Our meta-aggregative review (45) addressed the following question: What are the lived experiences of children and youth with disabilities regarding the SBRS they receive? The protocol was registered on the Open Science Framework (https://doi.org/10.17605/OSF.IO/BM48C).

The review question and search strategy were developed with guidance from the PICo framework (Population, Interest, Context) (45). The population included children and youth from school entry to school exit eligible for SBRS. Our focus was on their lived experiences and perspectives, specifically related to OT, PT, and SLP services provided in school settings. The context encompassed both publicly and privately funded services provided in mainstream and specialized schools.

The search strategy was developed in collaboration with a health sciences librarian at McMaster University. Using PICo, we identified subject headings and keywords related to our population, lived experiences and qualitative research, rehabilitation, and school settings. Terms within each concept were combined with “OR” and then the different concepts were connected with “AND.” The final strategy was refined in consultation with the librarian to ensure it was comprehensive and appropriately adapted for each database searched.

Searches were conducted in six databases: CINAHL, Embase, Emcare, ERIC, Medline, and Web of Science. Table 1 provides examples of search terms and the structure of search strategies. Complete search strategies for the six database searches can be found in Appendix A.

Meta-aggregation is an approach to aggregating evidence from existing qualitative research to inform policy and practice (45, 46). Rooted in pragmatism, it balances the importance of meaningfully representing human lived experience (47) with the need to produce actionable, evidence-based knowledge to inform decision-making in real-world contexts (45–48). Meta-aggregation is well suited to the aims of this review, which seeks to amplify the voices of children and youth with disabilities to inform SBRS policy and practice.

In contrast to interpretive synthesis approaches such as meta-ethnography, which aim to re-interpret data and generate new theoretical insights across studies, meta-aggregation involves a synthesis that remains close to the original interpretations of the authors and aggregates findings without re-conceptualization (45, 49). Avoiding reinterpretation of the original findings was essential for our review, as we aimed to authentically represent how children and youth with disabilities describe their lived experiences with SBRS.

This review included primary qualitative and mixed methods studies that employed research methods such as interviews, focus groups, and other qualitative approaches to explore the lived experiences and perspectives of children and youth eligible for SBRS. Methodologies of interest included studies that utilized phenomenology, grounded theory, and other qualitative methodologies. Quantitative studies were excluded. Only primary research was included, while secondary analyses such as systematic reviews, meta-analyses, and scoping reviews were excluded. Eligible literature consisted of scholarly sources, including research articles, dissertations, theses, and book chapters. Government documents, conference proceedings, and other non-scholarly literature were excluded.

The population of interest was children and youth with disabilities. We included studies that collected lived experiences and perspectives from children and youth from school entry to school exit. Perspectives from adults recounting their school-aged experiences were also included. Studies focusing on individuals in preschool, post-secondary education, or on non-student perspectives such as parents, educators, or healthcare providers were excluded. We included studies that collected lived experiences and perspectives from adult participants alongside those of our population of interest. However, studies were included only if the perspectives of children and youth were clearly distinguishable from those of adult participants (e.g., participant quotations were labeled such that it was clear whose perspectives were represented). This distinction allowed us to extract themes and illustrative data specific to children and youth. Only first-person perspectives were included to ensure the review captured the lived experiences and voices of children and youth themselves.

The context of the review was limited to services provided in school environments, including both publicly and privately funded schools, whether in mainstream or specialized settings. Studies examining rehabilitation services delivered outside of school settings were excluded, as were those focusing on preschools, daycares, before or after school programs, or post-secondary institutions. Eligible services were limited to OT, PT, and SLP services provided within the defined school context. Studies examining other types of services, such as psychology, nursing, social work, or dietetics, were excluded. A list of eligibility criteria can be found in Appendix B.

This review employed an Integrated Knowledge Translation (iKT) framework to engage youth with disabilities actively in the research process. The iKT framework emphasizes the co-production of knowledge through close collaboration between researchers and knowledge users across all stages of research (50). While participatory approaches, such as youth participatory action research (YPAR), provide important models for engaging youth as co-researchers, YPAR is primarily oriented toward action-based, primary research (51, 52). An iKT framework is designed to involve knowledge users across all stages of research to enhance the relevance and applicability of findings for policy and practice (50). Therefore, iKT was selected for its alignment with the review methodology and aims (50, 53).

Our review team included five individuals: primary reviewer (AB) and secondary reviewers (CMT, IK, KS, LW), three of whom (CMT, KS, LW) identify as having disabilities and have lived experiences with rehabilitation services. The members of the review team with lived experience (CMT, KS, LW) were recruited through Canada's Child-Bright Network's Training and Capacity Building Program, which aims to foster patient-oriented research by engaging partners with lived and living experience (54). Individuals who expressed interest in participating contacted the external reviewer (WC) to indicate their interest in being involved.

Following their expression of interest, review team members with lived experience were hired as research team members through McMaster University. As part of this process, team members completed standard institutional training requirements, including university-mandated health and safety modules. Although team members had varied prior experience with research ethics, no formal ethics training was provided.

Consistent with the iKT framework, the review team members with lived experience played a key role in shaping research decisions and ensuring that the perspectives of individuals with disabilities were meaningfully integrated throughout the review, from protocol development to dissemination (52). An additional member of the review team (IK) joined after the search was completed and was recruited through the external reviewer's network of research assistants. IK contributed to the screening, critical appraisal, and data extraction stages. However, unlike the review team members with lived experience, IK did not participate in advising on research decisions or data synthesis.

To establish clear roles, tasks, and responsibilities, the team used the Involvement Matrix (55). This tool supported effective communication between the secondary review team members and the primary reviewer, allowing them to specify where they wished to be most involved and to set clear expectations and roles throughout the review.

Prior to commencing the review, all review team members met with the primary reviewer to orient to the project's aims, methodology, and expectations. Review team members received tailored training related to qualitative research methods, systematic review processes, and the principles of meta-aggregation. These sessions were designed to support meaningful participation and research skill development and provided opportunities for secondary reviewers to indicate their preferred level of involvement at each stage of the review and to identify any accommodations required.

Before each stage of the review, review team members participated in group meetings, with additional individual meetings offered as needed to support skill development and understanding of each task. The primary reviewer developed and circulated accessible training materials, including written guides, examples, and step-by-step instructions, to support consistency and confidence across the team.

The review team conducted the screening process in two stages: title and abstract screening followed by full-text review, using Covidence software. Automatic deduplication was performed within Covidence prior to the title and abstract screening, and manual deduplication was conducted during screening to remove any duplicates missed by the software.

The primary reviewer facilitated two initial training sessions to establish reliability among team members. In the first session, all reviewers independently screened 10 titles and abstracts, and in the second session, an additional 10 titles and abstracts were reviewed. After each session, the team convened to compare decisions, resolve conflicts through discussion, and refine the eligibility criteria. Following the training, inter-rater reliability testing was conducted using 75 articles. The team reached a consensus level of 80% or higher before commencing the formal title and abstract screening phase. An 80% agreement threshold was selected, as agreement at or above this level reflects a strong level of agreement between raters (56, 57).

During the title and abstract screening, the primary reviewer met regularly with the secondary reviewers to address conflicts. Conflicts were resolved through discussion and consensus. When consensus could not be reached, an external reviewer was consulted to make a final decision. Any sources that did not have an abstract available for screening automatically advanced to full-text review.

Following the title and abstract screening, the same five reviewers proceeded to full-text review. Before starting this phase in Covidence, the primary reviewer led a training session where the team reviewed five full-text articles. The review team then met to discuss inclusion and exclusion decisions and further refine the eligibility criteria. Inter-rater reliability testing was conducted using 10 full-text articles, achieving an agreement level of 80% or higher between the primary reviewer and each secondary reviewer. Once this reliability threshold was met for each team member, the team completed full-text review in Covidence. Any disagreements were resolved by consensus; if consensus between the reviewers could not be reached, an external reviewer was consulted to make a final decision.

As outlined in the JBI Manual for Evidence Synthesis (45), because the findings of a meta-aggregative review are intended to inform policy and practice, critical appraisal is a necessary step for ensuring selection of high-quality studies (45).

For this step, the review team utilized a modified standardized JBI critical appraisal checklist (58). This modified checklist was created in consultation with the JBI and experienced qualitative researchers to enhance its use by novice researchers (58). The modifications included incorporating explanations and examples alongside critical appraisal criteria to guide decision-making (58). Given that all members of the review team were novice researchers, the added guidance enabled the team to critically assess with confidence whether articles met the pre-established quality criteria.

The critical appraisal checklist included two screening questions that assessed relevance of included articles to the review question. If a study did not pass both screening questions, it was excluded. Studies deemed relevant by both screening questions were further appraised for methodological quality using seven additional questions. The critical appraisal checklist is presented in Appendix C.

The same reviewers who conducted the screening also participated in a training session for critical appraisal led by the primary reviewer. Following the training session, secondary reviewers applied their training by independently appraising one study as a team and one study independently. Each reviewer then met with the primary reviewer to discuss their appraisal and decisions. Once all reviewers demonstrated understanding of the critical appraisal process, secondary reviewers were assigned specific studies to appraise. All articles were appraised by the primary reviewer and one of the four secondary reviewers. The primary reviewer met regularly with the secondary reviewers individually to discuss decisions and resolve any disagreements. In cases where consensus could not be reached, an external reviewer was consulted.

The studies included after the critical appraisal stage were extracted by the review team in two phases. In the first phase, the review team extracted the main study characteristics and relevant information to the research question (see Table 2). These data were extracted by the primary reviewer and one other member of the review team using Covidence. Covidence flagged any conflicts, which were then resolved through discussion and consensus between the primary reviewer and the second reviewer.

In the second phase, the primary reviewer extracted relevant findings from the included studies. Per the JBI Manual for Evidence Synthesis (45), a finding was defined as “a verbatim extract of the author's analytic interpretation of their results or “data”” [(45), p. 67]. Each finding was accompanied by extracted illustrations, defined as “a direct quotation of a participant's voice” [(45), p. 67].

A verbatim description of each theme or category was extracted, with sub-themes extracted separately when applicable. Additionally, positive and negative perspectives within themes were extracted as separate findings, as they would be classified differently during synthesis. When descriptions were lengthy or dispersed across multiple sections of the text, the primary reviewer paraphrased the description while maintaining the original meaning and interpretation of the authors. The first supporting illustration was extracted for each finding, with additional illustrations extracted when a single illustration did not adequately capture the complexity or full scope of the theme.

All extracted findings were verified by a secondary reviewer, who assessed the accuracy, completeness, and appropriateness of the extracted descriptions and illustrations.

Following extraction, each finding was assigned a level of credibility using the definitions provided in the JBI Manual for Evidence Synthesis (45). A finding was classified as unequivocal when it was supported by a participant illustration that clearly and unambiguously aligned with the author's interpretation. Findings were classified as credible when the illustration was logically consistent with the finding but open to challenge or alternative interpretation. Findings were classified as unsupported when no illustration was provided or when the illustration did not clearly support the stated finding.

Both the primary reviewer and a secondary reviewer independently assigned a level of credibility to each finding while blinded to one another's assessments. The primary reviewer then compared assigned credibility levels, and any conflicts were resolved through discussion and consensus. See Table 3 for the extraction template for study findings and examples of how findings were extracted, and credibility rating assigned.

After data extraction, the findings were synthesized by the primary reviewer and verified by review team members with lived experience, as well as the external reviewer. Following the JBI Manual for Evidence Synthesis (45), the primary reviewer organized the findings into categories. JBI defines a category as “a brief description of a key concept arising from the aggregation of two or more like findings and is accompanied by an explanatory statement that conveys the whole, inclusive meaning of a group of similar findings” [(45), p. 67]. These categories were then presented to the members of the review team with lived experience for verification. During the meeting, the review team members with lived experience provided input and guidance on the category names and descriptions, as well as suggestions for additional categories. The primary reviewer then met with the external reviewer to refine the categories based on the input from the review team and provide any additional input on the categories.

After refining the categories with input from both the review team members with lived experience and the external reviewer, the primary reviewer re-presented the categories to both groups for verification. At this time, all review team members with lived experience endorsed the categories. The primary reviewer then grouped the categories into synthesized findings. JBI defines a synthesized finding as “an overarching description of a group of categorized findings” [(45), p. 67]. “Synthesized findings are expressed as “indicatory” statements that can be used to generate recommendations for policy or practice” [(45), p. 67]. Like categories, each synthesized finding is accompanied by an explanatory statement that conveys the meaning of the grouped categories.

After generating the synthesized findings, the primary reviewer followed the same approach to synthesizing categories. The primary reviewer met with the review team with lived experience for feedback and suggestions and then refined the synthesized findings with the external reviewer. After all statements were finalized, review team members with lived experience were consulted for their final opinions.

The review process and roles of reviewers are outlined in Figure 1.

The 13 studies included were conducted across multiple countries and continents, including the United States (n = 3), the United Kingdom (n = 2), England (n = 2), Australia (n = 1), Belgium (n = 1), Ireland (n = 1), Israel (n = 1), Portugal (n = 1), and South Africa (n = 1). Publication years ranged from 2009 to 2024.

A spectrum of qualitative methodologies was used across the studies: phenomenology or descriptive phenomenology (n = 4), grounded theory (n = 3), appreciative inquiry (n = 1), descriptive qualitative (n = 1), participant-focused (n = 1), and participatory arts-based methods (n = 1). Two studies did not explicitly report their methodological approach.

Participants in the included studies were children and youth from school entry to school exit, attending either mainstream or specialized schools, and with a range of conditions and disabilities. The most frequently reported condition was stuttering (n = 4). Other conditions included cerebral palsy (n = 2), chronic idiopathic neck pain (n = 1), cleft lip and/or palate (n = 1), developmental language disorder (n = 1), paraplegia (n = 1), severe learning disabilities (n = 1), and speech, language, and communication needs (n = 2). Four studies included adult participants who were reflecting on their past school experiences. The remaining studies involved children and youth aged 5–18 years. All studies focused on collecting first-person perspectives, as outlined in the eligibility criteria.

Most studies focused on SLP services (n = 8), while five focused on PT services. No studies focusing exclusively on OT services met the inclusion criteria. See Table 4.

Across the 13 included studies, a total of 53 findings were extracted. One finding was judged by the reviewers as unsupported and was excluded from further synthesis as per the JBI guidelines. The remaining 52 findings were assessed as credible or unequivocal and included in the final synthesis.

Based on similarities in meaning, ideas, and concepts, the 52 findings were organized into 14 categories. Twenty findings were assigned to more than one category due to including more than one idea or concept. For example, the finding titled “The leadership of the support group: Physiotherapists' role regarding peer support” (71) was categorized into two categories because it encompassed two key themes: that therapists should act as advocates and therapists should be knowledgeable. Therefore, this finding was included in both Category 12: Therapists Should Be Advocates for Children and Category 13: The Importance of Knowledgeable, Supportive, and Empathetic Therapists. Two findings remained uncategorized because they did not align with any other category, and per guidance in the JBI Manual for Evidence Synthesis (48), these findings were not synthesized further.

Finally, one category comprising two findings was not included in any of the synthesized findings as it was dissimilar from all other categories. Specifically, this category addressed loss of access to services after aging out of school or certain programs. No other categories touched on reduced access and availability of service; therefore, it was not categorized into a synthesized finding. All categories and their corresponding findings are presented in Appendix D.

The remaining 13 categories were grouped into six synthesized findings, in accordance with the JBI Manual for Evidence Synthesis (45) and are reported below. Figures 3–8 show the number of findings in each category and the categories that were grouped together into each synthesized statement.

This section outlines key implications for SBRS practice and policy, with emphasis on the importance of supporting children's autonomy in therapy and at school, providing holistic and socially informed approaches to therapy, and aligning SBRS delivery with inclusive values. We build on the implications for practice to highlight what is important for policymakers.

One of the key strengths of this meta-aggregative review was our iKT approach, which actively involved youth with disabilities throughout the research process. Review team members with lived experience contributed from protocol development through to the final synthesis, including verifying review findings, categories, and synthesized statements to support alignment with lived experiences. It is important to note that although youth engagement throughout the research process was considered a strength of the review, it also required additional time and resources to teach youth new research skills, especially as their familiarity with conducting research reviews varied.

Regular team meetings facilitated peer debriefing and ongoing discussions about the research process. The primary reviewer also met independently and regularly with an external reviewer, who is an experienced qualitative researcher specializing in SBRS and service delivery, to discuss the research process, decisions, and to verify interpretations. This encouraged a reflexive process, and the primary researcher kept reflexive notes documenting key decisions and methodological adjustments. This process increased confidence that our synthesis incorporated multiple valuable perspectives rather than relying solely on the viewpoint of the primary reviewer.

Our review also had some limitations. First, despite efforts to develop a comprehensive search strategy, some relevant literature may not have been identified. The broad scope of our review question made it challenging to create a targeted yet comprehensive search strategy, potentially affecting the retrieval of all relevant studies. Because our research focused on lived experiences and perspectives, we encountered variability in how these concepts were described across studies. There is no universal terminology used to represent lived experience or first-person perspectives in research, meaning some studies may have captured these elements without explicitly stating so. To address this, we incorporated search terms related to qualitative research to identify studies that may have explored these concepts indirectly. This decision contributed to a broader, more comprehensive search. However, despite these efforts, key information needed to determine study eligibility was often located only in the full text or methods section rather than the abstract, which may have led to the omission of some relevant studies during screening.

A second limitation concerns the critical appraisal process, which may have excluded studies containing relevant information. The JBI methodology includes this step because a key aim of meta-aggregation is to develop recommendations for policy and practice, necessitating the inclusion of studies with high methodological quality (45, 105). Nevertheless, it is possible that some studies with relevant findings were excluded at this stage, potentially limiting the breadth of our final synthesis. Although there is ongoing debate about whether studies should be included regardless of methodological quality (106), adherence to JBI guidelines made this a crucial component of our review.

Finally, it is possible that publication bias may have limited the literature included in this review. In qualitative research, publication bias, also referred to as dissemination bias, can influence the body of available evidence (107). Dissemination bias occurs when studies are less likely to be published because their results are considered less noteworthy, contradict prevailing beliefs or values, are unpopular, or do not align with current or anticipated research agendas (107, 108). Future research is needed to examine how dissemination bias specifically affects qualitative evidence syntheses and the impact it has on the use of qualitative findings to inform policy and practice (107).

Despite these limitations, the rigorous methodology and inclusion of high-quality qualitative studies strengthen confidence in the findings. While potentially missed studies may have contributed additional findings and perspectives, the aggregated findings represent a credible and transparent synthesis of the best available qualitative evidence identified, supporting transferability to similar populations and contexts.

As we were unable to locate any relevant studies representing school-based OT services, one area for future exploration would be to engage children and youth receiving OT services to better understand their specific wants and needs. In addition, the literature disproportionately represented older children and youth, with limited inclusion of younger children (60–63, 65, 67, 70, 71). This overrepresentation highlights the importance of future research that captures more diverse perspectives across ages, as well from children and youth with a broader range of disabilities, abilities, and service needs. Child-centered and participatory qualitative methods are particularly well suited for engaging children and youth in research. Methods such as draw-and-tell techniques, task-based and play-based approaches, and visual methods including photovoice or photo elicitation allow children to express their perspectives in ways that extend beyond verbal communication alone (41, 42, 109, 110). These child-led approaches can enhance accessibility, reduce power imbalances, and support more authentic representation of children's lived experiences in research (41, 42, 109, 110).

Future research should also address the predominance of Western and Anglo-centric perspectives in the existing literature. In this review, the majority of included studies were conducted in the United States (63, 64, 67) and the United Kingdom (8, 60, 65, 66, 69), underscoring the need to incorporate more international perspectives by engaging children and youth from a broader range of countries, cultures, geographic regions, and socio-economic and political contexts. Similarly, the inclusive education literature remains largely concentrated in developed, Western, and Anglo-centric countries, where research, policy development, and documentation of inclusive practices have been more extensively established (111). This concentration limits understanding of how inclusive education and SBRS are implemented and experienced in developing countries and culturally diverse settings. Expanding research beyond Western and Anglo-centric contexts is therefore essential to support the development of more globally relevant, equitable, and culturally responsive evidence to inform policy and practice.