Relationship Between Participation Across Daily Environments and Bimanual Performance in Children With Unilateral Cerebral Palsy: An ICF-Based Cross-Sectional Study

Relationship Between Participation Across Daily Environments and Bimanual Performance in Children With Unilateral Cerebral Palsy: An ICF-Based Cross-Sectional Study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Relationship Between Participation Across Daily Environments and Bimanual Performance in Children With Unilateral Cerebral Palsy: An ICF-Based Cross-Sectional Study María Coello-Villalón, Purificación López-Muñoz, Giuseppina Sgandurra, and 5 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8872346/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 09 Mar, 2026 Read the published version in BMC Pediatrics → Version 1 posted 9 You are reading this latest preprint version Abstract Background . Bimanual performance is a primary rehabilitation target in unilateral cerebral palsy children, yet its relationship with real-world participation remains unclear. This study aims to examine the relationship between bimanual performance and Participation outcomes across home, school, and community environments in children with unilateral cerebral palsy within the International Classification of Functioning, Disability and Health Children & Youth Version framework. Methods . Cross-sectional observational study of 70 children with unilateral cerebral palsy (mean age 9.5 years, Manua Ability Classification System I–III). Bimanual performance was assessed using the Assisting Hand Assessment and the Children's Hand-use Experience Questionnaire; Participation was measured using the Participation and Environment Measure for Children and Youth. Correlation analyses examined associations between bimanual performance and Participation outcomes, adjusting for demographic characteristics, with a significance α<0.05. Results . Despite significant differences in bimanual performance across Manua Ability Classification System levels (p<0.001), neither Assisting Hand Assessment nor Children's Hand-use Experience Questionnaire scores correlated significantly with participation frequency, involvement, or environmental facilitators/barriers across any setting (all p>0.05). Demographic factors did not confound these associations. Environmental barriers increased progressively from home (24.5%) through school (30.5%) to community (34.1%), while participation remained high in familiar contexts despite motor limitations. Conclusions . Although bimanual performance is a prominent impairment in unilateral cerebral palsy due to the lateralized motor impairments, it does not appear to be directly related to Participation. Instead, daily-life Participation is probably related with factors beyond motor function, underscoring the need for more holistic, biopsychosocial approaches. Trial registration: NCT06073522, 10 October 2023 Unilateral cerebral palsy bimanual performance Participation ICF framework cross-sectional study Figures Figure 1 Figure 2 BACKGROUND The International Classification of Functioning, Disability and Health Children & Youth Version (ICF-CY) provides a conceptual framework for understanding human functioning in younger ages through four interrelated components (i.e., Body function and Structure, Activity, and Participation) influenced by personal and environmental factors. 1 Within this model, Activity is defined as the execution of a task or action by an individual, whereas Participation refers to involvement in real-life situations. 2 Understanding the interplay between these constructs is fundamental for identifying each child's unique functioning profile and consequently designing interventions that not only improve functional abilities but also promote meaningful daily engagement. Within the ICF framework, Participation is a multidimensional construct encompassing nine domains— learning and applying knowledge, general tasks and demands, communication, mobility, self-care, domestic life, interpersonal interactions and relationships, major life areas, and community, social and civic life—and can be evaluated in terms of both frequency and involvement . 3 , 4 Participation occurs across home, school, and community settings, fostering autonomy, social inclusion, and quality of life, and serving as both an outcome and a driver of child development. 5 It is shaped by a dynamic interplay of environmental supports (e.g., accessibility, social attitudes, policies), family context, and individual characteristics such as motor abilities, communication, executive functions, motivation, and age. 5 While motor function has traditionally been viewed as the primary determinant of Participation , growing evidence indicates that environmental and personal factors may impose equal or greater influence. 6 Findings from an European study —a large longitudinal cohort of children with CP across Europe— demonstrate that children with similar motor severity can display markedly different Participation patterns depending on environmental context, underscoring the modifiable nature of Participation restrictions beyond impairment. 7 Furthermore, personal factors—including motivation, self-efficacy, and family attitudes—are significant predictors of Participation . 8 Understanding how these multifactorial influences shape Participation in children with multifaceted conditions, such as cerebral palsy (CP), therefore remains critical. Unilateral cerebral palsy (UCP), the most common CP subtype—accounting for approximately 35% of all cases—primarily affects motor function on one side of the body, with greater involvement of the upper limb. 9 Children with UCP often exhibit asymmetrical hand use, strong reliance on the less-affected hand, and limited integration of the more-affected limb into bimanual activities. 10 , 11 These limitations often interfere with independence and functioning, given that the majority of daily activities (e.g., dressing, eating) require the effective use of both hands. 12 , 13 Therefore, quantifying the so-called bimanual performance is a crucial aspect of rehabilitation in children with UCP. Despite these bimanual limitations, many children with UCP develop compensatory strategies and rely on environmental supports that enable meaningful Participation . This suggests that Participation outcomes may not be solely determined by motor function, despite it being the primary impairment of children with UCP. 14 Although Activity gains are essential for functional autonomy, emerging research indicates that improvements in motor performance do not necessarily lead to increased Participation unless environmental barriers are addressed and empowerment strategies are integrated. 15 – 17 Environmental factors—such as accessibility, family engagement, and institutional policies—alongside personal characteristics like motivation and self-efficacy, have been shown to exert substantial influence on Participation outcomes. 15,16,18 However, evidence specifically examining these relationships in UCP remains limited, highlighting a gap in the literature that this study begins to address. While several studies have explored associations between bimanual performance in UCP and other ICF domains—such as cognition, executive functions, somatosensory function, and quality of life 19 – 22 , the specific relationship between standardized measures of bimanual performance and Participation in real-world environments remains underexplored. Preliminary intervention studies have shown that intensive bimanual training enhances motor capacity and real-world hand use, yet the extent to which these Activity gains translate into meaningful Participation remains unclear. 23 Moreover, a recent study has considered the moderating roles of environmental and personal factors in this relationship. 24 Therefore, this study aims to examine the relationship between bimanual performance, as a means of Activity , and Participation —in a large cohort of children with UCP. Different dimensions of Participation will be evaluated, specifically frequency and involvement—across home, school, and community environments. Given the multifactorial nature of Participation , we hypothesize that bimanual performance alone will not show significant isolate associations with Participation frequency or involvement. Instead, we expect wide variability in Participation among children with comparable manual ability, underscoring the influence of various contextual factors in a multifaceted construct of Participation . Additionally, the study aims to examine the persistence of the associations after adjusting for age, sex, and lesion laterality. METHODS Study design This was a cross-sectional, observational study conducted in accordance with the STROBE (STrengthening the Reporting of Observational Studies in Epidemiology) guidelines for cross-sectional studies. 25 The present work represents a secondary analysis of data prospectively collected from the Spanish site of the multicenter European project AInCP: Artificial Intelligence in Cerebral Palsy (ClinicalTrials.gov identifier: NCT06073522, registration date: 10 October 2023), conducted at University of Castilla-La Mancha. Study setting and recruitment Participants were recruited through collaboration with national and regional associations and local clinical networks. Families were contacted via informational emails, conferences, and social media posts disseminated through Hemiweb (Association of Childhood Hemiparesis) and ASPACE (Spanish Association of Cerebral Palsy) between January 2023 and May 2025. Families declared interest via an online registration form, after which the study team provided detailed information and scheduled assessments at the Neuroped Pediatric Neurodevelopment Center in Madrid, as well as a preliminary interview to see if they met the eligibility criteria. Participants Eligibility criteria Children were eligible if they were aged 5–15 years and met all the following criteria: confirmed diagnosis of predominantly spastic UCP; classification within the Manual Ability Classification System (MACS) levels I–III, with higher levels indicating better manual ability; and sufficient cognitive and communicative abilities to complete study assessments. Children were excluded if they presented with any of the following: severe upper limb impairment precluding completion of bimanual tasks; botulinum toxin-A injection in the affected upper limb within six months prior to enrolment; upper limb surgery within the preceding 12 months; or severe medical comorbidities or intellectual disability prohibiting comprehension of instructions. Sample size A target sample size of 70 participants was determined based on feasibility within the Spanish observational arm of the AInCP project and to ensure sufficient power to detect medium-sized correlations (r ≈ 0.35) between bimanual performance and Participation outcomes. Assuming a two-tailed α of 0.05 and β of 0.20 (80% power), a minimum of 62 participants was required to detect a correlation coefficient of 0.35. The sample size calculation was performed using G*Power version 3.1. To account for potential missing or unusable data, the target sample size was finally set at 70 participants. Ethics and informed consent Ethical approval for the Spanish observational arm of the AInCP project was obtained from the Institutional Review Board of the University Hospital of Toledo (approval number 1068). Written informed consent was obtained from all parents or legal guardians, and assent was sought from children over the age of 12 years, in accordance with the Declaration of Helsinki. All data were confidential and securely stored. After assessments, families received a report summarizing their child's performance. Data collection Demographic data: age, sex, MACS, affected side Demographic and clinical data were obtained through parent interviews and review of medical records using a standardized case report form. Information recorded at the start of each assessment included age (in years), sex (male/female), MACS level (I–III) and affected-sided (right/left). Activity domain Bimanual performance was evaluated using two complementary standardized measures operationalizing the ICF 'Activity' domain: the Assisting Hand Assessment (AHA) 26 and the Children's Hand-use Experience Questionnaire (CHEQ). 27 AHA: A performance-based observational measure that quantifies spontaneous use of the affected hand during bimanual activities. Age-appropriate play sessions were administered and video-recorded, then scored on 20 items using a four-point scale, with higher scores reflecting more effective use of the affected hand. Raw scores are converted to AHA logits (0–100), with higher scores indicating optimal bimanual performance. The AHA has demonstrated excellent interrater and intrarater reliability (ICC > 0.98) and strong construct validity across childhood and adolescence. 28 CHEQ: A parent-reported questionnaire designed to assess the child’s experience using the more-affected hand during bimanual activities in daily life. It consists of items related to typical bimanual tasks. For each activity, parents rate both the effectiveness of the affected hand and the level of difficulty encountered, as well as relevant contextual factors, using standardized response scales. In this study, three key CHEQ summary scores were used: the CHEQ Grip Efficiency score (range 0–100, with higher scores reflecting better perceived hand function), CHEQ Required Time (0–100, with higher scores indicating shorter time to complete tasks relative to peers), and CHEQ Feeling Bothered (0–100, higher scores indicating less perceived bother/discomfort during bimanual activities). The CHEQ has demonstrated good internal consistency (Cronbach's α = 0.89) and robust construct validity for assessing functional bimanual performance in children with UCP. 29 Participation domain ´ Participation´ , the dependent variable, was measured using the Participation and Environment Measure for Children and Youth (PEM-CY), 30 a standardized parent-report questionnaire capturing the ICF ‘Participation’ domain. Parents reported their child’s frequency of Participation, level of involvement, and desire for change across home, school, and community settings, as well as environmental facilitators and barriers. The PEM-CY generates scores for participation frequency (ranging from 0–7, with higher scores indicating more frequent participation) and participation involvement (ranging from 1–5, with higher scores reflecting greater involvement intensity). Environmental factors are scored as the percentage of facilitators and barriers present (0–100%), with higher percentages of facilitators and lower percentages of barriers indicating more supportive contexts. A desire-for-change score (0–100%) reflects parental perception of need for increased participation in each setting. The PEM-CY has demonstrated moderate to excellent internal consistency (Cronbach's α ranging from 0.69–0.92 across subscales), good test–retest reliability across cultural adaptations (ICC = 0.72–0.85), and robust construct validity in distinguishing children with and without disabilities. Data were collected using paper forms during the assessment session and checked for accuracy and completeness before analysis. 31 Procedures and data sources All questionnaire responses and assessment scores were entered into a secure electronic database immediately after scoring. To ensure measurement consistency, evaluators (CV-M and PC-R) completed the official AHA certification training and participated in quarterly focus groups with international AINCP project teams (IRCCS Fondazione Stella Maris, Italy and KU Leuven, Belgium). A random 15% of video recordings was double-scored, yielding ICCs > 0.97. For the PEM-CY, two raters (CV-M and LM-P) received joint scoring training, and 10% of questionnaires were double-entered and independently scored, with Cohen’s kappa values exceeding 0.85. Comprehensive data cleaning was performed to identify and resolve missing, implausible, or inconsistent entries prior to analysis. Bias control To minimize selection bias, preliminary screening interviews were conducted with all potential participants to confirm eligibility criteria before enrollment, and recruitment strategies included multiple channels—national associations, clinical referrals, and online platforms—to ensure representativeness of children with UCP in Spain. To reduce measurement bias, assessors were officially certified in the AHA and inter-rater consistency was reinforced through regular focus groups with international collaborators. To minimize information bias, standardized instruments with established psychometric properties were used, and data entry was double-checked. Data cleaning procedures were implemented before analysis to address missing or inconsistent entries. To address potential confounding, statistical analyses adjusted for age, sex, and affected side, and subgroup analyses by MACS level (I–III) were conducted. Statistical analysis Descriptive statistics were computed using IBM SPSS Statistics version 27. Normality of distributions was assessed using the Shapiro-Wilk test. Given that CHEQ subscales violated normality assumptions (all p < 0.05) and MACS is an ordinal variable, Spearman rank correlation (ρ) was used for all bivariate correlational analyses, providing a non-parametric approach robust to distributional violations. Bivariate associations between bimanual performance measures (AHA logit scores and CHEQ summary scores) and PEM-CY participation outcomes were examined using Spearman's rank correlation. Between-group differences across MACS levels were tested using ANOVA or Kruskal-Wallis H tests with Bonferroni correction. Partial correlations were computed to examine bimanual performance–participation relationships while statistically controlling for demographic variables (age, gender, affected side), providing supplementary analyses to assess whether demographic factors confounded underlying relationships. Model assumptions and effect sizes were evaluated as appropriate. Statistical significance was set at α = 0.05 (two-tailed). RESULTS Demographics characteristics Figure 1 shows the flow of participants through eligibility, enrolment, and analysis in the observational study. Of the 75 children assessed for eligibility, five were excluded. Consequently, 70 children with UCP were enrolled with a mean age of 9.5 years (Standard Deviation (SD) 2.5), and all completed the study assessments. Baseline demographic and clinical characteristics of the cohort are presented in Table 1. Figure 1. Flow of participants through eligibility, enrolment, and analysis in the observational study Table 1. Table 1. Participant characteristics, MACS distribution, and descriptive statistics of key measures Descriptives statistics of Key Measures Descriptive statistics for AHA, CHEQ, and PEM-CY outcomes in home, school, and community settings, are summarized in Table 1. Bimanual performance, as measured by the AHA, showed a mean logit score of 55.41 (SD 14.14), indicating moderate variability in hand function. Parent-reported hand-use experience (CHEQ) revealed moderate scores across domains, with the Feeling Bothered subscale showing the highest mean (50.34, SD 13.97). Participation frequency was highest in home (91.6% of activities) and school (82.6%) settings, with notably lower participation in community activities (70.0%). Over half of parents (56.4%) reported desire for increased home participation, whereas fewer desired change in school and community settings. Correlational analyses examining relationships among AHA, CHEQ subscales, and MACS classification levels are presented in Appendix 1. These analyses reveal that manual ability is strongly related with bimanual performance (AHA), whereas weakly related to parent-reported hand-use experience (CHEQ), highlighting important differences between performance-based and proxy-reported measures. Difference in Participation Across Manual Ability Levels Regarding differences in participation in daily life between manual ability levels (MACS I–III), as shown in Table 2, no statistically significant differences were observed in PEM-CY participation outcomes, involvement scores, desire for change, or environmental facilitators and barriers across MACS groups (all p > 0.05). These results suggest that, within this cohort of children with UCP, manual ability classification did not have a discernible impact on Participation patterns or related environmental factors in home, school, or community settings. Table 2. Participation and environmental outcomes across MACS levels in children with UCP Correlations between Participation and bimanual performance No statistically significant correlations were found between AHA scores (sum score or logit-scaled units) and any PEM-CY frequency, involvement, desire for change, or environmental facilitator/barrier variables across home, school, or community settings (all p > 0.05). Similarly, the three CHEQ summary scores—Grip Efficiency, Required Time, and Feeling Bothered—showed no statistically significant correlations with any PEM-CY participation or environmental outcomes across home, school, or community settings (all p > 0.05). Although some correlations approached marginal significance (e.g., CHEQ Grip Efficiency and community participation frequency, ρ = –0.23, p = 0.063; CHEQ Feeling Bothered and community participation frequency, ρ = –0.21, p = 0.097), none reached the conventional threshold for statistical significance (p ≤ 0.05). Figure 2 displays three side-by-side scatterplots of AHA logit units versus PEM-CY frequency (% activities) for home, school, and community settings. Datapoint spread in each plot suggests the lack of observable trends or patterns, reinforcing the absence of association across contexts. Figure 2. Scatterplots of AHA Versus PEM-CY Frequency at Home, School, and Community Settings Partial correlations adjusting demographic characteristics Controlling for age did not alter the pattern of results: correlations between AHA logit scores or CHEQ summary scores (Grip Efficiency, Required Time, Feeling Bothered) and PEM-CY participation and environmental variables across home, school, and community settings remained non-significant (all p > 0.05). Similarly, when sex or affected side were accounted for separately, none of the partial correlations reached statistical significance. DISCUSSION The purpose of this study was to explore the association between bimanual performance and domains of participation in children with UCP, using both performance-based and parent-reported measures of bimanual performance, alongside participation outcomes. The main finding of this study is that, despite clear differences in bimanual performance across manual ability levels, no significant associations were found between either AHA or CHEQ and participation outcomes as measured by the PEM-CY. These relationships remained non-significant after adjusting for demographic factors such as age, sex, and affected side, suggesting that participation across various settings might be more related to a combination of contextual factors rather than motor function alone. The moderate correlation observed between AHA and CHEQ in this cohort is consistent with previous work 32 , indicating that they capture related but distinct aspects of bimanual performance. In our sample, neither observed (AHA) nor perceived (CHEQ) bimanual performance was significantly associated with participation outcomes, which extends earlier evidence 33 by suggesting that despite the method of its assessment, bimanual function alone does not account for real-world participation. The results of this study further underscore the complexity of functioning domains within the ICF framework. While the bimanual performance measures effectively differentiated performance across MACS levels, in accordance with previous studies, 11 it did not capture the full range of determinants influencing Participation ; consistent with the “ Activity – Participation gap” described in recent literature. 34 , 35 This gap reflects the notion that impairments and Activity limitations do not automatically lead to reduced Participation , which is instead mainly influenced by contextual factors, encompassing environmental and personal domains. Given that UCP comprises a complex, multifaceted disorder, it is worthwhile considering environmental and personal factors when designing interventions aimed at promoting meaningful engagement in daily-life contexts. 10,14 Although the present study did not directly assess environmental factors, previous research has demonstrated that environmental moderators—such as accessibility of infrastructure, transportation, community programs, financial resources, and social attitudes—play a crucial role in shaping Participation in everyday life. 36–39 These factors may either facilitate or hinder engagement independently of motor ability. Therefore, it is important to consider the opportunities that children with disabilities get to participate in various contexts and ensure more inclusive environments. Notably, our descriptive findings showed a gradient of increasing environmental barriers from home (24.5%) through school (30.5%) to community settings (34.1%), suggesting that contextual demands increase as children move beyond familiar environments. The high Participation rates found in familiar contexts, such as home and school, despite motor limitations, likely reflect the use of compensatory strategies, adoption of routines or environmental adaptations. 40 Previous studies have shown that children with disabilities frequently employ task modifications, assistive devices, and supportive family routines to achieve meaningful engagement. 41 These adaptive strategies underscore Participation as a dynamic outcome shaped by the continuous interaction between the child and the environment, which is not limited by the inherent impairments of the disorder. Furthermore, personal factors have been shown to be equally important in explaining Participation variability among children with UCP. Previous studies have shown that cognitive and communication abilities, behavioral and emotional regulation, motivation, and personal preferences significantly influence engagement in daily and community activities, often independently of motor ability. 42 , 43 Our findings align with this evidence, suggesting that children with comparable bimanual performance may display very different Participation patterns due to these personal attributes or the interplay among a multitude of factors. Family and personal empowerment could further moderate this complex interaction. Empowerment, defined as self-efficacy, autonomy, advocacy, and collaborative goal-setting, has been associated with improved Participation outcomes and greater resilience in overcoming environmental barriers. 44 – 46 Empowered families tend to create more opportunities for their children’s engagement across settings, emphasizing the critical role of family-centered interventions. 47 In general, Participation outcomes frequently capture long-term involvement and are shaped by contextual opportunities rather than immediate performance alone, 48 potentially explaining the absence of direct associations. Overall, these findings suggest that Participation cannot be fully understood or optimized by focusing solely on motor function. Instead, holistic approaches that strengthen both child and family empowerment are essential to promote meaningful Participation , consistent with the multifactorial biopsychosocial model of the ICF. 46 , 49 Taken together, the current findings and previous evidence emphasize that the relationship between Activity and Participation cannot be interpreted in isolation from the contextual factors that modulate it, particularly in multifaceted disorders such as UCP. This reinforces the need to move beyond motor-centric rehabilitation paradigms and follow more holistic and tailored approaches. Since bimanual performance alone does not fully account for the complexity of Participation , effective interventions should extend beyond motor training to include environmental modifications and family-empowerment initiatives that enable children to engage more fully in meaningful activities. 15 , 50 As also shown in the meta-analytic findings of Dimakopoulos et al., participation in CP is more likely to improve when interventions address specific participation barriers. This underscores Participation as a multifaceted construct that requires a contextual perspective, rather than one primarily focused on impairments related to the disorder. Accordingly, future assessment and intervention planning should systematically incorporate Body functions and structures (executive functions) andcontextual factors (motivation, self-efficacy, preferences) as explicit components of the ICF biopsychosocial model, ensuring that clinical profiling captures the full spectrum of determinants influencing Participation . Multimodal approaches that integrate bimanual therapy with family coaching on barrier removal, activity adaptation, and goal-setting may be more effective than motor training alone. 51 , 52 Future research should identify which environmental and personal factors best predict Participation outcomes specifically in UCP and examine whether combined interventions yield superior benefits. Additionally, rehabilitation professionals should receive training in environmental assessment, personal factor identification, and family coaching, while health policies should prioritize accessibility and inclusion in educational and community settings alongside individual rehabilitation efforts. It is worthwhile considering a few limitations of this study. First, the single-center, convenience sample limits generalizability beyond this Spanish pediatric cohort. Nevertheless, all necessary methods were employed to minimize bias in various domains as much as possible. Second, Participation was assessed through parent-report, which may introduce bias related to parental perceptions, expectations, or recall. While child self-report would provide complementary data, parent-report is the established method for evaluating participation across multiple environments in pediatric populations and has demonstrated acceptable validity in previous studies. Third, personal factors such as motivation, self-efficacy, and coping strategies were not evaluated in this study, although their effect could have explained the observed variability in Participation . Finally, the high Participation rates observed at home and school may indicate ceiling effects, whereas community Participation showed greater variability. Despite these limitations, the present findings provide valuable evidence that motor function alone does not determine Participation in children with UCP, supporting the need for multifactorial, contextually-driven approaches to intervention. CONCLUSIONS Bimanual performance appears unrelated to daily participation frequency or involvement across home, school, and community settings in children with UCP, even after adjusting for age, sex, and lesion laterality. Participation variability among similar manual ability levels underscores the multifactorial influence of environmental and personal contextual factors. Findings support holistic ICF-based rehabilitation integrating family coaching and environmental adaptations beyond motor training. Abbreviations AHA: Assisting Hand Assessment AInCP: Artificial Intelligence in Cerebral Palsy CHEQ: Children's Hand-use Experience Questionnaire CP: Cerebral Palsy ICF: International Classification of Functioning, Disability and Health ICF-CY: International Classification of Functioning, Disability and Health Children & Youth MACS: Manual Ability Classification System PEM-CY: Participation and Environment Measure for Children and Youth SD: Standard Deviation STROBE: STrengthening the Reporting of Observational Studies in Epidemiology UCP: Unilateral Cerebral Palsy Declarations Ethics approval and consent to participate Ethical approval for the Spanish observational arm of the AInCP project was obtained from the Institutional Review Board of the University Hospital of Toledo (approval number 1068). Written informed consent was obtained from all parents or legal guardians, and assent was sought from children over the age of 12 years, in accordance with the Declaration of Helsinki. All data were confidential and securely stored. Consent for publication Not applicable. Availability of data and materials The datasets analysed during the current study are available from the corresponding author on reasonable request. Competing interests The authors declare no competing interests. Funding This research was conducted as part of the AinCP project, funded by the European Union’s Horizon 2020 programme and the Spanish Ministry of Science and Innovation. Authors' contributions MC-V: Investigation, Data curation, software, Formal analysis, Writing – original draft, Visualization, Project administration. PL-M: Investigation, Formal analysis, Writing – original draft. GS: Funding acquisition, Conceptualization, Methodology, Supervision. AK (Alexandra Kalkantzi): Conceptualization, formal analysis, validation, Writing – original draft. JL-B: Investigation. HR-B: Investigation. EB: Investigation, conceptualization, Methodology, resources, supervision. RP-C: Conceptualization, Funding acquisition, Project administration, Methodology, Supervision, validation, Writing – original draft. Acknowledgements This work was supported by the European Union’s Horizon 2020 research and innovation programme under grant agreement No. 101017727 (AInCP project). GS has also partially funded by Italian Ministry of Health - Grant RC (and the 5x1000 voluntary contributions). The authors gratefully acknowledge the AinCP Consortium for their invaluable support in study coordination and data management. We also thank Hemiweb and ASPACE for their assistance with participant recruitment and engagement throughout the study. Special thanks to the families and children who participated. References Pless M, Granlund M. Implementation of the International Classification of Functioning, Disability and Health (ICF) and the ICF Children and Youth Version (ICF-CY) within the context of augmentative and alternative communication. Augment Altern Commun. 2012 Mar;28(1):11–20. Organization WH. International Classification of Functioning, Disability, and Health: Children & Youth Version : ICF-CY. World Health Organization; 2007. 352 p. Hadar-Frumer M, Ten-Napel H, Yuste-Sánchez MJ, Rodríguez-Costa I. Feasibility of Using the International Classification of Functioning, Disability and Health for Children and Youth (ICF-CY) as a Framework for Aquatic Activities: A Scoping Review. Children [Internet]. 2023;10(12). Available from: https://www.scopus.com/inward/record.uri?eid=2-s2.0-85180727320&doi=10.3390%2Fchildren10121856&partnerID=40&md5=ba357c5746e5f46f8514957fb4f09f15 Chien CW, Rodger S, Copley J, Skorka K. Comparative content review of children’s participation measures using the International Classification of Functioning, Disability and Health-Children and Youth. Arch Phys Med Rehabil. 2014 Jan;95(1):141–52. Björklund AC, Darcy L, Santacroce SJ, Granlund M, Björk M. Individual patterns of problems with participation, activity, body function and environment in everyday life for children who completed brain tumor treatment. Disabil Rehabil. 2023 Nov;45(23):3841–51. Riccardi JS, Dart L, Lundine JP, Ciccia A. Correlations between injury- and child-related factors and participation and quality of life after childhood traumatic brain injury. Neuropsychol Rehabil. 2025 Oct;35(9):1848–64. Michelsen SI, Flachs EM, Damsgaard MT, Parkes J, Parkinson K, Rapp M, et al. European study of frequency of participation of adolescents with and without cerebral palsy. Eur J Paediatr Neurol. 2014 May;18(3):282–94. Badia M, Orgaz BM, Verdugo MA, Ullán AM, Martínez MM. Personal factors and perceived barriers to participation in leisure activities for young and adults with developmental disabilities. Res Dev Disabil. 2011;32(6):2055–63. Makki D, Duodu J, Nixon M. Prevalence and pattern of upper limb involvement in cerebral palsy. J Child Orthop. 2014 May;8(3):215–9. Rosenbaum P, Paneth N, Leviton A, Goldstein M, Bax M, Damiano D, et al. A report: the definition and classification of cerebral palsy April 2006. Dev Med Child Neurol Suppl. 2007 Feb;109:8–14. Eliasson A, Nordstrand L, Backheden M, Holmefur M. Longitudinal development of hand use in children with unilateral spastic cerebral palsy from 18 months to 18 years. Dev Med Child Neurol. 2023 Mar;65(3):376–84. Wang TN, Howe TH, Liang KJ, Chang TW, Shieh JY, Chen HL. Bimanual motor performance in everyday life activities of children with hemiplegic cerebral palsy. Eur J Phys Rehabil Med. 2021 Aug;57(4):568–76. Park H, Choi JY, Yi SH, Park ES, Shim D, Choi TY, et al. Relationship between the more-affected upper limb function and daily activity performance in children with cerebral palsy: a cross-sectional study. BMC Pediatr. 2021 Oct 19;21(1):459. Imms C, Adair B, Keen D, Ullenhag A, Rosenbaum P, Granlund M. “Participation”: a systematic review of language, definitions, and constructs used in intervention research with children with disabilities. Dev Med Child Neurol. 2016 Jan;58(1):29–38. van der Kemp J, Ketelaar M, Gorter JW. Environmental factors associated with participation and its related concepts among children and youth with cerebral palsy: a rapid review. Disabil Rehabil. 2022 May;44(9):1571–82. Alves ML de F, Souto DO, Romeros ACSF, Magalhães EDD, Mendes LG, Ayupe KMA, et al. Characterization of environmental factors in children and adolescents with cerebral palsy in Minas Gerais: Participa Minas. Rev Paul Pediatr. 2024;42:e2023043. Dimakopoulos R, Vakalaki T, Spinou A, Michopoulos I, Papadopoulou Μ. Effectiveness of therapeutic interventions on participation in children with cerebral palsy: A systematic review and meta-analysis. Child Care Health Dev. 2024 July;50(4):e13301. Huus K, Schlebusch L, Ramaahlo M, Samuels A, Berglund IG, Dada S. Barriers and facilitators to participation for children and adolescents with disabilities in low- and middle-income countries - A scoping review. Afr J Disabil. 2021;10:771. Hoare B, Ditchfield M, Thorley M, Wallen M, Bracken J, Harvey A, et al. Cognition and bimanual performance in children with unilateral cerebral palsy: protocol for a multicentre, cross-sectional study. BMC Neurol. 2018 May 8;18(1):63. Kalkantzi A, Kleeren L, Baeyens D, Decraene L, Crotti M, Klingels K, et al. Daily-life executive functions and bimanual performance in children with unilateral cerebral palsy. Dev Med Child Neurol. 2025 Oct;67(10):1290–300. Kinnucan E, Van Heest A, Tomhave W. Correlation of motor function and stereognosis impairment in upper limb cerebral palsy. J Hand Surg Am. 2010 Aug;35(8):1317–22. Tonmukayakul U, Imms C, Mihalopoulos C, Reddihough D, Carter R, Mulhern B, et al. Health-related quality of life and upper-limb impairment in children with cerebral palsy: developing a mapping algorithm. Dev Med Child Neurol. 2020 July;62(7):854–60. Gardas SS, Lysaght C, McMillan AG, Kantak S, Willson JD, Patterson CG, et al. Bimanual Movement Characteristics and Real-World Performance Following Hand-Arm Bimanual Intensive Therapy in Children with Unilateral Cerebral Palsy. Behav Sci (Basel). 2023 Aug 13;13(8):681. van der Kemp J, Ketelaar M, Gorter JW. Environmental factors associated with participation and its related concepts among children and youth with cerebral palsy: a rapid review. Disabil Rehabil. 2022 May;44(9):1571–82. von Elm E, Altman DG, Egger M, Pocock SJ, Gøtzsche PC, Vandenbroucke JP, et al. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies. Lancet. 2007 Oct 20;370(9596):1453–7. Krumlinde-Sundholm L, Holmefur M, Kottorp A, Eliasson AC. The Assisting Hand Assessment: current evidence of validity, reliability, and responsiveness to change. Dev Med Child Neurol. 2007 Apr;49(4):259–64. Sköld A, Hermansson LN, Krumlinde-Sundholm L, Eliasson AC. Development and evidence of validity for the Children’s Hand-use Experience Questionnaire (CHEQ). Dev Med Child Neurol. 2011 May;53(5):436–42. Holmefur MM, Krumlinde-Sundholm L. Psychometric properties of a revised version of the Assisting Hand Assessment (Kids-AHA 5.0). Dev Med Child Neurol. 2016 June;58(6):618–24. Ryll UC, Eliasson AC, Bastiaenen CH, Green D. To Explore the Validity of Change Scores of the Children’s Hand-use Experience Questionnaire (CHEQ) in Children with Unilateral Cerebral Palsy. Phys Occup Ther Pediatr. 2019;39(2):168–80. Coster W, Law M, Bedell G, Khetani M, Cousins M, Teplicky R. Development of the participation and environment measure for children and youth: conceptual basis. Disabil Rehabil. 2012;34(3):238–46. Coster W, Bedell G, Law M, Khetani MA, Teplicky R, Liljenquist K, et al. Psychometric evaluation of the Participation and Environment Measure for Children and Youth. Dev Med Child Neurol. 2011 Nov;53(11):1030–7. Ryll UC, Bastiaenen CHG, Eliasson AC. Assisting Hand Assessment and Children’s Hand-Use Experience Questionnaire -Observed Versus Perceived Bimanual Performance in Children with Unilateral Cerebral Palsy. Phys Occup Ther Pediatr. 2017 May;37(2):199–209. Ryll UC, Bastiaenen CHG, Eliasson AC. Assisting Hand Assessment and Children’s Hand-Use Experience Questionnaire -Observed Versus Perceived Bimanual Performance in Children with Unilateral Cerebral Palsy. Phys Occup Ther Pediatr. 2017 May;37(2):199–209. Mutlu A, Büğüşan S, Kara ÖK. Impairments, activity limitations, and participation restrictions of the international classification of functioning, disability, and health model in children with ambulatory cerebral palsy. Saudi Med J. 2017 Feb;38(2):176–85. Burak M, Kavlak E. Investigation of the relationship between quality of life, activity participation and environmental factors in adolescents with cerebral palsy. NeuroRehabilitation. 2019 Sept 18;45(4):555–65. Aljuhani T, Alzahrani SA, Aldosary AM, Alzamil LA, Alshehri RK, Gmmash AS, et al. Measuring Community and Home Participation and Environmental Factors in Children with Cerebral Palsy. Pediatr Rep. 2025 Feb 7;17(1):17. van der Kemp J, Ketelaar M, Gorter JW. Environmental factors associated with participation and its related concepts among children and youth with cerebral palsy: a rapid review. Disabil Rehabil. 2022 May;44(9):1571–82. Colver A, Thyen U, Arnaud C, Beckung E, Fauconnier J, Marcelli M, et al. Association between participation in life situations of children with cerebral palsy and their physical, social, and attitudinal environment: a cross-sectional multicenter European study. Arch Phys Med Rehabil. 2012 Dec;93(12):2154–64. Africa LE, Human A, Tshabalala MD. Participation patterns of children with cerebral palsy: A caregiver’s perspective. Afr J Disabil. 2023;12:1058. Colver A, Thyen U, Arnaud C, Beckung E, Fauconnier J, Marcelli M, et al. Association between participation in life situations of children with cerebral palsy and their physical, social, and attitudinal environment: a cross-sectional multicenter European study. Arch Phys Med Rehabil. 2012 Dec;93(12):2154–64. Imms C, Adair B, Keen D, Ullenhag A, Rosenbaum P, Granlund M. “Participation”: a systematic review of language, definitions, and constructs used in intervention research with children with disabilities. Dev Med Child Neurol. 2016 Jan;58(1):29–38. Predictors of community participation from preschool to school age in children with cerebral palsy. Dev Med Child Neurol. 2025 Aug;67(8):e142. Bingol H, Fidan H, Asena Sel S, Burc E, Gunel MK. Causal pathways of potential factors affecting participation level of individuals with unilateral cerebral palsy. Br J Occup Ther. 2024 Sept;87(9):546–55. Kalleson R, Jahnsen R, Østensjø S. Empowerment in families raising a child with cerebral palsy during early childhood: Associations with child, family and service characteristics. Child Care Health Dev. 2019 Sept 10; Kalleson R, Jahnsen R, Østensjø S. Exploring participation in family and recreational activities among children with cerebral palsy during early childhood: how does it relate to motor function and parental empowerment? Disabil Rehabil. 2022 May;44(9):1560–70. Mohamed Abdelrahman B, NabawyElaasar H, Rady El Said R. Effect of Family Empowerment Program on Parents’ Performance regarding Care of Their Children with Cerebral Palsy. Egyptian Journal of Health Care. 2021 Sept 1;12(3):2072–93. Kalleson R, Jahnsen R, Østensjø S. Exploring participation in family and recreational activities among children with cerebral palsy during early childhood: how does it relate to motor function and parental empowerment? Disabil Rehabil. 2022 May;44(9):1560–70. Imms C, Granlund M, Wilson PH, Steenbergen B, Rosenbaum PL, Gordon AM. Participation, both a means and an end: a conceptual analysis of processes and outcomes in childhood disability. Dev Med Child Neurol. 2017 Jan;59(1):16–25. Massey J, Harniess P, Chinn D, Robert G. Barriers and facilitators to parent-delivered interventions for children with or infants at risk of cerebral palsy. An integrative review informed by behaviour change theory. Disabil Rehabil. 2025 Jan;47(2):287–301. Urbina T, Balasundaram M, Coughlin M, Sorrells K, Toney-Noland C, Day C. The Why and How of Family-Centered Care. Neoreviews. 2024 July 1;25(7):e393–400. Jackman M, Sakzewski L, Morgan C, Boyd RN, Brennan SE, Langdon K, et al. Interventions to improve physical function for children and young people with cerebral palsy: international clinical practice guideline. Dev Med Child Neurol. 2022 May;64(5):536–49. Dirks T, Hadders-Algra M. The role of the family in intervention of infants at high risk of cerebral palsy: a systematic analysis. Dev Med Child Neurol. 2011 Sept;53 Suppl 4:62–7. Tables Table 1. Participant characteristics, MACS distribution, and descriptive statistics of key measures Unilateral Cerebral Palsy (n 70) Sex n (%) Male 44 (62.9) Affected side (n (%) Right 49 (70) Age Mean (SD) Median (IQR) 9.5 (2.5) 9 (7-11) MACS Level (n 70) Level I (n 15) Level II (n 28) Level III (n 27) p-value Sex n (%) Female Male 6 (40.0) 9 ( 60.0) 11 (39.3) 17 (60.7) 9 (33.3) 18 (66.7) 0.87 Affected side n (%) Left Right 5 (33.3) 10 (66.7) 6 (21.4) 22 (78.6) 10 (37.0) 17 (63.0) 0.56 Assisting Hand Assessment (n 70) Mean SD Median IQR AHA sum score (0-80) 51.13 11.32 50.00 44.00–58.25 AHA logit score (0-100) 55.41 14.14 54.00 47.00–64.50 Children's Hand-use Experience Questionnaire (n 68) Mean SD Median IQR Global CHEQ score 40.74 11.51 39.0 9-75 CHEQ Required Time 39.46 13.77 40.0 0-76 CHEQ Feeling Bothered 50.34 13.97 47.50 9-100 Participation and Environmental Outcomes (n 70) Mean SD Median IQR Frequency of Participation in the home 5.8 0.6 5.9 5.4-6.1 Frequency of Participation in the home (% activities) 91.6 11.1 90 90-100 Level of involucration in the home 3.9 0.6 4 3.6-4.3 Desire for change of Participation in the home (%) 56.4 26.0 60 40-80 Home environment total (/3) 2.7 0.3 2.7 2.5-2.9 Home environment facilitators 75.5 18.3 75.8 64.3-91.7 Home environment barriers 24.5 18.3 24.3 8.3-35.4 Frequency of Participation in the school 4.9 0.8 5 4.6-5.5 Frequency of Participation in the school (% activities) 82.6 16.9 80 80-100 Level of involucration in the school 4.8 5.1 4.5 3.8-5.0 Desire for change of Participation in the school (%) 39.7 32.7 40 15-60 School environment total (/3) 2.6 0.3 2.7 2.4-2.8 School environment facilitators 69.5 20.1 70.6 58.6-82.4 School environment barriers 30.5 20.1 29.4 17.6-41.6 Frequency of Participation in the community 4.3 0.8 4.5 3.6-5.0 Frequency of Participation in the community (% activities) 70.0 13.9 70 60-80 Level of involucration in the community 4.3 3.5 4.1 3.5-4.6 Desire for change of Participation in the community (%) 42.1 28.3 40 20.0-66.3 Community environment total (/3) 2.6 0.3 2.7 2.3-2.8 Community environment facilitators 65.9 24.3 69 50.0-87.5 Community environment barriers 34.1 24.3 31 12.5-50.0 *SD: Standard Deviation, IQR: Interquartile range Table 2. Participation and environmental outcomes across MACS levels in children with UCP MACS p Level I Level II Level III Mean SD Median IQR Mean SD Median IQR Mean SD Median IQR PEM-CY frequency of participation in the home 5.7 0.7 5.9 5.4-6.1 5.8 0.6 5.9 5.6-6.2 5.8 0.5 5.9 5.4-6.1 0.923 2 PEM-CY frequency of participation in the home (% activities) 91.3 10.6 100 80-100 90.4 12.9 90 90-100 93.0 9.5 100 90-100 0.749 2 PEM-CY level of involucration in the home 4.0 0.6 4 3.6-4.6 3.8 0.7 3.9 3.4-4.3 3.9 0.5 4 3.7-4.2 0.612 2 PEM-CY desire for change of participation in the home (%) 53.3 25.0 50 30-70 55.7 28.6 70 40-80 58.9 24.4 60 40-80 0.685 2 PEM-CY home environment total (/3) 2.7 0.2 2.7 2.6-3.0 2.7 0.4 2.8 2.4-2.8 2.7 0.3 2.7 2.4-2.9 0.676 2 PEM-CY home environment facilitators 77.3 19.5 76.5 66.7-100 73.8 18.7 79.2 58.1-83.3 76.3 17.8 75 66.7-91.7 0.793 2 PEM-CY home environment barriers 22.7 19.5 23.5 0-33.3 26.2 18.7 20.8 16.7-41.9 23.7 17.8 25 8.3-33.3 0.828 2 PEM-CY frequency of participation in the school 4.9 0.7 5 4.6-5.6 5.0 0.7 5.3 4.7-5.5 4.9 1.0 5 4.0-5.4 0.706 1 PEM-CY frequency of participation in the school (% activities) 84.0 15.5 80 80-100 78.9 18.9 80 60-100 85.6 15.3 80 80-100 0.407 2 PEM-CY level of involucration in the school 4.4 0.7 4.4 4-5 4.1 0.8 4 3.7-4.8 5.7 8.1 4.5 4.0-4.8 0.336 2 PEM-CY desire for change of participation in the school (%) 28.0 31.0 20 0-60 43.6 29.3 40 20-60 42.2 36.5 40 0-80 0.262 2 PEM-CY school environment total (/3) 2.6 0.2 2.7 2.5-2.8 2.6 0.3 2.7 2.4-2.9 2.6 0.3 2.7 2.4-2.9 0.932 2 PEM-CY school environment facilitators 69.7 16.8 76.5 58.8-76.5 68.4 20.8 69.4 54.3-86.6 70.6 21.6 70.6 53.0-88.2 0.773 2 PEM-CY school environment barriers 30.3 16.8 22.5 23.5-41.2 31.7 20.8 30.6 13.4-45.8 29.4 21.6 29.4 11.8-47.0 0.775 2 PEM-CY frequency of participation in the community 4.5 0.7 4.4 3.9-5.2 4.3 0.8 4.6 3.9-4.8 4.3 0.9 4.5 3.4-5.0 0.922 2 PEM-CY frequency of participation in the community (% activities) 73.6 11.5 75 67.5-80.0 66.8 14.9 70 52.5-77.5 71.5 13.8 70 60-80 0.261 1 PEM-CY level of involucration in the community 4.1 0.7 4.1 3.6-5.0 3.7 1.0 4 3.0-4.4 5.1 5.4 4.1 3.7-4.7 0.222 2 PEM-CY desire for change of participation in the community (%) 40.0 24.2 40 20-70 47.9 29.7 50 22.5-67.5 37.1 28.6 30 10.0-62.5 0.360 1 PEM-CY community environment total (/3) 2.6 0.3 2.8 2.3-2.9 2.6 0.3 2.7 2.3-2.9 2.5 0.3 2.6 2.4-2.8 0.740 2 PEM-CY community environment facilitators 67.9 28.4 81.3 43.8-89.1 65.6 24.6 71.8 45.3-87.5 65.1 22.7 64.7 50.0-87.5 0.830 2 PEM-CY community environment barriers 32.1 28.4 18.8 10.9-56.3 34.4 24.6 28.1 12.5-54.7 34.9 22.7 35.3 12.5-50.0 0.830 2 1 One-way ANOVA 2 Kruskal-Wallis test for independent samples SD: Standard Deviation, IQR: Interquartile range Additional Declarations No competing interests reported. Supplementary Files APPENDIX.docx Cite Share Download PDF Status: Published Journal Publication published 09 Mar, 2026 Read the published version in BMC Pediatrics → Version 1 posted Editorial decision: Revision requested 02 Mar, 2026 Reviews received at journal 02 Mar, 2026 Reviews received at journal 25 Feb, 2026 Reviewers agreed at journal 23 Feb, 2026 Reviewers agreed at journal 17 Feb, 2026 Reviewers invited by journal 17 Feb, 2026 Editor assigned by journal 16 Feb, 2026 Submission checks completed at journal 16 Feb, 2026 First submitted to journal 13 Feb, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8872346","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":594416484,"identity":"865be1b7-fca0-4df9-844a-d3eaf9464a58","order_by":0,"name":"María Coello-Villalón","email":"","orcid":"","institution":"University of Castilla-La Mancha","correspondingAuthor":false,"prefix":"","firstName":"María","middleName":"","lastName":"Coello-Villalón","suffix":""},{"id":594416485,"identity":"e341747b-5e9e-471c-91b3-fc0ce2dc2b30","order_by":1,"name":"Purificación López-Muñoz","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABCklEQVRIie2RMUvDQBTHnxycy8GtFwT9Ck8ES0Dbr5ISSCel4JLRzaUlaz5Gp6w+OegUcQ10sUvnTNLBwbtaU4RnZqH3G45/4H68/8sBBAL/FMrRncLHqT8E7UOPUneKDyCTfeih7tLupsJeZWDu1kTT4YV+Est3wJt7resPs8UKtCZWicsJEmF6WVo5QcDsIXp8raIZriAqE1bBJgPbIp0shLo2gHa8eJlXZ+AUbPhiXnFTaNQpz1ZtdsrojS/2o4wPU6SS31OALxbPNl5JU7dLZhK3i6nlVex2UabhlcFpJlr6HN4WhV2aNnd/rLDrZpuvznXxR7FfXwkcyih+eebJ+DKBQCBw1HwBi05bVAxrLy0AAAAASUVORK5CYII=","orcid":"","institution":"University of Castilla-La Mancha","correspondingAuthor":true,"prefix":"","firstName":"Purificación","middleName":"","lastName":"López-Muñoz","suffix":""},{"id":594416486,"identity":"4ed73493-89eb-4044-9e7f-55e9fb2a7a44","order_by":2,"name":"Giuseppina Sgandurra","email":"","orcid":"","institution":"Developmental Neurology and Neurorehabilitation Unit, IRCCS Stella Maris Foundation","correspondingAuthor":false,"prefix":"","firstName":"Giuseppina","middleName":"","lastName":"Sgandurra","suffix":""},{"id":594416487,"identity":"236a71aa-f240-4442-a8fc-721189931341","order_by":3,"name":"Alexandra Kalkantzi","email":"","orcid":"","institution":"KU Leuven, Department of Rehabilitation Sciences","correspondingAuthor":false,"prefix":"","firstName":"Alexandra","middleName":"","lastName":"Kalkantzi","suffix":""},{"id":594416488,"identity":"ede5e22e-a31f-4fb7-95da-b750a96279b6","order_by":4,"name":"Julián A Basco-López","email":"","orcid":"","institution":"University of Castilla-La Mancha","correspondingAuthor":false,"prefix":"","firstName":"Julián","middleName":"A","lastName":"Basco-López","suffix":""},{"id":594416489,"identity":"b87d144e-400d-4b56-9d9f-e312561c8554","order_by":5,"name":"Helena Romay-Barrero","email":"","orcid":"","institution":"University of Castilla-La Mancha","correspondingAuthor":false,"prefix":"","firstName":"Helena","middleName":"","lastName":"Romay-Barrero","suffix":""},{"id":594416491,"identity":"6d2d3df8-4507-4bb3-980f-eff30aeec1a7","order_by":6,"name":"Elena Beani","email":"","orcid":"","institution":"Developmental Neurology and Neurorehabilitation Unit, IRCCS Stella Maris Foundation","correspondingAuthor":false,"prefix":"","firstName":"Elena","middleName":"","lastName":"Beani","suffix":""},{"id":594416492,"identity":"8f338daa-bb2f-4c07-a50d-91063820bd66","order_by":7,"name":"Rocío Palomo-Carrión","email":"","orcid":"","institution":"University of Castilla-La Mancha","correspondingAuthor":false,"prefix":"","firstName":"Rocío","middleName":"","lastName":"Palomo-Carrión","suffix":""}],"badges":[],"createdAt":"2026-02-13 13:23:42","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8872346/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8872346/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12887-026-06712-x","type":"published","date":"2026-03-09T15:57:53+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":103301868,"identity":"09fceb54-b36d-437c-b9fe-32687aff102f","added_by":"auto","created_at":"2026-02-24 08:20:19","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":16461,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eFlow of participants through eligibility, enrolment, and analysis in the observational study\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-8872346/v1/8308423d2058ce440bbc6a39.png"},{"id":103301869,"identity":"24a9f2b7-defd-4143-b894-20a358db094d","added_by":"auto","created_at":"2026-02-24 08:20:19","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":118255,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eScatterplots of AHA Versus PEM-CY Frequency at Home, School, and Community Settings\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"floatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-8872346/v1/6f4d4a68bcfa99dc5e18559b.png"},{"id":104739339,"identity":"b9de7942-3c08-4f37-bd8b-246434936fe1","added_by":"auto","created_at":"2026-03-16 16:03:11","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2043760,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8872346/v1/08cc6482-992f-432a-9cda-32049a043635.pdf"},{"id":103301867,"identity":"e39edff1-e307-444e-90ed-d76fcc56427d","added_by":"auto","created_at":"2026-02-24 08:20:19","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":47677,"visible":true,"origin":"","legend":"","description":"","filename":"APPENDIX.docx","url":"https://assets-eu.researchsquare.com/files/rs-8872346/v1/7e67870e593c7e64340d0d82.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Relationship Between Participation Across Daily Environments and Bimanual Performance in Children With Unilateral Cerebral Palsy: An ICF-Based Cross-Sectional Study","fulltext":[{"header":"BACKGROUND","content":"\u003cp\u003eThe International Classification of Functioning, Disability and Health Children \u0026amp; Youth Version \u003cem\u003e(ICF-CY)\u003c/em\u003e provides a conceptual framework for understanding human functioning in younger ages through four interrelated components (i.e., Body function and Structure, Activity, and Participation) influenced by personal and environmental factors. \u003csup\u003e1\u003c/sup\u003e Within this model, \u003cem\u003eActivity\u003c/em\u003e is defined as the execution of a task or action by an individual, whereas \u003cem\u003eParticipation\u003c/em\u003e refers to involvement in real-life situations.\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e Understanding the interplay between these constructs is fundamental for identifying each child's unique functioning profile and consequently designing interventions that not only improve functional abilities but also promote meaningful daily engagement.\u003c/p\u003e \u003cp\u003eWithin the ICF framework, \u003cem\u003eParticipation\u003c/em\u003e is a multidimensional construct encompassing nine domains\u0026mdash; learning and applying knowledge, general tasks and demands, communication, mobility, self-care, domestic life, interpersonal interactions and relationships, major life areas, and community, social and civic life\u0026mdash;and can be evaluated in terms of both \u003cem\u003efrequency\u003c/em\u003e and \u003cem\u003einvolvement\u003c/em\u003e.\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e,\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e \u003cem\u003eParticipation\u003c/em\u003e occurs across home, school, and community settings, fostering autonomy, social inclusion, and quality of life, and serving as both an outcome and a driver of child development.\u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e It is shaped by a dynamic interplay of environmental supports (e.g., accessibility, social attitudes, policies), family context, and individual characteristics such as motor abilities, communication, executive functions, motivation, and age.\u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e While motor function has traditionally been viewed as the primary determinant of \u003cem\u003eParticipation\u003c/em\u003e, growing evidence indicates that environmental and personal factors may impose equal or greater influence.\u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e Findings from an European study \u0026mdash;a large longitudinal cohort of children with CP across Europe\u0026mdash; demonstrate that children with similar motor severity can display markedly different \u003cem\u003eParticipation\u003c/em\u003e patterns depending on environmental context, underscoring the modifiable nature of \u003cem\u003eParticipation\u003c/em\u003e restrictions beyond impairment.\u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e Furthermore, personal factors\u0026mdash;including motivation, self-efficacy, and family attitudes\u0026mdash;are significant predictors of \u003cem\u003eParticipation\u003c/em\u003e.\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e Understanding how these multifactorial influences shape \u003cem\u003eParticipation\u003c/em\u003e in children with multifaceted conditions, such as cerebral palsy (CP), therefore remains critical.\u003c/p\u003e \u003cp\u003eUnilateral cerebral palsy (UCP), the most common CP subtype\u0026mdash;accounting for approximately 35% of all cases\u0026mdash;primarily affects motor function on one side of the body, with greater involvement of the upper limb.\u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e Children with UCP often exhibit asymmetrical hand use, strong reliance on the less-affected hand, and limited integration of the more-affected limb into bimanual activities.\u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e,\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e These limitations often interfere with independence and functioning, given that the majority of daily activities (e.g., dressing, eating) require the effective use of both hands.\u003csup\u003e\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e,\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e Therefore, quantifying the so-called bimanual performance is a crucial aspect of rehabilitation in children with UCP. Despite these bimanual limitations, many children with UCP develop compensatory strategies and rely on environmental supports that enable meaningful \u003cem\u003eParticipation\u003c/em\u003e. This suggests that \u003cem\u003eParticipation\u003c/em\u003e outcomes may not be solely determined by motor function, despite it being the primary impairment of children with UCP.\u003csup\u003e\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e Although \u003cem\u003eActivity\u003c/em\u003e gains are essential for functional autonomy, emerging research indicates that improvements in motor performance do not necessarily lead to increased \u003cem\u003eParticipation\u003c/em\u003e unless environmental barriers are addressed and empowerment strategies are integrated.\u003csup\u003e\u003cspan additionalcitationids=\"CR16\" citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u003c/sup\u003e Environmental factors\u0026mdash;such as accessibility, family engagement, and institutional policies\u0026mdash;alongside personal characteristics like motivation and self-efficacy, have been shown to exert substantial influence on \u003cem\u003eParticipation\u003c/em\u003e outcomes. \u003csup\u003e15,16,18\u003c/sup\u003e However, evidence specifically examining these relationships in UCP remains limited, highlighting a gap in the literature that this study begins to address.\u003c/p\u003e \u003cp\u003eWhile several studies have explored associations between bimanual performance in UCP and other ICF domains\u0026mdash;such as cognition, executive functions, somatosensory function, and quality of life\u003csup\u003e\u003cspan additionalcitationids=\"CR20 CR21\" citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u003c/sup\u003e, the specific relationship between standardized measures of bimanual performance and \u003cem\u003eParticipation\u003c/em\u003e in real-world environments remains underexplored. Preliminary intervention studies have shown that intensive bimanual training enhances motor capacity and real-world hand use, yet the extent to which these \u003cem\u003eActivity\u003c/em\u003e gains translate into meaningful \u003cem\u003eParticipation\u003c/em\u003e remains unclear.\u003csup\u003e\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u003c/sup\u003e Moreover, a recent study has considered the moderating roles of environmental and personal factors in this relationship.\u003csup\u003e\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eTherefore, this study aims to examine the relationship between bimanual performance, as a means of \u003cem\u003eActivity\u003c/em\u003e, and \u003cem\u003eParticipation\u003c/em\u003e\u0026mdash;in a large cohort of children with UCP. Different dimensions of \u003cem\u003eParticipation\u003c/em\u003e will be evaluated, specifically frequency and involvement\u0026mdash;across home, school, and community environments. Given the multifactorial nature of \u003cem\u003eParticipation\u003c/em\u003e, we hypothesize that bimanual performance alone will not show significant isolate associations with \u003cem\u003eParticipation\u003c/em\u003e frequency or involvement. Instead, we expect wide variability in \u003cem\u003eParticipation\u003c/em\u003e among children with comparable manual ability, underscoring the influence of various contextual factors in a multifaceted construct of \u003cem\u003eParticipation\u003c/em\u003e. Additionally, the study aims to examine the persistence of the associations after adjusting for age, sex, and lesion laterality.\u003c/p\u003e"},{"header":"METHODS","content":"\u003cp\u003e\u003cstrong\u003eStudy design \u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis was a cross-sectional, observational study conducted in accordance with the STROBE (STrengthening the Reporting of Observational Studies in Epidemiology) guidelines for cross-sectional studies.\u003csup\u003e25\u003c/sup\u003e The present work represents a secondary analysis of data prospectively collected from the Spanish site of the multicenter European project AInCP: Artificial Intelligence in Cerebral Palsy (ClinicalTrials.gov identifier: NCT06073522, registration date: 10 October 2023), conducted at University of Castilla-La Mancha. \u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStudy setting and recruitment \u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eParticipants were recruited through collaboration with national and regional associations and local clinical networks. Families were contacted via informational emails, conferences, and social media posts disseminated through Hemiweb (Association of Childhood Hemiparesis) and ASPACE (Spanish Association of Cerebral Palsy) between January 2023 and May 2025. Families declared interest via an online registration form, after which the study team provided detailed information and scheduled assessments at the Neuroped Pediatric Neurodevelopment Center in Madrid, as well as a preliminary interview to see if they met the eligibility criteria.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eParticipants\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEligibility criteria \u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eChildren were eligible if they were aged 5\u0026ndash;15 years and met all the following criteria: confirmed diagnosis of predominantly spastic UCP; classification within the Manual Ability Classification System (MACS) levels I\u0026ndash;III, with higher levels indicating better manual ability; and sufficient cognitive and communicative abilities to complete study assessments.\u003c/p\u003e\n\u003cp\u003eChildren were excluded if they presented with any of the following: severe upper limb impairment precluding completion of bimanual tasks; botulinum toxin-A injection in the affected upper limb within six months prior to enrolment; upper limb surgery within the preceding 12 months; or severe medical comorbidities or intellectual disability prohibiting comprehension of instructions.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSample size \u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA target sample size of 70 participants was determined based on feasibility within the Spanish observational arm of the AInCP project and to ensure sufficient power to detect medium-sized correlations (r \u0026asymp; 0.35) between bimanual performance and Participation outcomes. Assuming a two-tailed \u0026alpha; of 0.05 and \u0026beta; of 0.20 (80% power), a minimum of 62 participants was required to detect a correlation coefficient of 0.35. The sample size calculation was performed using G*Power version 3.1. To account for potential missing or unusable data, the target sample size was finally set at 70 participants.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics and informed consent \u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthical approval for the Spanish observational arm of the AInCP project was obtained from the Institutional Review Board of the University Hospital of Toledo (approval number 1068). Written informed consent was obtained from all parents or legal guardians, and assent was sought from children over the age of 12 years, in accordance with the Declaration of Helsinki. All data were confidential and securely stored. After assessments, families received a report summarizing their child\u0026apos;s performance. \u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData collection\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDemographic data: age, sex, MACS, affected side \u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDemographic and clinical data were obtained through parent interviews and review of medical records using a standardized case report form. Information recorded at the start of each assessment included age (in years), sex (male/female), MACS level (I\u0026ndash;III) and affected-sided (right/left).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eActivity domain\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eBimanual performance was evaluated using two complementary standardized measures operationalizing the ICF \u003cem\u003e\u0026apos;Activity\u0026apos;\u003c/em\u003e domain: the Assisting Hand Assessment (AHA) \u003csup\u003e26\u003c/sup\u003e and the Children\u0026apos;s Hand-use Experience Questionnaire (CHEQ).\u003csup\u003e27\u003c/sup\u003e\u003c/p\u003e\n\u003cul\u003e\n\u003cli\u003e\u003cstrong\u003eAHA:\u003c/strong\u003e A performance-based observational measure that quantifies spontaneous use of the affected hand during bimanual activities. Age-appropriate play sessions were administered and video-recorded, then scored on 20 items using a four-point scale, with higher scores reflecting more effective use of the affected hand. Raw scores are converted to AHA logits (0\u0026ndash;100), with higher scores indicating optimal bimanual performance. The AHA has demonstrated excellent interrater and intrarater reliability (ICC \u0026gt; 0.98) and strong construct validity across childhood and adolescence.\u003csup\u003e28\u003c/sup\u003e\u003c/li\u003e\n\u003cli\u003e\u003cstrong\u003eCHEQ:\u003c/strong\u003e A parent-reported questionnaire designed to assess the child\u0026rsquo;s experience using the more-affected hand during bimanual activities in daily life. It consists of items related to typical bimanual tasks. For each activity, parents rate both the effectiveness of the affected hand and the level of difficulty encountered, as well as relevant contextual factors, using standardized response scales. In this study, three key CHEQ summary scores were used: the CHEQ Grip Efficiency score (range 0\u0026ndash;100, with higher scores reflecting better perceived hand function), CHEQ Required Time (0\u0026ndash;100, with higher scores indicating shorter time to complete tasks relative to peers), and CHEQ Feeling Bothered (0\u0026ndash;100, higher scores indicating less perceived bother/discomfort during bimanual activities). The CHEQ has demonstrated good internal consistency (Cronbach\u0026apos;s \u0026alpha; = 0.89) and robust construct validity for assessing functional bimanual performance in children with UCP.\u003csup\u003e29\u003c/sup\u003e\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003e\u003cstrong\u003eParticipation domain\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u0026acute;\u003cem\u003eParticipation\u0026acute;\u003c/em\u003e, the dependent variable, was measured using \u003cem\u003ethe Participation and Environment Measure for Children and Youth (PEM-CY),\u003c/em\u003e\u003csup\u003e30\u003c/sup\u003e a standardized parent-report questionnaire capturing the ICF \u0026lsquo;Participation\u0026rsquo; domain. Parents reported their child\u0026rsquo;s frequency of Participation, level of involvement, and desire for change across home, school, and community settings, as well as environmental facilitators and barriers.\u003c/p\u003e\n\u003cp\u003eThe PEM-CY generates scores for participation frequency (ranging from 0\u0026ndash;7, with higher scores indicating more frequent participation) and participation involvement (ranging from 1\u0026ndash;5, with higher scores reflecting greater involvement intensity). Environmental factors are scored as the percentage of facilitators and barriers present (0\u0026ndash;100%), with higher percentages of facilitators and lower percentages of barriers indicating more supportive contexts. A desire-for-change score (0\u0026ndash;100%) reflects parental perception of need for increased participation in each setting. The PEM-CY has demonstrated moderate to excellent internal consistency (Cronbach\u0026apos;s \u0026alpha; ranging from 0.69\u0026ndash;0.92 across subscales), good test\u0026ndash;retest reliability across cultural adaptations (ICC = 0.72\u0026ndash;0.85), and robust construct validity in distinguishing children with and without disabilities. Data were collected using paper forms during the assessment session and checked for accuracy and completeness before analysis.\u003csup\u003e31\u003c/sup\u003e \u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eProcedures and data sources \u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll questionnaire responses and assessment scores were entered into a secure electronic database immediately after scoring. To ensure measurement consistency, evaluators (CV-M and PC-R) completed the official AHA certification training and participated in quarterly focus groups with international AINCP project teams (IRCCS Fondazione Stella Maris, Italy and KU Leuven, Belgium). A random 15% of video recordings was double-scored, yielding ICCs \u0026gt; 0.97. For the PEM-CY, two raters (CV-M and LM-P) received joint scoring training, and 10% of questionnaires were double-entered and independently scored, with Cohen\u0026rsquo;s kappa values exceeding 0.85. Comprehensive data cleaning was performed to identify and resolve missing, implausible, or inconsistent entries prior to analysis.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eBias control \u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTo minimize selection bias, preliminary screening interviews were conducted with all potential participants to confirm eligibility criteria before enrollment, and recruitment strategies included multiple channels\u0026mdash;national associations, clinical referrals, and online platforms\u0026mdash;to ensure representativeness of children with UCP in Spain. To reduce measurement bias, assessors were officially certified in the AHA and inter-rater consistency was reinforced through regular focus groups with international collaborators. To minimize information bias, standardized instruments with established psychometric properties were used, and data entry was double-checked. Data cleaning procedures were implemented before analysis to address missing or inconsistent entries. To address potential confounding, statistical analyses adjusted for age, sex, and affected side, and subgroup analyses by MACS level (I\u0026ndash;III) were conducted. \u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStatistical analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDescriptive statistics were computed using IBM SPSS Statistics version 27. Normality of distributions was assessed using the Shapiro-Wilk test. Given that CHEQ subscales violated normality assumptions (all p \u0026lt; 0.05) and MACS is an ordinal variable, Spearman rank correlation (\u0026rho;) was used for all bivariate correlational analyses, providing a non-parametric approach robust to distributional violations. Bivariate associations between bimanual performance measures (AHA logit scores and CHEQ summary scores) and PEM-CY participation outcomes were examined using Spearman\u0026apos;s rank correlation. Between-group differences across MACS levels were tested using ANOVA or Kruskal-Wallis H tests with Bonferroni correction. Partial correlations were computed to examine bimanual performance\u0026ndash;participation relationships while statistically controlling for demographic variables (age, gender, affected side), providing supplementary analyses to assess whether demographic factors confounded underlying relationships. Model assumptions and effect sizes were evaluated as appropriate. Statistical significance was set at \u0026alpha; = 0.05 (two-tailed).\u003c/p\u003e"},{"header":"RESULTS","content":"\u003cp\u003e\u003cstrong\u003eDemographics characteristics\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFigure 1 shows the flow of participants through eligibility, enrolment, and analysis in the observational study. Of the 75 children assessed for eligibility, five were excluded. Consequently, 70 children with UCP were enrolled with a mean age of 9.5 years (Standard Deviation (SD) 2.5), and all completed the study assessments. Baseline demographic and clinical characteristics of the cohort are presented in Table 1.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eFigure 1. Flow of participants through eligibility, enrolment, and analysis in the observational study\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eTable 1. Table 1. Participant characteristics, MACS distribution, and descriptive statistics of key measures\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDescriptives statistics of Key Measures \u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDescriptive statistics for AHA, CHEQ, and PEM-CY outcomes in home, school, and community settings, are summarized in Table 1. Bimanual performance, as measured by the AHA, showed a mean logit score of 55.41 (SD 14.14), indicating moderate variability in hand function. Parent-reported hand-use experience (CHEQ) revealed moderate scores across domains, with the Feeling Bothered subscale showing the highest mean (50.34, SD 13.97). Participation frequency was highest in home (91.6% of activities) and school (82.6%) settings, with notably lower participation in community activities (70.0%). Over half of parents (56.4%) reported desire for increased home participation, whereas fewer desired change in school and community settings.\u003c/p\u003e\n\u003cp\u003eCorrelational analyses examining relationships among AHA, CHEQ subscales, and MACS classification levels are presented in Appendix 1. These analyses reveal that manual ability is strongly related with bimanual performance (AHA), whereas weakly related to parent-reported hand-use experience (CHEQ), highlighting important differences between performance-based and proxy-reported measures.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDifference in Participation Across Manual Ability Levels \u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eRegarding differences in participation in daily life between manual ability levels (MACS I\u0026ndash;III), as shown in Table 2, no statistically significant differences were observed in PEM-CY participation outcomes, involvement scores, desire for change, or environmental facilitators and barriers across MACS groups (all p \u0026gt; 0.05). These results suggest that, within this cohort of children with UCP, manual ability classification did not have a discernible impact on Participation patterns or related environmental factors in home, school, or community settings.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eTable 2. Participation and environmental outcomes across MACS levels in children with UCP\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCorrelations between Participation and bimanual performance \u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo statistically significant correlations were found between AHA scores (sum score or logit-scaled units) and any PEM-CY frequency, involvement, desire for change, or environmental facilitator/barrier variables across home, school, or community settings (all p \u0026gt; 0.05). Similarly, the three CHEQ summary scores\u0026mdash;Grip Efficiency, Required Time, and Feeling Bothered\u0026mdash;showed no statistically significant correlations with any PEM-CY participation or environmental outcomes across home, school, or community settings (all p \u0026gt; 0.05). Although some correlations approached marginal significance (e.g., CHEQ Grip Efficiency and community participation frequency, \u0026rho; = \u0026ndash;0.23, p = 0.063; CHEQ Feeling Bothered and community participation frequency, \u0026rho; = \u0026ndash;0.21, p = 0.097), none reached the conventional threshold for statistical significance (p \u0026le; 0.05).\u003c/p\u003e\n\u003cp\u003eFigure 2 displays three side-by-side scatterplots of AHA logit units versus PEM-CY frequency (% activities) for home, school, and community settings. Datapoint spread in each plot suggests the lack of observable trends or patterns, reinforcing the absence of association across contexts.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eFigure 2. Scatterplots of AHA Versus PEM-CY Frequency at Home, School, and Community Settings\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePartial correlations adjusting demographic characteristics\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eControlling for age did not alter the pattern of results: correlations between AHA logit scores or CHEQ summary scores (Grip Efficiency, Required Time, Feeling Bothered) and PEM-CY participation and environmental variables across home, school, and community settings remained non-significant (all p \u0026gt; 0.05). Similarly, when sex or affected side were accounted for separately, none of the partial correlations reached statistical significance. \u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003e The purpose of this study was to explore the association between bimanual performance and domains of participation in children with UCP, using both performance-based and parent-reported measures of bimanual performance, alongside participation outcomes. The main finding of this study is that, despite clear differences in bimanual performance across manual ability levels, no significant associations were found between either AHA or CHEQ and participation outcomes as measured by the PEM-CY. These relationships remained non-significant after adjusting for demographic factors such as age, sex, and affected side, suggesting that participation across various settings might be more related to a combination of contextual factors rather than motor function alone.\u003c/p\u003e \u003cp\u003eThe moderate correlation observed between AHA and CHEQ in this cohort is consistent with previous work\u003csup\u003e\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e\u003c/sup\u003e, indicating that they capture related but distinct aspects of bimanual performance. In our sample, neither observed (AHA) nor perceived (CHEQ) bimanual performance was significantly associated with participation outcomes, which extends earlier evidence\u003csup\u003e\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e\u003c/sup\u003e by suggesting that despite the method of its assessment, bimanual function alone does not account for real-world participation.\u003c/p\u003e \u003cp\u003eThe results of this study further underscore the complexity of functioning domains within the ICF framework. While the bimanual performance measures effectively differentiated performance across MACS levels, in accordance with previous studies, \u003csup\u003e11\u003c/sup\u003e it did not capture the full range of determinants influencing \u003cem\u003eParticipation\u003c/em\u003e; consistent with the \u0026ldquo;\u003cem\u003eActivity\u003c/em\u003e\u0026ndash;\u003cem\u003eParticipation\u003c/em\u003e gap\u0026rdquo; described in recent literature.\u003csup\u003e\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e,\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e\u003c/sup\u003e This gap reflects the notion that impairments and \u003cem\u003eActivity\u003c/em\u003e limitations do not automatically lead to reduced \u003cem\u003eParticipation\u003c/em\u003e, which is instead mainly influenced by contextual factors, encompassing environmental and personal domains. Given that UCP comprises a complex, multifaceted disorder, it is worthwhile considering environmental and personal factors when designing interventions aimed at promoting meaningful engagement in daily-life contexts. \u003csup\u003e10,14\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eAlthough the present study did not directly assess environmental factors, previous research has demonstrated that environmental moderators\u0026mdash;such as accessibility of infrastructure, transportation, community programs, financial resources, and social attitudes\u0026mdash;play a crucial role in shaping \u003cem\u003eParticipation\u003c/em\u003e in everyday life. \u003csup\u003e36\u0026ndash;39\u003c/sup\u003e These factors may either facilitate or hinder engagement independently of motor ability. Therefore, it is important to consider the opportunities that children with disabilities get to participate in various contexts and ensure more inclusive environments. Notably, our descriptive findings showed a gradient of increasing environmental barriers from home (24.5%) through school (30.5%) to community settings (34.1%), suggesting that contextual demands increase as children move beyond familiar environments. The high \u003cem\u003eParticipation\u003c/em\u003e rates found in familiar contexts, such as home and school, despite motor limitations, likely reflect the use of compensatory strategies, adoption of routines or environmental adaptations.\u003csup\u003e\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e\u003c/sup\u003e Previous studies have shown that children with disabilities frequently employ task modifications, assistive devices, and supportive family routines to achieve meaningful engagement.\u003csup\u003e\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e\u003c/sup\u003e These adaptive strategies underscore \u003cem\u003eParticipation\u003c/em\u003e as a dynamic outcome shaped by the continuous interaction between the child and the environment, which is not limited by the inherent impairments of the disorder.\u003c/p\u003e \u003cp\u003eFurthermore, personal factors have been shown to be equally important in explaining \u003cem\u003eParticipation\u003c/em\u003e variability among children with UCP. Previous studies have shown that cognitive and communication abilities, behavioral and emotional regulation, motivation, and personal preferences significantly influence engagement in daily and community activities, often independently of motor ability.\u003csup\u003e\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e,\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e\u003c/sup\u003e Our findings align with this evidence, suggesting that children with comparable bimanual performance may display very different \u003cem\u003eParticipation\u003c/em\u003e patterns due to these personal attributes or the interplay among a multitude of factors.\u003c/p\u003e \u003cp\u003eFamily and personal empowerment could further moderate this complex interaction. Empowerment, defined as self-efficacy, autonomy, advocacy, and collaborative goal-setting, has been associated with improved \u003cem\u003eParticipation\u003c/em\u003e outcomes and greater resilience in overcoming environmental barriers.\u003csup\u003e\u003cspan additionalcitationids=\"CR45\" citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e\u003c/sup\u003e Empowered families tend to create more opportunities for their children\u0026rsquo;s engagement across settings, emphasizing the critical role of family-centered interventions.\u003csup\u003e\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e\u003c/sup\u003e In general, \u003cem\u003eParticipation\u003c/em\u003e outcomes frequently capture long-term involvement and are shaped by contextual opportunities rather than immediate performance alone,\u003csup\u003e48\u003c/sup\u003e potentially explaining the absence of direct associations. Overall, these findings suggest that \u003cem\u003eParticipation\u003c/em\u003e cannot be fully understood or optimized by focusing solely on motor function. Instead, holistic approaches that strengthen both child and family empowerment are essential to promote meaningful \u003cem\u003eParticipation\u003c/em\u003e, consistent with the multifactorial biopsychosocial model of the ICF.\u003csup\u003e\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e,\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eTaken together, the current findings and previous evidence emphasize that the relationship between \u003cem\u003eActivity\u003c/em\u003e and \u003cem\u003eParticipation\u003c/em\u003e cannot be interpreted in isolation from the contextual factors that modulate it, particularly in multifaceted disorders such as UCP. This reinforces the need to move beyond motor-centric rehabilitation paradigms and follow more holistic and tailored approaches. Since bimanual performance alone does not fully account for the complexity of \u003cem\u003eParticipation\u003c/em\u003e, effective interventions should extend beyond motor training to include environmental modifications and family-empowerment initiatives that enable children to engage more fully in meaningful activities.\u003csup\u003e\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e,\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e\u003c/sup\u003e As also shown in the meta-analytic findings of Dimakopoulos et al., participation in CP is more likely to improve when interventions address specific participation barriers. This underscores \u003cem\u003eParticipation\u003c/em\u003e as a multifaceted construct that requires a contextual perspective, rather than one primarily focused on impairments related to the disorder. Accordingly, future assessment and intervention planning should systematically incorporate Body functions and structures (executive functions) andcontextual factors (motivation, self-efficacy, preferences) as explicit components of the ICF biopsychosocial model, ensuring that clinical profiling captures the full spectrum of determinants influencing \u003cem\u003eParticipation\u003c/em\u003e. Multimodal approaches that integrate bimanual therapy with family coaching on barrier removal, activity adaptation, and goal-setting may be more effective than motor training alone.\u003csup\u003e\u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e,\u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e\u003c/sup\u003e Future research should identify which environmental and personal factors best predict \u003cem\u003eParticipation\u003c/em\u003e outcomes specifically in UCP and examine whether combined interventions yield superior benefits. Additionally, rehabilitation professionals should receive training in environmental assessment, personal factor identification, and family coaching, while health policies should prioritize accessibility and inclusion in educational and community settings alongside individual rehabilitation efforts.\u003c/p\u003e \u003cp\u003eIt is worthwhile considering a few limitations of this study. First, the single-center, convenience sample limits generalizability beyond this Spanish pediatric cohort. Nevertheless, all necessary methods were employed to minimize bias in various domains as much as possible. Second, \u003cem\u003eParticipation\u003c/em\u003e was assessed through parent-report, which may introduce bias related to parental perceptions, expectations, or recall. While child self-report would provide complementary data, parent-report is the established method for evaluating participation across multiple environments in pediatric populations and has demonstrated acceptable validity in previous studies. Third, personal factors such as motivation, self-efficacy, and coping strategies were not evaluated in this study, although their effect could have explained the observed variability in \u003cem\u003eParticipation\u003c/em\u003e. Finally, the high \u003cem\u003eParticipation\u003c/em\u003e rates observed at home and school may indicate ceiling effects, whereas community \u003cem\u003eParticipation\u003c/em\u003e showed greater variability. Despite these limitations, the present findings provide valuable evidence that motor function alone does not determine \u003cem\u003eParticipation\u003c/em\u003e in children with UCP, supporting the need for multifactorial, contextually-driven approaches to intervention.\u003c/p\u003e"},{"header":"CONCLUSIONS","content":"\u003cp\u003eBimanual performance appears unrelated to daily participation frequency or involvement across home, school, and community settings in children with UCP, even after adjusting for age, sex, and lesion laterality. Participation variability among similar manual ability levels underscores the multifactorial influence of environmental and personal contextual factors. Findings support holistic ICF-based rehabilitation integrating family coaching and environmental adaptations beyond motor training.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eAHA: Assisting Hand Assessment\u003c/p\u003e\n\u003cp\u003eAInCP: Artificial Intelligence in Cerebral Palsy \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eCHEQ: Children\u0026apos;s Hand-use Experience Questionnaire\u003c/p\u003e\n\u003cp\u003eCP: Cerebral Palsy\u003c/p\u003e\n\u003cp\u003eICF: International Classification of Functioning, Disability and Health\u003c/p\u003e\n\u003cp\u003eICF-CY: International Classification of Functioning, Disability and Health Children \u0026amp; Youth\u003c/p\u003e\n\u003cp\u003eMACS: Manual Ability Classification System\u003c/p\u003e\n\u003cp\u003ePEM-CY: Participation and Environment Measure for Children and Youth\u003c/p\u003e\n\u003cp\u003eSD: Standard Deviation\u003c/p\u003e\n\u003cp\u003eSTROBE: STrengthening the Reporting of Observational Studies in Epidemiology\u003c/p\u003e\n\u003cp\u003eUCP: Unilateral Cerebral Palsy\u003c/p\u003e"},{"header":"Declarations","content":"\u003cul type=\"disc\"\u003e\n \u003cli\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eEthical approval for the Spanish observational arm of the AInCP project was obtained from the Institutional Review Board of the University Hospital of Toledo (approval number 1068). Written informed consent was obtained from all parents or legal guardians, and assent was sought from children over the age of 12 years, in accordance with the Declaration of Helsinki. All data were confidential and securely stored.\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eNot applicable.\u0026nbsp;\u003c/p\u003e\n\u003cul type=\"disc\"\u003e\n \u003cli\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eThe datasets analysed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cul type=\"disc\"\u003e\n \u003cli\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e\n\u003cul type=\"disc\"\u003e\n \u003cli\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eThis research was conducted as part of the AinCP project, funded by the European Union\u0026rsquo;s Horizon 2020 programme and the Spanish Ministry of Science and Innovation.\u003c/p\u003e\n\u003cul type=\"disc\"\u003e\n \u003cli\u003e\u003cstrong\u003eAuthors\u0026apos; contributions\u003c/strong\u003e\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eMC-V: Investigation, Data curation, software, Formal analysis, Writing \u0026ndash; original draft, Visualization, Project administration. PL-M: Investigation, Formal analysis, Writing \u0026ndash; original draft. GS: Funding acquisition, Conceptualization, Methodology, Supervision. AK (Alexandra Kalkantzi): Conceptualization, formal analysis, validation, Writing \u0026ndash; original draft. JL-B: Investigation. HR-B: Investigation. EB: Investigation, conceptualization, Methodology, resources, supervision. RP-C: Conceptualization, Funding acquisition, Project administration, Methodology, Supervision, validation, Writing \u0026ndash; original draft.\u0026nbsp;\u003c/p\u003e\n\u003cul type=\"disc\"\u003e\n \u003cli\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eThis work was supported by the European Union\u0026rsquo;s Horizon 2020 research and innovation programme under grant agreement No. 101017727 (AInCP project). GS has also partially funded by Italian Ministry of Health - Grant RC (and the 5x1000 voluntary contributions).\u003c/p\u003e\n\u003cp\u003eThe authors gratefully acknowledge the AinCP Consortium for their invaluable support in study coordination and data management. We also thank Hemiweb and ASPACE for their assistance with participant recruitment and engagement throughout the study. Special thanks to the families and children who participated.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003ePless M, Granlund M. Implementation of the International Classification of Functioning, Disability and Health (ICF) and the ICF Children and Youth Version (ICF-CY) within the context of augmentative and alternative communication. Augment Altern Commun. 2012 Mar;28(1):11\u0026ndash;20. \u003c/li\u003e\n\u003cli\u003eOrganization WH. International Classification of Functioning, Disability, and Health: Children \u0026amp; Youth Version : ICF-CY. World Health Organization; 2007. 352 p. \u003c/li\u003e\n\u003cli\u003eHadar-Frumer M, Ten-Napel H, Yuste-S\u0026aacute;nchez MJ, Rodr\u0026iacute;guez-Costa I. Feasibility of Using the International Classification of Functioning, Disability and Health for Children and Youth (ICF-CY) as a Framework for Aquatic Activities: A Scoping Review. Children [Internet]. 2023;10(12). Available from: https://www.scopus.com/inward/record.uri?eid=2-s2.0-85180727320\u0026amp;doi=10.3390%2Fchildren10121856\u0026amp;partnerID=40\u0026amp;md5=ba357c5746e5f46f8514957fb4f09f15\u003c/li\u003e\n\u003cli\u003eChien CW, Rodger S, Copley J, Skorka K. Comparative content review of children\u0026rsquo;s participation measures using the International Classification of Functioning, Disability and Health-Children and Youth. Arch Phys Med Rehabil. 2014 Jan;95(1):141\u0026ndash;52. \u003c/li\u003e\n\u003cli\u003eBj\u0026ouml;rklund AC, Darcy L, Santacroce SJ, Granlund M, Bj\u0026ouml;rk M. Individual patterns of problems with participation, activity, body function and environment in everyday life for children who completed brain tumor treatment. Disabil Rehabil. 2023 Nov;45(23):3841\u0026ndash;51. \u003c/li\u003e\n\u003cli\u003eRiccardi JS, Dart L, Lundine JP, Ciccia A. Correlations between injury- and child-related factors and participation and quality of life after childhood traumatic brain injury. Neuropsychol Rehabil. 2025 Oct;35(9):1848\u0026ndash;64. \u003c/li\u003e\n\u003cli\u003eMichelsen SI, Flachs EM, Damsgaard MT, Parkes J, Parkinson K, Rapp M, et al. European study of frequency of participation of adolescents with and without cerebral palsy. Eur J Paediatr Neurol. 2014 May;18(3):282\u0026ndash;94. \u003c/li\u003e\n\u003cli\u003eBadia M, Orgaz BM, Verdugo MA, Ull\u0026aacute;n AM, Mart\u0026iacute;nez MM. Personal factors and perceived barriers to participation in leisure activities for young and adults with developmental disabilities. Res Dev Disabil. 2011;32(6):2055\u0026ndash;63. \u003c/li\u003e\n\u003cli\u003eMakki D, Duodu J, Nixon M. Prevalence and pattern of upper limb involvement in cerebral palsy. J Child Orthop. 2014 May;8(3):215\u0026ndash;9. \u003c/li\u003e\n\u003cli\u003eRosenbaum P, Paneth N, Leviton A, Goldstein M, Bax M, Damiano D, et al. A report: the definition and classification of cerebral palsy April 2006. Dev Med Child Neurol Suppl. 2007 Feb;109:8\u0026ndash;14. \u003c/li\u003e\n\u003cli\u003eEliasson A, Nordstrand L, Backheden M, Holmefur M. Longitudinal development of hand use in children with unilateral spastic cerebral palsy from 18\u0026thinsp;months to 18\u0026thinsp;years. Dev Med Child Neurol. 2023 Mar;65(3):376\u0026ndash;84. \u003c/li\u003e\n\u003cli\u003eWang TN, Howe TH, Liang KJ, Chang TW, Shieh JY, Chen HL. Bimanual motor performance in everyday life activities of children with hemiplegic cerebral palsy. Eur J Phys Rehabil Med. 2021 Aug;57(4):568\u0026ndash;76. \u003c/li\u003e\n\u003cli\u003ePark H, Choi JY, Yi SH, Park ES, Shim D, Choi TY, et al. Relationship between the more-affected upper limb function and daily activity performance in children with cerebral palsy: a cross-sectional study. BMC Pediatr. 2021 Oct 19;21(1):459. \u003c/li\u003e\n\u003cli\u003eImms C, Adair B, Keen D, Ullenhag A, Rosenbaum P, Granlund M. \u0026ldquo;Participation\u0026rdquo;: a systematic review of language, definitions, and constructs used in intervention research with children with disabilities. Dev Med Child Neurol. 2016 Jan;58(1):29\u0026ndash;38. \u003c/li\u003e\n\u003cli\u003evan der Kemp J, Ketelaar M, Gorter JW. Environmental factors associated with participation and its related concepts among children and youth with cerebral palsy: a rapid review. Disabil Rehabil. 2022 May;44(9):1571\u0026ndash;82. \u003c/li\u003e\n\u003cli\u003eAlves ML de F, Souto DO, Romeros ACSF, Magalh\u0026atilde;es EDD, Mendes LG, Ayupe KMA, et al. Characterization of environmental factors in children and adolescents with cerebral palsy in Minas Gerais: Participa Minas. Rev Paul Pediatr. 2024;42:e2023043. \u003c/li\u003e\n\u003cli\u003eDimakopoulos R, Vakalaki T, Spinou A, Michopoulos I, Papadopoulou \u0026Mu;. Effectiveness of therapeutic interventions on participation in children with cerebral palsy: A systematic review and meta-analysis. Child Care Health Dev. 2024 July;50(4):e13301. \u003c/li\u003e\n\u003cli\u003eHuus K, Schlebusch L, Ramaahlo M, Samuels A, Berglund IG, Dada S. Barriers and facilitators to participation for children and adolescents with disabilities in low- and middle-income countries - A scoping review. Afr J Disabil. 2021;10:771. \u003c/li\u003e\n\u003cli\u003eHoare B, Ditchfield M, Thorley M, Wallen M, Bracken J, Harvey A, et al. Cognition and bimanual performance in children with unilateral cerebral palsy: protocol for a multicentre, cross-sectional study. BMC Neurol. 2018 May 8;18(1):63. \u003c/li\u003e\n\u003cli\u003eKalkantzi A, Kleeren L, Baeyens D, Decraene L, Crotti M, Klingels K, et al. Daily-life executive functions and bimanual performance in children with unilateral cerebral palsy. Dev Med Child Neurol. 2025 Oct;67(10):1290\u0026ndash;300. \u003c/li\u003e\n\u003cli\u003eKinnucan E, Van Heest A, Tomhave W. Correlation of motor function and stereognosis impairment in upper limb cerebral palsy. J Hand Surg Am. 2010 Aug;35(8):1317\u0026ndash;22. \u003c/li\u003e\n\u003cli\u003eTonmukayakul U, Imms C, Mihalopoulos C, Reddihough D, Carter R, Mulhern B, et al. Health-related quality of life and upper-limb impairment in children with cerebral palsy: developing a mapping algorithm. Dev Med Child Neurol. 2020 July;62(7):854\u0026ndash;60. \u003c/li\u003e\n\u003cli\u003eGardas SS, Lysaght C, McMillan AG, Kantak S, Willson JD, Patterson CG, et al. Bimanual Movement Characteristics and Real-World Performance Following Hand-Arm Bimanual Intensive Therapy in Children with Unilateral Cerebral Palsy. Behav Sci (Basel). 2023 Aug 13;13(8):681. \u003c/li\u003e\n\u003cli\u003evan der Kemp J, Ketelaar M, Gorter JW. Environmental factors associated with participation and its related concepts among children and youth with cerebral palsy: a rapid review. Disabil Rehabil. 2022 May;44(9):1571\u0026ndash;82. \u003c/li\u003e\n\u003cli\u003evon Elm E, Altman DG, Egger M, Pocock SJ, G\u0026oslash;tzsche PC, Vandenbroucke JP, et al. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies. Lancet. 2007 Oct 20;370(9596):1453\u0026ndash;7. \u003c/li\u003e\n\u003cli\u003eKrumlinde-Sundholm L, Holmefur M, Kottorp A, Eliasson AC. The Assisting Hand Assessment: current evidence of validity, reliability, and responsiveness to change. Dev Med Child Neurol. 2007 Apr;49(4):259\u0026ndash;64. \u003c/li\u003e\n\u003cli\u003eSk\u0026ouml;ld A, Hermansson LN, Krumlinde-Sundholm L, Eliasson AC. Development and evidence of validity for the Children\u0026rsquo;s Hand-use Experience Questionnaire (CHEQ). Dev Med Child Neurol. 2011 May;53(5):436\u0026ndash;42. \u003c/li\u003e\n\u003cli\u003eHolmefur MM, Krumlinde-Sundholm L. Psychometric properties of a revised version of the Assisting Hand Assessment (Kids-AHA 5.0). Dev Med Child Neurol. 2016 June;58(6):618\u0026ndash;24. \u003c/li\u003e\n\u003cli\u003eRyll UC, Eliasson AC, Bastiaenen CH, Green D. To Explore the Validity of Change Scores of the Children\u0026rsquo;s Hand-use Experience Questionnaire (CHEQ) in Children with Unilateral Cerebral Palsy. Phys Occup Ther Pediatr. 2019;39(2):168\u0026ndash;80. \u003c/li\u003e\n\u003cli\u003eCoster W, Law M, Bedell G, Khetani M, Cousins M, Teplicky R. Development of the participation and environment measure for children and youth: conceptual basis. Disabil Rehabil. 2012;34(3):238\u0026ndash;46. \u003c/li\u003e\n\u003cli\u003eCoster W, Bedell G, Law M, Khetani MA, Teplicky R, Liljenquist K, et al. Psychometric evaluation of the Participation and Environment Measure for Children and Youth. Dev Med Child Neurol. 2011 Nov;53(11):1030\u0026ndash;7. \u003c/li\u003e\n\u003cli\u003eRyll UC, Bastiaenen CHG, Eliasson AC. Assisting Hand Assessment and Children\u0026rsquo;s Hand-Use Experience Questionnaire -Observed Versus Perceived Bimanual Performance in Children with Unilateral Cerebral Palsy. Phys Occup Ther Pediatr. 2017 May;37(2):199\u0026ndash;209. \u003c/li\u003e\n\u003cli\u003eRyll UC, Bastiaenen CHG, Eliasson AC. Assisting Hand Assessment and Children\u0026rsquo;s Hand-Use Experience Questionnaire -Observed Versus Perceived Bimanual Performance in Children with Unilateral Cerebral Palsy. Phys Occup Ther Pediatr. 2017 May;37(2):199\u0026ndash;209. \u003c/li\u003e\n\u003cli\u003eMutlu A, B\u0026uuml;ğ\u0026uuml;şan S, Kara \u0026Ouml;K. Impairments, activity limitations, and participation restrictions of the international classification of functioning, disability, and health model in children with ambulatory cerebral palsy. Saudi Med J. 2017 Feb;38(2):176\u0026ndash;85. \u003c/li\u003e\n\u003cli\u003eBurak M, Kavlak E. Investigation of the relationship between quality of life, activity participation and environmental factors in adolescents with cerebral palsy. NeuroRehabilitation. 2019 Sept 18;45(4):555\u0026ndash;65. \u003c/li\u003e\n\u003cli\u003eAljuhani T, Alzahrani SA, Aldosary AM, Alzamil LA, Alshehri RK, Gmmash AS, et al. Measuring Community and Home Participation and Environmental Factors in Children with Cerebral Palsy. Pediatr Rep. 2025 Feb 7;17(1):17. \u003c/li\u003e\n\u003cli\u003evan der Kemp J, Ketelaar M, Gorter JW. Environmental factors associated with participation and its related concepts among children and youth with cerebral palsy: a rapid review. Disabil Rehabil. 2022 May;44(9):1571\u0026ndash;82. \u003c/li\u003e\n\u003cli\u003eColver A, Thyen U, Arnaud C, Beckung E, Fauconnier J, Marcelli M, et al. Association between participation in life situations of children with cerebral palsy and their physical, social, and attitudinal environment: a cross-sectional multicenter European study. Arch Phys Med Rehabil. 2012 Dec;93(12):2154\u0026ndash;64. \u003c/li\u003e\n\u003cli\u003eAfrica LE, Human A, Tshabalala MD. Participation patterns of children with cerebral palsy: A caregiver\u0026rsquo;s perspective. Afr J Disabil. 2023;12:1058. \u003c/li\u003e\n\u003cli\u003eColver A, Thyen U, Arnaud C, Beckung E, Fauconnier J, Marcelli M, et al. Association between participation in life situations of children with cerebral palsy and their physical, social, and attitudinal environment: a cross-sectional multicenter European study. Arch Phys Med Rehabil. 2012 Dec;93(12):2154\u0026ndash;64. \u003c/li\u003e\n\u003cli\u003eImms C, Adair B, Keen D, Ullenhag A, Rosenbaum P, Granlund M. \u0026ldquo;Participation\u0026rdquo;: a systematic review of language, definitions, and constructs used in intervention research with children with disabilities. Dev Med Child Neurol. 2016 Jan;58(1):29\u0026ndash;38. \u003c/li\u003e\n\u003cli\u003ePredictors of community participation from preschool to school age in children with cerebral palsy. Dev Med Child Neurol. 2025 Aug;67(8):e142. \u003c/li\u003e\n\u003cli\u003eBingol H, Fidan H, Asena Sel S, Burc E, Gunel MK. Causal pathways of potential factors affecting participation level of individuals with unilateral cerebral palsy. Br J Occup Ther. 2024 Sept;87(9):546\u0026ndash;55. \u003c/li\u003e\n\u003cli\u003eKalleson R, Jahnsen R, \u0026Oslash;stensj\u0026oslash; S. Empowerment in families raising a child with cerebral palsy during early childhood: Associations with child, family and service characteristics. Child Care Health Dev. 2019 Sept 10; \u003c/li\u003e\n\u003cli\u003eKalleson R, Jahnsen R, \u0026Oslash;stensj\u0026oslash; S. Exploring participation in family and recreational activities among children with cerebral palsy during early childhood: how does it relate to motor function and parental empowerment? Disabil Rehabil. 2022 May;44(9):1560\u0026ndash;70. \u003c/li\u003e\n\u003cli\u003eMohamed Abdelrahman B, NabawyElaasar H, Rady El Said R. Effect of Family Empowerment Program on Parents\u0026rsquo; Performance regarding Care of Their Children with Cerebral Palsy. Egyptian Journal of Health Care. 2021 Sept 1;12(3):2072\u0026ndash;93. \u003c/li\u003e\n\u003cli\u003eKalleson R, Jahnsen R, \u0026Oslash;stensj\u0026oslash; S. Exploring participation in family and recreational activities among children with cerebral palsy during early childhood: how does it relate to motor function and parental empowerment? Disabil Rehabil. 2022 May;44(9):1560\u0026ndash;70. \u003c/li\u003e\n\u003cli\u003eImms C, Granlund M, Wilson PH, Steenbergen B, Rosenbaum PL, Gordon AM. Participation, both a means and an end: a conceptual analysis of processes and outcomes in childhood disability. Dev Med Child Neurol. 2017 Jan;59(1):16\u0026ndash;25. \u003c/li\u003e\n\u003cli\u003eMassey J, Harniess P, Chinn D, Robert G. Barriers and facilitators to parent-delivered interventions for children with or infants at risk of cerebral palsy. An integrative review informed by behaviour change theory. Disabil Rehabil. 2025 Jan;47(2):287\u0026ndash;301. \u003c/li\u003e\n\u003cli\u003eUrbina T, Balasundaram M, Coughlin M, Sorrells K, Toney-Noland C, Day C. The Why and How of Family-Centered Care. Neoreviews. 2024 July 1;25(7):e393\u0026ndash;400. \u003c/li\u003e\n\u003cli\u003eJackman M, Sakzewski L, Morgan C, Boyd RN, Brennan SE, Langdon K, et al. Interventions to improve physical function for children and young people with cerebral palsy: international clinical practice guideline. Dev Med Child Neurol. 2022 May;64(5):536\u0026ndash;49. \u003c/li\u003e\n\u003cli\u003eDirks T, Hadders-Algra M. The role of the family in intervention of infants at high risk of cerebral palsy: a systematic analysis. Dev Med Child Neurol. 2011 Sept;53 Suppl 4:62\u0026ndash;7. \u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003e\u003cstrong\u003eTable 1. \u0026nbsp;Participant characteristics, MACS distribution, and descriptive statistics of key measures\u003c/strong\u003e\u003c/p\u003e\n\u003cdiv align=\"\"\u003e\n \u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"596\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"8\" valign=\"top\" style=\"width: 596px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eUnilateral Cerebral Palsy (n 70)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 189px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSex n (%)\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"7\" style=\"width: 407px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e44 (62.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 189px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAffected side\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003e(n (%)\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eRight\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"7\" style=\"width: 407px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e49 (70)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 189px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eMean (SD)\u003c/p\u003e\n \u003cp\u003eMedian (IQR)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"7\" style=\"width: 407px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e9.5 (2.5)\u003c/p\u003e\n \u003cp\u003e9 (7-11)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"8\" valign=\"top\" style=\"width: 596px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMACS Level (n 70)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 189px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eLevel I (n 15)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eLevel II (n 28)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eLevel III (n 27)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003ep-value\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 189px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSex n (%)\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e6 (40.0)\u003c/p\u003e\n \u003cp\u003e9\u003cstrong\u003e\u0026nbsp;(\u003c/strong\u003e60.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e11 (39.3)\u003c/p\u003e\n \u003cp\u003e17 (60.7)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e9 (33.3)\u003c/p\u003e\n \u003cp\u003e18 (66.7)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 86px;\"\u003e\n \u003cp\u003e0.87\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 189px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAffected side n (%)\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eLeft\u003c/p\u003e\n \u003cp\u003eRight\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e5 (33.3)\u003c/p\u003e\n \u003cp\u003e10 (66.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e6 (21.4)\u003c/p\u003e\n \u003cp\u003e22 (78.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e10 (37.0)\u003c/p\u003e\n \u003cp\u003e17 (63.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 86px;\"\u003e\n \u003cp\u003e0.56\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"8\" valign=\"top\" style=\"width: 596px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAssisting Hand Assessment (n 70)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 189px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 119px;\"\u003e\n \u003cp\u003e\u003cem\u003eMean\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e\u003cem\u003eSD\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e\u003cem\u003eMedian\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e\u003cem\u003eIQR\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 189px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAHA sum score (0-80)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 119px;\"\u003e\n \u003cp\u003e51.13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e11.32\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e50.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e44.00\u0026ndash;58.25\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 189px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAHA logit score (0-100)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 119px;\"\u003e\n \u003cp\u003e55.41\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e14.14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e54.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e47.00\u0026ndash;64.50\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"8\" valign=\"top\" style=\"width: 596px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eChildren\u0026apos;s Hand-use Experience Questionnaire (n 68)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 189px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e\u003cem\u003eMean\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e\u003cem\u003eSD\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e\u003cem\u003eMedian\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e\u003cem\u003eIQR\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 189px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGlobal CHEQ score\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e40.74\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e11.51\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e39.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e9-75\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 189px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCHEQ Required Time\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e39.46\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e13.77\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e40.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e0-76\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 189px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCHEQ Feeling Bothered\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e50.34\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e13.97\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e47.50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e9-100\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"8\" valign=\"top\" style=\"width: 596px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eParticipation and Environmental Outcomes (n 70)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 189px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e\u003cem\u003eMean\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e\u003cem\u003eSD\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e\u003cem\u003eMedian\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e\u003cem\u003eIQR\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 189px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFrequency of Participation in the home\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e5.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e0.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e5.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e5.4-6.1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 189px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFrequency of Participation in the home (% activities)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e91.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e11.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e90\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e90-100\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 189px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eLevel of involucration in the home\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e3.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e0.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e3.6-4.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 189px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDesire for change of Participation in the home (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e56.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e26.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e60\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e40-80\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 189px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHome environment total (/3)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e2.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e0.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e2.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e2.5-2.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 189px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHome environment facilitators\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e75.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e18.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e75.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e64.3-91.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 189px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHome environment barriers\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e24.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e18.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e24.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e8.3-35.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 189px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFrequency of Participation in the school\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e4.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e0.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e4.6-5.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 189px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFrequency of Participation in the school (% activities)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e82.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e16.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e80\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e80-100\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 189px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eLevel of involucration in the school\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e4.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e5.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e4.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e3.8-5.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 189px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDesire for change of Participation in the school (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e39.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e32.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e40\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e15-60\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 189px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSchool environment total (/3)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e2.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e0.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e2.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e2.4-2.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 189px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSchool environment facilitators\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e69.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e20.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e70.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e58.6-82.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 189px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSchool environment barriers\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e30.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e20.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e29.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e17.6-41.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 189px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFrequency of Participation in the community\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e4.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e0.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e4.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e3.6-5.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 189px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFrequency of Participation in the community (% activities)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e70.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e13.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e70\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e60-80\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 189px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eLevel of involucration in the community\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e4.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e3.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e4.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e3.5-4.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 189px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDesire for change of Participation in the community (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e42.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e28.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e40\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e20.0-66.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 189px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCommunity environment total (/3)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e2.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e0.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e2.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e2.3-2.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 189px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCommunity environment facilitators\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e65.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e24.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e69\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e50.0-87.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 189px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCommunity environment barriers\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e34.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e24.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e31\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e12.5-50.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u003cem\u003e*SD: Standard Deviation, IQR: Interquartile range\u003c/em\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2. Participation and environmental outcomes across MACS levels in children with UCP\u003c/strong\u003e\u003c/p\u003e\n\u003cdiv align=\"\"\u003e\n \u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"12\"\u003e\n \u003cp\u003e\u003cstrong\u003eMACS\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"3\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003ep\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\"\u003e\n \u003cp\u003e\u003cstrong\u003eLevel I\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"4\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eLevel II\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"4\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eLevel III\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eMean\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eSD\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eMedian\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eIQR\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eMean\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eSD\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eMedian\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eIQR\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eMean\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eSD\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eMedian\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eIQR\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ePEM-CY frequency of participation in the home\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e5.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e5.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e5.4-6.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e5.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e5.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e5.6-6.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e5.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e5.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e5.4-6.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.923\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ePEM-CY frequency of participation in the home (% activities)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e91.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e10.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e100\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e80-100\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e90.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e12.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e90\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e90-100\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e93.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e9.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e100\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e90-100\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.749\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ePEM-CY level of involucration in the home\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e4.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e3.6-4.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e3.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e3.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e3.4-4.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e3.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e3.7-4.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.612\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ePEM-CY desire for change of participation in the home (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e53.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e25.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e30-70\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e55.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e28.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e70\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e40-80\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e58.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e24.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e60\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e40-80\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.685\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ePEM-CY home environment total (/3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2.6-3.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2.4-2.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2.4-2.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.676\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ePEM-CY home environment facilitators\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e77.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e19.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e76.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e66.7-100\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e73.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e18.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e79.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e58.1-83.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e76.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e17.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e75\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e66.7-91.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.793\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ePEM-CY home environment barriers\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e22.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e19.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e23.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0-33.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e26.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e18.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e20.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e16.7-41.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e23.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e17.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e8.3-33.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.828\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ePEM-CY frequency of participation in the school\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e4.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e4.6-5.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e5.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e5.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e4.7-5.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e4.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e4.0-5.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.706\u003csup\u003e1\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ePEM-CY frequency of participation in the school (% activities)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e84.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e15.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e80\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e80-100\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e78.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e18.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e80\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e60-100\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e85.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e15.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e80\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e80-100\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.407\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ePEM-CY level of involucration in the school\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e4.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e4.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e4-5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e4.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e3.7-4.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e5.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e8.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e4.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e4.0-4.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.336\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ePEM-CY desire for change of participation in the school (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e28.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e31.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0-60\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e43.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e29.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e40\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e20-60\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e42.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e36.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e40\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0-80\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.262\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ePEM-CY school environment total (/3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2.5-2.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2.4-2.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2.4-2.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.932\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ePEM-CY school environment facilitators\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e69.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e16.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e76.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e58.8-76.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e68.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e20.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e69.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e54.3-86.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e70.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e21.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e70.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e53.0-88.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.773\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ePEM-CY school environment barriers\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e30.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e16.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e22.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e23.5-41.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e31.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e20.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e30.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e13.4-45.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e29.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e21.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e29.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e11.8-47.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.775\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ePEM-CY frequency of participation in the community\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e4.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e4.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e3.9-5.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e4.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e4.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e3.9-4.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e4.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e4.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e3.4-5.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.922\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ePEM-CY frequency of participation in the community (% activities)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e73.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e11.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e75\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e67.5-80.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e66.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e14.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e70\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e52.5-77.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e71.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e13.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e70\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e60-80\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.261\u003csup\u003e1\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ePEM-CY level of involucration in the community\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e4.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e4.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e3.6-5.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e3.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e3.0-4.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e5.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e5.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e4.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e3.7-4.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.222\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ePEM-CY desire for change of participation in the community (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e40.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e24.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e40\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e20-70\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e47.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e29.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e22.5-67.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e37.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e28.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e10.0-62.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.360\u003csup\u003e1\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ePEM-CY community environment total (/3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2.3-2.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2.3-2.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2.4-2.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.740\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ePEM-CY community environment facilitators\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e67.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e28.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e81.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e43.8-89.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e65.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e24.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e71.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e45.3-87.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e65.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e22.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e64.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e50.0-87.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.830\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ePEM-CY community environment barriers\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e32.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e28.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e18.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e10.9-56.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e34.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e24.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e28.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e12.5-54.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e34.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e22.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e35.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e12.5-50.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.830\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u003csup\u003e1\u003c/sup\u003e One-way ANOVA \u003csup\u003e2\u003c/sup\u003eKruskal-Wallis test for independent samples\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eSD: Standard Deviation, IQR: Interquartile range\u003c/em\u003e\u003cstrong\u003e\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-pediatrics","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bped","sideBox":"Learn more about [BMC Pediatrics](http://bmcpediatr.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bped/default.aspx","title":"BMC Pediatrics","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Unilateral cerebral palsy, bimanual performance, Participation, ICF framework, cross-sectional study","lastPublishedDoi":"10.21203/rs.3.rs-8872346/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8872346/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e. Bimanual performance is a primary rehabilitation target in unilateral cerebral palsy children, yet its relationship with real-world participation remains unclear. This study aims to examine the relationship between bimanual performance and Participation outcomes across home, school, and community environments in children with unilateral cerebral palsy within the International Classification of Functioning, Disability and Health Children \u0026amp; Youth Version framework.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e. Cross-sectional observational study of 70 children with unilateral cerebral palsy (mean age 9.5 years, Manua Ability Classification System I–III). Bimanual performance was assessed using the Assisting Hand Assessment and the Children's Hand-use Experience Questionnaire; Participation was measured using the Participation and Environment Measure for Children and Youth. Correlation analyses examined associations between bimanual performance and Participation outcomes, adjusting for demographic characteristics, with a significance α\u0026lt;0.05.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e. \u0026nbsp;Despite significant differences in bimanual performance across Manua Ability Classification System levels (p\u0026lt;0.001), neither Assisting Hand Assessment nor Children's Hand-use Experience Questionnaire scores correlated significantly with participation frequency, involvement, or environmental facilitators/barriers across any setting (all p\u0026gt;0.05). Demographic factors did not confound these associations. Environmental barriers increased progressively from home (24.5%) through school (30.5%) to community (34.1%), while participation remained high in familiar contexts despite motor limitations.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions\u003c/strong\u003e. Although bimanual performance is a prominent impairment in unilateral cerebral palsy due to the lateralized motor impairments, it does not appear to be directly related to Participation. Instead, daily-life Participation is probably related with factors beyond motor function, underscoring the need for more holistic, biopsychosocial approaches.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTrial registration: \u003c/strong\u003eNCT06073522, 10 October 2023\u003c/p\u003e","manuscriptTitle":"Relationship Between Participation Across Daily Environments and Bimanual Performance in Children With Unilateral Cerebral Palsy: An ICF-Based Cross-Sectional Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-02-24 08:20:14","doi":"10.21203/rs.3.rs-8872346/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-03-02T13:36:03+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-03-02T12:33:11+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-02-25T15:19:26+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"98557672030580825653869715285733642799","date":"2026-02-23T13:50:14+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"282504937605744371840685432704524555563","date":"2026-02-17T13:48:29+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-02-17T12:06:12+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-02-17T01:29:58+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-02-17T01:28:40+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Pediatrics","date":"2026-02-13T13:11:02+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-pediatrics","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bped","sideBox":"Learn more about [BMC Pediatrics](http://bmcpediatr.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bped/default.aspx","title":"BMC Pediatrics","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"b07a75d9-6952-46d9-b8e0-4003b06faf8f","owner":[],"postedDate":"February 24th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2026-03-16T16:01:23+00:00","versionOfRecord":{"articleIdentity":"rs-8872346","link":"https://doi.org/10.1186/s12887-026-06712-x","journal":{"identity":"bmc-pediatrics","isVorOnly":false,"title":"BMC Pediatrics"},"publishedOn":"2026-03-09 15:57:53","publishedOnDateReadable":"March 9th, 2026"},"versionCreatedAt":"2026-02-24 08:20:14","video":"","vorDoi":"10.1186/s12887-026-06712-x","vorDoiUrl":"https://doi.org/10.1186/s12887-026-06712-x","workflowStages":[]},"version":"v1","identity":"rs-8872346","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8872346","identity":"rs-8872346","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}