Participation, environment, and quality of life in children with cerebral palsy and physical disabilities

Abstract

Aim

To compare and examine relationships between participation, environmental factors, and quality of life (QoL) in children with cerebral palsy and physical disability (CP/PD) and typically developing children.

Method

Participants were 59 children (6–12 years; 31 females): 30 with CP/PD (mean age 8 years 7 months, standard deviation 1 year 6 months) and 29 with typical development (mean age 8 years 2 months, standard deviation 1 year 6 months). Parents completed the Participation and Environment Measure for Children and Youth to assess participation, the Pediatric Quality of Life Inventory to assess QoL, and a socio‐demographic questionnaire. Gross motor function and additional functional classifications were recorded for the CP/PD group.

Results

Involvement in activities, frequency of participation, and QoL were significantly lower in the CP/PD group than in the typically developing group. The gross motor function levels of the CP/PD group positively correlated with their participation in home activities levels. Community‐setting support significantly predicted QoL and mediated (β = 0.66, p < 0.001) between disability level and QoL.

Interpretation

Community‐setting support is crucial for enhancing QoL for children with CP/PD. Rehabilitation should emphasize community engagement to improve the children's participation and well‐being.

Abbreviations

CFCS

Communication Function Classification System

CP/PD

cerebral palsy and physical disability

EDACS

Eating and Drinking Ability Classification System

FMS

Functional Mobility Scale

ICF

International Classification of Functioning, Disability and Health

MACS

Manual Ability Classification System

PedsQ

Pediatric Quality of Life Inventory

PEM‐CY

Participation and Environment Measure for Children and Youth

QoL

quality of life

What this paper adds

• Children with cerebral palsy and physical disability (CP/PD) show reduced participation and quality of life (QoL) compared with typically developing peers.

• Community support predicts QoL in children with CP/PD more than motor function and participation.

• Community support, more than home support, mediates disability and QoL in children with CP/PD.

• Parents of children with CP/PD desire environmental changes, especially in community settings.

Understanding the nexus between an individual's bodily (e.g. motor, sensory, and cognitive) abilities, disabilities, and their environment is paramount. This is essential for drawing upon the International Classification of Functioning, Disability and Health (ICF) model ¹ to develop interventions for daily functioning, participation, and quality of life (QoL). Participation denotes an individual's involvement in life situations. Across dimensions, its objective measurements include diversity (how many activities), intensity (participation frequency), independence, satisfaction, and interests. ² Dynamic interactions among the person's health condition, functioning, and environmental factors influence their participation.

Participation in enjoyable, meaningful activities is crucial to children's development of functional and social skills and independence. ³ Thus, restricted participation may reduce development, QoL, and well‐being, ⁴ and special attention should be given to factors that may affect children's participation, such as physical and intellectual disabilities. ⁵ Furthermore, children with disabilities such as cerebral palsy (CP) and mild sensory–motor disability tend to participate less than their typically developing peers in domestic, leisure, educational, and social activities. ⁶ , ⁷ The environmental factors encompassing the physical, social, and attitudinal aspects of a person's living environment ¹ may also significantly enhance or limit participation. For example, children with disabilities, including developmental, speech, and motor disabilities, tend to participate less in community activities and spend more time at home. ⁸ Children with CP, which occurs in approximately 1 in 500 newborns, ⁹ have shown reduced participation in the community setting from an early age. ¹⁰

Children with CP and other physical disabilities (CP/PD) may face challenges in motor skills, sensory perception, cognition, communication, and behaviour that affect their participate in daily activities and their QoL. ¹¹ The literature has identified various factors as barriers or facilitators, including the child's factors (e.g. motor and cognitive abilities) and environmental factors (e.g. family lifestyle and community accessibility). ⁴ The recently updated description of CP by Dan et al. ¹² highlights participation and the environmental context as central to practice and research. Thus, examining the relationship between home and community settings and QoL in children with CP/PD may shed light on key factors influencing their QoL. ¹³ As an important endpoint in clinical practice and research, ¹⁴ QoL reflects a person's perception of their life in cultural, value, goals, and expectational terms. ¹ It encompasses multiple domains, including physical health, social and emotional well‐being, and solitude. ¹⁵ Environmental factors such as care type, parenting style, culture, and inclusion also influence the QoL of children with CP/PD. ¹⁶ , ¹⁷ Participation and QoL are primary outcomes of intervention efficiency, highlighting the need for a comprehensive understanding of their association and interaction with the environment and the child's disability. ¹

Therefore, this study aimed to (1) compare participation, environmental factors, and QoL between children with CP/PD and typically developing children, (2) examine relationships between child factors, participation, environmental factors, and QoL in the study group, and (3) investigate whether home‐ and community‐setting factors mediate between child factors and participation and QoL.

We hypothesized that (1) participation, environmental factors, and QoL would be significantly lower in children with CP/PD than in typically developing children, (2) a significant positive correlation would be found between supportive environmental factors, participation, and QoL in children with CP/PD, (3) beyond child factors, supportive environmental factors and participation would predict QoL levels of children with CP/PD (accounting for 35% of the variance in QoL), and (4) home‐ and community‐setting factors would mediate between child factors and QoL.

METHOD

Procedure

The Ethics Committees at The Faculty of Social Welfare and Health Sciences Ethics Committee at the University of Haifa and by Chief Scientist's Office of the Israeli Ministry of Education approved this study (approval number 160/18). Children (6–12 years) and their parents were recruited from regional educational therapy centres. Those who wished to participate were invited to individual online meetings with the researcher and signed informed consent forms.

Participants

This study's sample included 59 children and their parents. The inclusion criterion was children with near‐typical cognitive levels studying in mainstream schools. Children who had undergone a surgical intervention or hospitalization in the previous 3 months, had other chronic diseases, or who took medication affecting their functioning were excluded. The study group comprised 30 children with CP/PD and a physical disability code in the educational setting: 26 children with CP and four children with physical disability.

We conducted a power analysis using G*Power ¹⁸ on the basis of correlations reported in previous studies (see, for example, Di Lieto et al. ¹⁹ ) which found that various domains of the Participation and Environment Measure for Children and Youth (PEM‐CY) were associated with QoL at r = 0.41–0.61. Conservatively assuming an effect size of r = 0.45, α = 0.05, and power = 0.80, G*Power indicated that a sample of 29 was required to detect a significant correlation. Therefore, our sample was sufficiently powered to observe the expected effect.

As Table 1 shows, about 80% of the children with CP/PD could walk according to the Functional Mobility Scale (FMS) and the Gross Motor Function Classification System (GMFCS, levels I–III); 65% needed no mobility aids. ²⁰ The children demonstrated varied abilities across the Manual Ability Classification System (MACS), Communication Function Classification System (CFCS), and Eating and Drinking Ability Classification System (EDACS).

TABLE 1.

Demographic characteristics and variables in both groups.

Characteristic	CP/PD group (n = 30)	Typically developing group (n = 29)	p (df2)
Sex
Males	15 (50)	13 (44.8)	0.69 (1)ns
Females	15 (50)	16 (55.2)
Mean age (SD), years:months	8:7 (1:6)	8:2 (1:6)
Family income NIS (monthly)
Less than average	10 (34.5)	6 (21.4)	0.40 (2)ns
Average (7000–14 000)	4 (13.8)	7 (25.0)
More than average	15 (51.7)	15 (53.6)
Mother's education
High school	4 (14.3)	2 (6.9)	0.84 (2)ns
Professional	7 (25)	2 (6.9)
Academic	17 (60.7)	25 (86.2)
Number of tenants	5.21 (1.26)	5.04 (0.84)
Number of rooms	4.76 (0.74)	4.57 (0.69)
Residence
City	25 (83.3)	25 (86.2)
Village	5 (16.6)	4 (13.8)
CP type/condition
Bilateral (quadriplegia)	11 (36.7)a
Bilateral (diplegia)	2 (6.7)
Right‐sided unilateral	5 (16.7)
Left‐sided unilateral	8 (26.7)
SMA type I	1 (3.3)
CLOVES syndrome	1 (3.3)
S/P pelvis cancer	1 (3.3)
Sotos syndrome	1 (3.3)

Notes: Data are n (%) unless otherwise stated. ^aGMFCS distribution in the group with bilateral CP (quadriplegia): level I, one child; level II, one child; level III, three children; level IV, four children; level V, one child.

Abbreviations: CLOVES, congenital lipomatous overgrowth, vascular malformations, epidermal nevi, and scoliosis or spinal deformities; CP/PD, cerebral palsy and physical disability; df, degrees of freedom; GMFCS, Gross Motor Function Classification System; ns, not significant; SD, standard deviation; SMA, spinal muscular atrophy; S/P, status post.

Teachers at the therapy centre and the class teachers of children with CP referred 30 typically developing children and their parents as comparisons. The researcher verified and matched 29 of them to the study group by sex, living environment, and socioeconomic background (Table 2).

TABLE 2.

FMS and functional characteristic distribution in the group with CP/PD.

FMS distribution (n = 30)
Level	Mobility	FMS5	FMS50	FMS500
1	Wheelchair	6 (20.0)	6 (20.0)	8 (26.7)
2	Walker	4 (13.3)	5 (16.7)	4 (13.3)
3	Crutches	—	—	—
4	Sticks	—	—	—
5	Walk on flat level	5 (16.7)	6 (20.0)	5 (16.7)
6	Walk on difficult surface	14 (46.6)	13 (43.3)	11 (36.7)
C	Crawl	1 (3.3)	—	—
N	No mobility	—	—	2 (6.7)

Functional characteristics by instrument (n = 26)
Level	GMFCS	MACS	CFCS	EDACS
1	11 (42.3)	3 (11.50)	17 (65.4)	22 (84.6)
2	5 (19.2)	10 (38.46)	5 (19.2)	4 (15.4)
3	5 (19.2)	8 (30.77)	2 (7.7)	—
4	4 (15.4)	5 (19.20)	2 (7.7)	—
5	1 (3.8)		—	—

Note: Data are n (%) unless otherwise stated.

Abbreviations: CFCS, Communication Function Classification System; CP/PD, cerebral palsy and physical disability; EDACS, Eating and Drinking Classification System; FMS, Functional Mobility Scale; FMS5, FMS50, FMS500, respectively, 5 m, 50 m, and 500 m on Functional Mobility Scale; GMFCS, Gross Motor Function Classification System; MACS, Manual Ability Classification System.

Instruments

We administered a socio‐demographic health questionnaire characterizing each child's personal factors, such as health condition, socioeconomic status, maternal education, household size, and number of tenants.

We used the PEM‐CY ²¹ to evaluate the child's participation and environmental factors in 25 activity sets across three settings: home (10 items, e.g. watching TV or playing with toys), school (five items, e.g. class activities or trips), and community (10 items, e.g. physical activities and community events). It assessed participation by number of activities, frequency (daily, weekly, etc.), involvement ranked from 5 (very involved) to 1 (minimally involved), and desire for change (no change, more or fewer activities). Its environmental part included questions on the necessity and availability of factors in the natural environment that may have affected the child's participation (e.g. resources, attitudes, programmes, and accessibility). These factors were assessed separately for each setting: home (13 items), school (17 items), and community (16 items). Parents indicated whether each item was a barrier or facilitator for their child's participation and whether resources were available or lacking. ²¹

The PEM‐CY generated four summary scores related to participation in each environment: (1) number of activities done, (2) participation frequency (mean score), (3) involvement level (mean score), and (4) number of activities needing change. Additionally, two environmental summary scores were calculated by counting items marked as ‘usually helps/resource available’ or ‘usually makes harder/resource not available’ to assess supports and barriers. The PEM‐CY has demonstrated sufficient reliability (internal consistency 0.59–0.91; test–retest reliability 0.58–0.95) and can distinguish between children with and without disabilities across all scales (effect size 0.51–1.44), supporting its validity. ²¹ We collected PEM‐CY school‐setting data but did not include them in this analysis. They will be reported separately.

The Pediatric Quality of Life Inventory (PedsQL) measures health‐related QoL in children from 2 to 18 years using 23 items in four core domains: ²² physical (eight items), emotional (five items), social (five items), and school (five items). Each item is scored on a five‐point scale from 0 to 4. These scores are converted to percentages, with higher percentages representing better QoL. Summary scores for psychosocial and physical health and a total score can be computed. The PedsQL has demonstrated sufficient reliability (internal consistency 0.90–0.84). It has been used in research on children with disabilities, various health conditions, and typical development. ²² We used the parent‐report version.

Study‐group‐only measures

A therapist or family member performed ratings with the FMS, ²³ measuring mobility ability at 5 m, 50 m, and 500 m (representing typical distances children walk in all settings). Depending on the amount of assistance required for each distance, a mobility rating from 1 (in a wheelchair) to 6 (walking on unstable surfaces) was assigned. If the child did not complete the distance, the letters C (crawling) or N (not completed) were used instead. These evidence‐based alpha‐numeric classification tools provided information about the child's functional level within each ability. Each tool ranged from level I (minimal disability) to level V (totally dependent on external assistance). We used the FMS50 for the statistical correlation tests to represent the child's mobility abilities.

In addition, we used the GMFCS ²⁰ with the children with CP to classify the child's movement ability, and the MACS ²⁴ to represent the child's manual capability. Further, the CFCS ²⁵ represented communication functions, and EDACS represented eating and drinking abilities. ²⁶

Data analysis

We used SPSS (version 27, IBM Corp., Armonk, NY, USA) for data analyses, performing descriptive statistics, and confirming normal distributions using skewness kurtosis. We tested group differences using multivariate analyses of variances for subscales and t‐tests for total scores. Pearson's correlation tests were conducted. On the basis of the ICF model ¹ and the significant correlations shown in our analysis, we conducted a stepwise linear regression to examine QoL prediction by child and participation factors and environmental support at home and in the community. Hayes's process Model 4 (5000 samples and 95% confidence interval) was used to investigate whether environmental or participation factors mediated between the child's disability and QoL (p < 0.05). ²⁷

RESULTS

Participation, environment, and QoL factors: between‐group

The children with CP/PD demonstrated significantly lower participation frequency and involvement across home and community settings than the typically developing comparison children.

Although participation frequency was only slightly different in the community setting, the involvement level showed a marked disparity (CP/PD 3.58 vs typically developing 4.31, p < 0.001). Environmental factors were particularly striking: the CP/PD group faced significantly higher environmental barriers (e.g. physical demands: 3.00 vs 0.89) and lower support factors (e.g. friends' support, public transport, or inclusive community programmes). Importantly, parents of children with CP/PD expressed a significantly higher ‘desire for change’, highlighting the challenges these families navigate (CP/PD 55.33 vs typically developing 29.65, p < 0.001). Table 3 shows that, across all domains, QoL revealed profound differences. The most substantial gap was in physical functioning (CP/PD 48.96 vs typically developing 93.86).

TABLE 3.

Participation, environment factors, and quality of life: between‐group comparison.

PEM‐CY domain	CP/PD group (n = 30)		Comparison group (n = 29)
	Mean	SD	Mean	SD	F 1,57	p
Home participation
Participation frequency	5.50	0.77	5.93	0.55	6.02	0.01
Number of activities	8.83	1.17	9.31	0.80	3.27	0.76
Involvement level	3.58	0.67	4.31	0.57	19.89	0.00
Desire for change	55.33	21.61	29.65	16.79	25.84	0.00
Home setting
Environmental support factors	4.86	1.30	6.06	0.92	16.56	0.00
Environmental barrier factors	2.13	1.30	0.93	0.92	16.56	0.00
Available environmental resources	2.93	1.23	2.93	0.88	0.00	0.99
Lack of environmental resources	1.53	1.16	0.48	0.63	18.29	0.00
Community participation
Participation frequency	2.44	0.87	3.01	0.92	5.89	0.02
Number of activities	5.46	1.69	6.51	18.88	5.07	0.03
Involvement level	2.41	0.76	3.06	0.83	9.89	0.00
Desire for change	34.66	21.61	15.51	17.64	13.84	0.00
Community setting
Environmental support factors	5.96	2.41	8.10	1.44	18.66	0.00
Environmental barrier factors	3.00	2.36	0.89	1.14	18.71	0.00
Available environmental resources	3.76	1.45	4.68	1.64	5.20	0.02
Lack of environmental resources	2.06	1.46	1.03	1.34	7.93	0.00
PedsQL functioning
Physical	48.96	23.81	93.86	6.16	96.73	0.00
Emotional	62.50	18.08	76.63	12.17	12.31	0.00
Social	58.50	16.08	92.06	10.04	91.65	0.00
School	63.16	15.89	84.39	14.28	29.28	0.00
Total PedsQL score	61.38	11.04	84.39	8.54	79.70	0.00

Abbreviations: CP/PD, cerebral palsy/physical disability; PEM‐CY, Participation and Environment Measure for Children and Youth; PedsQL, Pediatric Quality of Life Inventory; SD, standard deviation.

Correlations: environmental factors, function level, participation, and QoL in the study group

Home‐setting correlations

In the study group, higher participation frequency in home‐setting activities correlated with more environmental support (r = 0.370, p ≤ 0.01). Lower environmental resources and higher environmental barriers at home correlated with lower PedsQL total (r = 0.376, p ≤ 0.01), psychosocial (r = 0.435, p ≤ 0.01), and school (r = 0.378, p ≤ 0.01) domain scores (Table 4).

TABLE 4.

Correlations between participation, environment, quality of life, and personal factors: child functional classifications.

Note: Bold type indicates significant p‐values:

^* p ≤ 0.05;

^** p ≤ 0.01.

Abbreviations: CFCS, Communication Function Classification System; EDACS, Eating and Drinking Classification System; GMFCS, Gross Motor Function Classification System; MACS, Manual Ability Classification System; PedsQL, Pediatric Quality of Life Inventory; PEM‐CY, Participation and Environment Measure for Children and Youth.

Community‐setting correlations

Higher participation frequency (r = 0.278, p ≤ 0.01), number of activities (r = 0.272, p ≤ 0.01), and community‐setting involvement (r = 0.264, p ≤ 0.01) correlated positively with the child's age. Community‐setting involvement also correlated with FMS50 scores (r = 0.367, p ≤ 0.01). Additionally, higher community support (physical, social, and communication support and information) correlated with higher PedsQL total (r = 0.627, p ≤ 0.05), school (r = 0.691, p ≤ 0.05), and psychosocial (r = 0.434, p ≤ 0.01) domain scores. Conversely, higher environmental barriers correlated with lower PedsQL total scores (r = 0.626, p ≤ 0.05). A lack of community resources (inclusive programmes, transportation, and time) correlated with lower PedsQL total (r = 0.525, p ≤ 0.05), physical (r = 0.525, p ≤ 0.05), and social (r = 0.370, p ≤ 0.01) scores.

Functional level and QoL correlations

Participation involvement levels correlated positively with FMS50 (r = 0.401, p ≤ 0.01) and physical QoL (r = 0.446, p ≤ 0.01) scores and negatively with GMFCS (r = −0.411, p ≤ 0.01), MACS (r = −0.392, p ≤ 0.01), CFCS (r = −0.541, p ≤ 0.01), and EDACS (r = −0.481, p ≤ 0.01) scores.

Furthermore, better physical domain scores correlated with better GMFCS (r = 0.872, p ≤ 0.05), MACS (r = 0.479, p ≤ 0.05), and CFCS (r = 0.390, p ≤ 0.01) functional levels. In addition, better social QoL domain scores correlated with higher GMFCS motor function (r = 0.522, p ≤ 0.05), and better total PedsQL scores correlated with higher motor function on the GMFCS (r = 0.375, p ≤ 0.01) and FMS50 (r = 0.446, p ≤ 0.05).

Family and personal factors

Parents' desire for change was associated with higher mother's education (r = 0.363, p ≤ 0.05) and family socioeconomics (r = 0.388, p ≤ 0.05), and higher emotional QoL domain scores positively correlated with the child's age (r = 0.310, p ≤ 0.01) and sex (r = 0.355, p ≤ 0.05; higher for males).

QoL prediction by child, participation, and environment factors

In the CP/PD group, higher community support significantly predicted higher QoL scores (F = 19.131, p < 0.001, R ² = 0.406) above the GMFCS, which also significantly predicted QoL (F = 6.616, p < 0.001, R ² = 0.117) and above the FMS50 (not significant). Although a supportive home setting did not significantly predict QoL, a supportive community environment accounted for 40% of the QoL variance (p < 0.001).

Environmental factors mediated between child factors and QoL

The CP/PD group had lower environmental support at community (β = −0.98, p < 0.001) and home (β = −0.94, p < 0.001) than the typically developing group (Figure 1). Following the correlations, the Hayes process results showed that community support mediated higher QoL in the CP/PD group (β = 0.41, p < 0.001), but support at home did not (β = 0.04, p = 0.65). These findings suggest that community support mediated the differences in QoL between the study and typically developing groups. Consistent with this interpretation, the indirect effect of group on QoL through community support was statistically significant (95% confidence interval −0.65 to −0.17).

FIGURE 1.

Community mediation model. ^a p < 0.001. Mediation effect for support community: 95% CI = −0.65 to −0.17. Mediation effect for support home: 95% CI = −0.17 to 0.10. Abbreviations: CI, confidence interval; CP/PD, cerebral palsy/physical disability.

DISCUSSION

This study examined relationships between child factors, participation, and (home and community) environmental factors and their impact on the QoL of children with CP/PD compared with typically developing peers. It also identified the predictive value of environmental and personal factors in explaining QoL in children with CP/PD, a novel contribution of this study.

Our findings corroborate previous research indicating reduced participation frequency and involvement in home and community settings for children with CP/PD, ²⁸ with a reduced number of activities in the community setting. ² , ²⁹ They participated more frequently in home activities, such as playing computer games, watching television, and socializing on the phone. The lower community participation was particularly evident in physical and social activities, consistent with previous research on children with disabilities and CP. ⁶ , ⁸ , ²⁸ Addressing these aspects is essential because physical and social skills are major predictors of participation in leisure activities for school‐aged children. ³⁰

Insufficient environmental support and resources and increased barriers were observed in home and community settings for this study's CP/PD group. Parents in this group expressed a strong desire for change. They reported a lack of resources (e.g. time and money) to support their child's participation, a scarcity of nearby inclusive programmes tailored to the child's abilities and preferences, and insufficient information about available activities, support, and transportation. These results are crucial because increased participation in leisure activities in the community predicts future participation and the child's sense of self. ²⁸ Furthermore, the family's perception of restrictions may predict participation limitations among school‐age children with CP. ³⁰ Allocating resources for community programmes and providing families with adequate information is key to increasing the children's community participation.

Although our study strengthens the literature on participation and environment, it showed no significant correlation between participation factors and environmental barriers. This finding may be attributed to other participation aspects not captured in the study. For example, factors such as activity preference, meaningfulness, competence, appropriate actions, and self‐perception or self‐confidence can influence a child's choice and motivation to participate in specific activities. ³ This result exemplifies the need for further research to explore other factors influencing participation outcomes for children with CP, especially in community settings. ¹³

The study's findings highlight potential barriers to environmental support beyond physical and structural factors, as Arakelyan et al. ²⁹ suggested. Support, such as empowering families through information and counselling services, improving access to physical and social‐support programmes, and tailoring community‐inclusive programmes with classmates, may influence the children's ability and motivation to participate in community activities and leisure activities. ⁴ , ³¹ Financial assistance and transportation for children to beyond‐school programmes may further help families enhance the opportunities and experiences of children with disabilities.

This study's results reveal reduced QoL among children with CP/PD compared with their typically developing peers. Research focusing on body function and activity limitations has shown a relationship between motor and cognitive abilities and QoL. ⁵ , ³² , ³³ We observed a correlation between GMFCS levels and QoL, but its impact was less significant than that of environmental support. This finding emphasizes the importance of providing environmental support in addition to physical support on its own—especially in the community—in influencing QoL outcomes.

Participation is closely associated with QoL both in children with CP and in their typically developing peers, ¹³ , ¹⁶ and reduced participation in daily activities in all settings influences QoL levels. ³⁴ Research has shown that engaging in meaningful, adapted leisure activities aligned with the children's skills and preferences has a stronger impact on QoL than basic daily activities. ¹⁶ Current interventions emphasize promoting participation across life domains. ¹³ , ³⁴

However, our results show no significant correlation between participation and QoL. Nevertheless, they indicate that community‐environmental support correlates with, predicts, and mediates QoL in children with CP/PD, surpassing the effects of child function and participation levels. Parents and children and adolescents with CP have reported the importance of social and family attitudinal factors, support from service providers, and relationships with friends and schoolmates in facilitating their ability to participate in leisure activities. ⁴ , ³¹

The quotation in Dunbar, ³⁵ ‘Friendships (including family) are important factors affecting our health, well‐being and happiness,’ points to other QoL issues for children with CP not assessed in our study, such as social and emotional well‐being, acceptance, self‐esteem, communication, and relationships with parents and friends. Furthermore, people with disabilities may choose activities they can accomplish, resulting in fewer participation restrictions. ³⁶ Whiteneck and Dijkers ³⁶ argued that aggregating disparate, non‐hierarchical items into a single participation score, as many studies have done, may not offer a comprehensive understanding of the situation.

In contrast, our study highlights the complex relationship between ICF domains and reveals environmental support as both a predictor and mediator of the relationship between child factors and QoL. ¹ , ⁵ Although research on the impact of environmental factors on QoL in children with CP/PD is growing, ⁵ , ¹³ our findings emphasize the need to reconsider therapeutic approaches and prioritized environmental interventions—especially in the community setting. Environmental accessibility encompasses physical spaces, services, social inclusion, and a supportive organizational culture. ¹

Although national policy (in this study's context) focuses mainly on accessibility programmes in home and school settings for children with disabilities, our results stress the importance of programmes to enhance community support. Our findings highlight the significance of non‐physical environmental aspects, such as positive values and social support, inclusive and adapted community programmes, and access to information, in fostering inclusive, participation‐oriented communities for children with disabilities. ⁴

Programmes prioritizing the positive aspects of environmental components can support children's goal achievement, improve their participation levels, and even change body function and structure components. ³⁷ This perspective emphasizes the environment's role as a mediated space between the disability level and the participation of children with disabilities. ⁴ Our study also provides initial evidence suggesting the direct, significant, and mediating effects of environmental support in the community on the QoL of children with CP/PD, distinct from that of typically developing children.

This study used a relatively small sample of solely primary‐school‐aged children. The participation of very few children classified in GMFCS level V in the study may have affected the results. Data were gathered from a specific area in a specific country, which may affect generalizing the results. Future studies with larger samples from different locations should be performed to enable generalizability. Additionally, the parent‐reported questionnaires we used present only the parents' (not the children's) perceptions. The study did not measure actual environmental adjustments or assess their adequacy. Further research should address these aspects to advocate for appropriate environmental programmes and support.

CONCLUSION

This study adds to the comprehensive understanding of the complex interactions that affect functioning, participation, and QoL in children with CP/PD. It highlights the impact of environmental variables on participation, as researched in previous studies. Our results show a significant association between environmental variables in home and community settings and the QoL of children with CP/PD. Importantly, they reveal that environmental support in the community mediates the effects of the child's disability on their QoL. These findings highlight the need to develop and implement community programmes that create supportive environments, integrating and facilitating leisure activities for children with CP/PD.

Early intervention programmes should prioritize strengthening integration because declining community activity leads to social isolation after these populations leave school. ³⁴ , ³⁸ Enhancing participation early in life may set the tone and direction for later adult participation. ¹⁰ Our findings align with previous research emphasizing that impairments alone do not determine QoL aspects. Instead, they are also influenced by personal and environmental factors. ¹⁶ Our results reinforce current approaches that increase participation involvement by modifying environmental settings and creating community leisure programmes with promising results. ⁴ Further, they emphasize the importance of guiding parents on existing policies and benefits and seeking knowledge to advocate for the rights of children with disabilities. ³¹

CONFLICT OF INTEREST STATEMENT

The authors have stated that they had no interests that might be perceived as posing a conflict or bias.

DATA AVAILABILITY STATEMENT

Due to ethical restrictions involving identifiable information of children, data are available from the corresponding author upon reasonable request and with ethics committee approval.