2014) suggest aspects of physical (e.g., space and equipment), social (e.g., attitude and relationship of peers and other family members), and temporal (e.g., sequence of routines and activities) environments that can be altered to support young children’s learning [5
]. Practitioners and families are encouraged to provide inclusive and enriched learning environments that fosters children’s overall health and development [5
Children who have health conditions associated with physical disabilities (PD), such as cerebral palsy, or motor or developmental delay, have impairments in body functions and activity limitations that often restrict their daily participation. However, unsupportive environments can even have greater impacts on the restriction of participation [2
]. Previous research has focused on school-age children with disabilities, in which inaccessible physical environments, negative societal attitudes, and lack of supports, assistance, and resources were frequently identified barriers to participation [7
]. Among the few studies involving preschool children with disabilities, lack of time and money, limited access to social support, transportation, programs, and services were perceived as barriers to preschool or community participation [1
]. Despite the growing evidence on the environmental impacts on children’s participation, little is known about environmental barriers experienced by preschool children with disabilities in Taiwan. Knowledge of environmental barriers will help to develop solutions or strategies of environmental modification to support children’s access to and participation in daily activities [5
Research indicates diverse patterns of home, education, or community environmental supports/barriers to participation between children with and without disabilities [16
]. To be specific, parents of school-age children with disabilities tend to report more environmental barriers and less supports in home, school, and community than those of children without disabilities [19
]. On the other hand, parents of children without disabilities were more likely to consider an environmental factor to not be an issue, or indicated no additional needs for resources such as public transportation and community programs or services [20
]. Similarly, parents of preschool children with developmental disabilities reported less preschool and community environmental supports in comparison to parents of children without disabilities [1
]. However, it is still not clear whether parent-reported barriers differ between children with and without disabilities [1
]. To our knowledge, no study has used a comprehensive environment measure to capture the barriers from home, school, and community settings for preschool children with and without disabilities in Taiwan.
The Child and Adolescent Scale of Environment (CASE) is designed to measure environmental features that impact children’s participation across home, school, and community settings [22
]. The CASE has been successfully used in several studies involving children with acquired brain injury and a variety of chronic conditions [12
]. Previously, we reported evidence of cross-cultural validation of the Chinese version of the CASE (CASE-C) among Taiwanese children 6–18 years with a variety of disabilities [23
]. The impact of environmental barriers was found to vary on the basis of severity of impairments and medical conditions of children. However, we did not include children under the age of 6 or a comparison group of children without disabilities. This present study aimed to identify the environmental barriers perceived by parents of preschool children with and without physical disabilities in Taiwan. There were two research questions:
What environmental factors were perceived by parents as barriers to participation of children with and without physical disabilities?
Does the impact of environmental barriers on participation differ between children with and without physical disabilities?
Parents of preschool children with PD identified more environmental barriers and perceived higher impacts of barriers than parents of children with TD. The results were comparable to previous studies involving young children in the United States [3
] and Singapore [1
] and expand our current knowledge about environmental challenges of young children in Taiwan. Based on the biopsychosocial model of the ICF, disability is the result of interactions between health conditions and contextual factors (e.g., environmental factors) [4
]. Developmental and health assessment is recommended to evaluate the environmental factors as well as other components of the ICF to get a comprehensive functional profile for each individual with developmental needs [29
]. In Taiwan, measurement of children’s participation and environmental factors is a key component of the assessment in the new Disability Evaluation System (DES) [30
]. The national sample demonstrated that children and youth with disabilities who had higher levels of severity of impairment encountered more environmental barriers and those experiencing more environmental problems also had greater restrictions in participation [32
]. This present study further identified that children with PD and TD experienced different patterns of environmental barriers, which supports the interplay of child’s functioning and surrounding environment within the ICF. Therefore, environmental factor assessment is very important for children with disabilities.
Despite the group differences, the results were encouraging, given that the scores for both groups indicated a relatively low impact of environmental barriers (i.e., scores were close to the minimum scores of 33.3). The ratings may suggest that efforts have been made to create an available and accessible environment that supports participation of young children. The results may also be explained by the young age of our sample. Living environment and daily activities performed by young children are more easily arranged and managed by parents than that of older children. It is possible that parents may perceive more environmental problems as their children grow and expand living areas.
Parents of children with PD more often identified needs for improving availability and adequacy of information, and community and governmental resources. Parents of children with PD in our study frequently indicated needs for information about intervention resources, and wanted adapted community programs for their child [33
]. In addition, parents of children with PD were more often worried about financial issues and also reported problems with family stress that might hinder their child’s participation. In our sample, there were more children with PD whose parent respondents were not employed and lived in households with lower income levels. During the interviews in our study, some parents of children with PD indicated having financial burden after resigning from jobs to take care of their children [33
]. The above factors seemed less of an issue for children with TD, as a relatively low percentage of parents (2–13%) perceived problems. A relatively prominent barrier is programs and services outside of home (identified by 13% parents of children with TD).
Parents of children with PD more often perceived problems with assistance, attitudes, and supports from others in places outside of home. For example, some parents of children with PD in our study reported that they felt uncomfortable by the ways people looked at them and their children while going out. Parents also reported lack of assistance from service providers when they took a taxi or went to a hospital [33
]. Negative social attitudes have been identified as a key barrier that might even prevent change in other aspects of barriers, such as problems with physical environment [34
]. Parents of children with PD also indicated needs for additional help and supports at preschool, which reflects the limited time and manpower of school personnel. Preschool educators often spend a lot of time in managing the whole class and may not have either the time or ability to address the special needs of each child [36
]. Professional supports are needed to enable children’s engagement in classroom activities [36
Parents of children with PD were more often worried about the inaccessible physical environments at home and nearby areas, and lack of transportation systems and assistive devices or equipment, which were frequently mentioned barriers in the literature [34
]. We also noticed an increased percentage of parents of children with TD who perceived problems with design and layout at home and nearby areas. For example, parents may want more spaces for their child to move around and play safely, and need public toilets or buses to be appropriate heights. Those were common problems encountered by parents of young children regardless of disability. This highlights that some environmental barriers are common for children with and without disabilities and that environmental accessibility is important for all children.
Children have the right to live in an environment that enables resources provision, protection, and participation [40
]. A universal design [41
] and developmental appropriate approach [42
] suggest eliminating barriers to create an inclusive and rich learning environment. Our findings have provided evidence of environmental barriers that inform child care practices and policies to form a supportive environment for families with young children. The CASE-C measures physical and social environmental features and resources which are aligned with the ICF and DEC Recommended Practices. The CASE-C provides a comprehensive measure for practitioners and parents to identify barriers and plan strategies collaboratively to modify and adapt the environment. For example, practitioners may discuss family financial situations and stress with parents, and provide information or resources based on family needs. Practitioners may provide emotional supports to families who perceive negative social attitudes, and advocate promoting acceptance of community members. Positive attitudes and assistance from others to children and parents in need can be encouraged by providing education and promotion of the value of inclusion in the community and society.
Regulations in Taiwan, such as the People with Disabilities Rights Protection Act
amended in 2015 [43
], promote applying the concept of universal design to the development of public facilities, product and technology, transportation systems, and services. Local authorities have the responsibility to provide social, cultural, recreation, and leisure activities to optimize community inclusion of individuals with disabilities. However, what we learned from this study is that parents might not know their rights or currently available resources, and thus many parents did not get enough of the resources they need. It is important for local governments to fully implement social welfare policies and establish an integrated and accessible information system for young children with disabilities.
There are several limitations of this study which inform future research directions. This is a sample of convenience with relatively high physical functioning, and therefore the sample considered in this study might not be representative of all young children with and without PD in Taiwan. During recruitment, it was not feasible to individually match the two groups by age, income, or other factors known to influence participation. In addition, environmental barriers may vary depending on various factors such as children’s functional ability and living areas [39
]. Further study on a large and representative sample of Taiwanese children would enable the investigation of variation in environmental impacts between children with different abilities who reside in different regions. This study did not measure positive environmental features that promote participation and thus this warrants further investigation. As part of a larger study, this study focused on identifying environmental barriers reported by the parents but did not, as of yet, examine their associations with children’s actual participation. Previous studies suggest a medicating role of environmental features between the child and family factors and participation of children with and without disabilities [2
]. Further analyses of our study will focus on the influence of child, family, and environmental factors collectively on participation of preschool children with and without PD.