Autism spectrum disorders (ASD) is one of the most common neurodevelopmental disorders in children (1). With the advancement in diagnosis of mental disorders, it seems that ASD prevalence is more than before. Current research reports high prevalence of this disorder (2, 3). So that, the prevalence of ASD increased to 1 in 68 children in 2010 (4). Prevalence of ASD in other countries indicate that 1 percent of the population is affected by ASD (5, 6). The prevalence of this disorder in Iranian children aged 5 years is reported to be 26.6 per 10,000 (6). The ratio of boys to girls was 4/5;1 (5). According to the new edition of the" Diagnostic and statistical manual of mental disorder–fifth edition" (DSM-5), ASD is characterized by limited social function, Restricted and repetitive behaviors and interests (1). Wide diversity of symptoms in this group of children can impact on occupational performance and participation. Occupation is groups of activities and task of routine life that meaning by individuals and culture; and participation is engagement in occupation in real situation (7).
 According to the Occupational Therapy Practice Framework (OTPF), “participation in occupations is a vital part of human development and life experience, by which it acquires skills and competencies and finds meaning and purpose in life” (p.625) (7). According to the International Classification of Functioning, Disability and Health (ICF), participation is defined as “involvement in life situation that occurs in the environment of life, work and play of the person” (p.640) (8, 9). The nature of ASD and its underlying causes can limit the children during activity participation of these children in daily occupations (10).
In recent years, the focus of studies on participation has been limited to physical disabilities (11, 12); however, participation in daily activities is restricted in other disability, too. Pusponegoro et al. (2016) concluded that children with ASD were more and more difficult to cope with social functions such as interpersonal communication, play and leisure, as well as adaptive skills (13). Dehghan et al. in 2015 reported that the Sensory Processing Disorders in children with ASD was associated with anxiety, aggression and hyperactivity (14). Hillton et al. (2007) showed limited social participation in children with ASD (15). According to the mentioned studies, it can be concluded that the main symptoms in ASD can be barriers to active participation. On the other hand, the diversity and content of the issues that people learn, perform and participate in real life activities can be influenced by the social context and cultural expectations (9, 16-20).
The purpose of all therapies and rehabilitation in ASD is appropriate participation in real life; additionally, the comprehensive assessment is base of the successful treatment. So that, preparing an assessment tool can help clinician that focus on problems of children with ASD in participation in all areas of occupations at home, school, and community, in accordance with native culture and social expectations. Therefore, the study aims to evaluate the psychometric properties of CPAS-P in Iranian children with ASD. Children with ASD, due to their disorder nature, have a greater constraint on their participation in the environment than their peers (13, 21, 22). Therefore, occupational therapists for improving their position in the health system, also to achieve the most appropriate intervention for each individual with ASD need a scale with good psychometric properties to assess their interventions’ outcome. In other words, occupational therapists use their science to interact with the environment and conditions in order to their occupation- based interventions. Currently, there are tools to measure children's participation, Among the tools which, assess the children participation is: Children Assessment of Participation and Enjoyment (CAPE), Pediatric Activity Card Sort (PACS), Children Participation Questioner (CPQ), Life-Habit (Life-H). Those Available tools, despite their advantages, have limitations (23, 24). This would reveal the necessity of a tool with less constraint. In other words, the studies clearly state that all developed tools are influenced by the social and cultural factors of each society and that their applicability in other societies may be accompanied by limitations (25). Studies show that the motivation and experience of participation in activities can be influenced by the cultural and social factors of children (26, 27). Each of these sub-tests can be used separately.  Therefore, having a tool that fits any culture and society seems important. Investigating the participation of children with ASD due to the importance of their participation in ADL requires their own dedicated tools.  CPAS-P is a tool which developed in 2016 for assessing the participation of 6 to 12 years Old Iranian children. This tool is provided in both child and parent versions. In this research the parent version has been used. All the areas of occupations presented in the OTPF (Activity Daily of Living (ADL), Instrumental Activity Daily of Living (IADL), Play, Leisure, Social participation, Education, Work, and Sleep / Rest) are covered in this tool (20). On the other hand, studies in recent years point to the importance of the issue of the cultural and social appropriateness of each research and experiment as an important and contemplative point (9, 16). CPAS-P is the only tool built in Iran and assesses the participation of children based on Iranian culture. This issue itself is considered as the point of strength of this scale (13).

 

In this descriptive study, 55 parents of children with ASD were included. Parents of children in this study did not have any psychology problems; also, they were literate. Children of this group of parents were 6-12 years old. ASD children selected from rehabilitation centers, ordinary schools, special schools and special schools for children with ASD. The inclusion criteria of this study were as follows; diagnosis of ASD spectrum disorder based on the DSM-5 by a psychiatrist, obtaining a minimum score of 50 in "ASD Spectrum Screening Questionnaire" (ASSQ), lack of vision, hearing and motor problems, and finally, collaboration of parents or any caregiver who had supervised the child for at least 8 months. The exclusion criteria of this study were failure of parents to complete the questionnaires despite initial satisfaction.

Children Participation Assessment Scale in Activities Outside of School-Parent Version (CPAS-P)
Children Participation Assessment Scale in Activities outside of school was designed for children aged 6 to 12 years old in Parent and Child version (CPAS-P, CPAS-C). This scale assesses child participation in activities outside-of-school in two important life situations (home and community) (20).  In this study the CPAS-P has been studied. A pilot study conducted during the development of the scale, indicates that the CPAS-P is appropriate for the age range of 6-12 years. OTPF-3 was used in the design, and development of this tool (20). OTPF is a classification system for occupations and activities, all of the areas of occupations presented in the OTPF (Activity Daily of Living (ADL), Instrumental Activity Daily of Living (IADL), Play, Leisure, Social participation, Education, Work, and Sleep / Rest) are covered in this tool (20). Therefore, this tool evaluates the 8 areas of occupations (ADL, IADL, Play, Leisure, Social participation, Education, Work, and Sleep / Rest). This tool can be used as a descriptive and evaluative tool in studies on healthy children and children with disabilities. The number of items in this tool is 71 items that are in the form of eight areas of occupations: ADL (such as bathing), IADL (such as the use of audio and video equipment), Play (such as computer games), Leisure (such as watching TV), Social Participation (such as attending to a friend’s birthday party), Education (such as participating in sports classes), Work (such as doing paid work) And sleep / rest (like relaxation time detection). For each activity that the child performs, the parents should report the frequency; enjoyment, with whom and the parent satisfaction domains of activities. So that CPAS-P has 5 dimensions, 1) doing or not doing an activity that takes 0 for not doing and 1 for doing an activity. 2) The frequency of an activity that the scores, ranges from 1 (once in the last 4 months) to 6 (every day). 3) Performing an activity with whom, that the range is from 1 (alone) to 5 (with others). 4) The level of enjoyment of the activity, which the range is from 1 (at all) to 5 (high interest); and 5) the parent satisfaction which the score ranges from 1 (dissatisfaction) to 4 (high satisfaction). This scale is a kind of self-report scale which takes 30 to 45 minutes to complete it and this tool has acceptable psychometric properties in normal Iranian children (20).

This tool assesses the adaptive behaviors of children in: communication domains, ADL & IADLs skills, socialization, and motor skills. This test is a suitable test for people under the age of 1-18 years. In this study, the items which are related to the age 6 to 12 years old were evaluated. This tool with Intraclass Correlation Coefficient (ICC=0.98) has acceptable reliability in Iran (28).

Initially, the code of ethics (IR.IUMS.FMD.REC 1396.9411355006) was received from the Ethics Committee of Iran University of Medical Sciences. Available samples were selected from rehabilitation centers, ordinary schools, special schools and special schools for children with ASD. The purpose of this study was described for the parents of children with ASD who refer to these centers. In order to make parents more collaborative, a commitment was made to hold educational classes aimed at increasing the parental involvement of these children. The educational content of these classes provided simple sensory instructions to improve the sensory status of children, held in groups of five in three sessions per hour. After obtaining the consent form from each parent, the initial evaluations to select the samples were carried out. Demographic questionnaire, VABS and CPAS-P were provided to the parents of children for completion. After completing the tests by parents, the mentioned educational classes were held. For assessing the test-retest reliability of CPAS-P in children with ASD two weeks after the initial test was performed the 55 of the same parents of children with ASD completed the tests again.

Statistical analysis was performed using SPSS 21 (IBM Inc. Chicago, IL, USA). ICC was used to measure the test-retest reliability, Cronbach's alpha, to measure the internal consistency of the CPAS-P, and for converging validity the Spearman test was used.
 

The mean age of children was 7.62 years (SD=1.64). 63.6% of the parents of children with ASD were housewives and 36.4% of them were employed.

Based on the result from the Cronbach's alpha, the levels of scores are follows. Up to 0.9 is (excellent), 0.7-0.9 is (good), 0.6-0.7 is (acceptable), 0.5-0.6 is (weak), and finally lower than 0.5 is non-Acceptable (26- 28). The results of the Cronbach's alpha coefficient for the dimensions of participation (frequency, with whom, level of enjoyment, and parental satisfaction) and for areas of occupations are reported in (Table 1). On the other hand, for the test-retest reliability of the CPAS-P, the Intraclass Correlation Coefficient (ICC) was used. In ICC, scores above 0.75 indicate excellent reliability and high scores of 0.70 represent acceptable reliability. Also, the scores between (0.60 -0.75) have good reliability and the scores (0.40-0.59) are weak (29, 30) (Table 2).

According to the definition of convergent validity, the correlation value of a questionnaire is validated by other tests, which measure the same structure. In Iran, VABS seems to be the only valid tool that has some of the areas of CPAS-P. To assess the correlation between CPAS-P domains (frequency, with whom, the level of enjoyment and parent satisfaction) and VABS (ADL & IADL, communication, socialization and motor skills) the Spearman correlation coefficient test was used. The correlation between the domains of CPAS-P and VABS which is presented in Table 3, the results shows that the correlation between the two domains of ADL and socialization in both scales is significant. However, there is no significant relationship between the other domains of two tests.

 
*P<0.05;   **P<0.001.