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1. Introduction
Children’s participation has different aspects. Participation is seen not only as a way of making all the decisions in one’s life but it has been mentioned as a children’s right too. Considering participation, an important concern in children’s lives, made them the center of focus instead of being passive subjects of research [1]. Participation is one of the outcomes of occupational therapy intervention and is defined as an engagement in daily life activities [2]. Participation has different aspects and depends on several factors, such as motivation and interest [3, 4]. The difficulties in participation lead clients to occupational therapy [5].
According to the diagnostic and statistical manual of mental disorders, fifth edition (DSM-5), attention-deficit/hyperactivity disorder (ADHD) is a disorder that has three main symptoms of inattention, hyperactivity, and impulsivity. These symptoms can be seen together or separately and affect occupations [6]. After depression and anxiety, ADHD is the most common mental disorder that almost 3.4% of children and adolescents can experience worldwide [7]. The prevalence of ADHD is studied in Iran as well. It has been estimated that 4% of 6 to 18 years old children in Iran have been diagnosed with ADHD, which is relatively higher than the average world prevalence [8].
Children with ADHD face serious problems in their participation in different occupations, from activities of daily living to play and leisure activities [9]. Participation is related to the quality of life (QoL) [10]. Therefore it is crucial to assess participation carefully and have plans to increase it among children with ADHD.
Several participation measures in Persian are studied to be used among different groups. Fifty measures were introduced in a systematic review in 2020, and participation in their psychometric issues has been studied [11]. Not all of these measures are suitable for children, and some of them only cover one area of occupation. There are only 6 measures for assessing participation that is developed based on the Iranian population. There are some other tools in the world, but none of them are based on Iranian culture. The only suitable for Iranian children is the Iranian children’s participation assessment scale (I-CPAS). It has two versions for parents and children and assesses all the occupation domains [11]. I-CPAS was developed in Iran, and it has many similarities with the children participation questionnaire (CPQ). CPQ studies Iranian children and covers age groups from 4 to 6 years old. As I-CPAS is designed for 6 to 12 years old children and these two tests have a great match in their structure, and both of them are developed regarding occupational therapy practice framework (OTPF), considering both as potential tests for participation is beneficial [12, 13, 14, 15]. These tests have been used for children with cerebral palsy and cancer [14, 16]. We want to use the test for a quite different population, and these tests have not been used in children with ADHD before; however, it was studied among children with mental disorders before this study. Saljooghi et al. worked on the psychometric issues of I-CPAS for children with mental illnesses [17]. They did not study children with ADHD, so we need to run a psychometric study, including face and content validity and test-retest reliability, to make the test ready to be considered a proper tool for clinical and research purposes. 
This study aimed to examine the face and content validities of I-CPAS (parents’ version), as well as its test-retest reliability. As the original version was in Persian, we worked based on the same version.

2. Materials and Methods
This psychometric study was done in two major steps: the validity step and the reliability step. Regarding the validity part, occupational therapists were invited to assess the content validity. Regarding the reliability part, a total population of 30 children was included (aged 6-12 years). These children answered the questionnaire twice at a 15-day interval via electronic questionnaire.

Content validity
Regarding content validity, we invited 8 occupational therapy experts with more than 5 years of experience in mental health services. Five people in this group had a PhD in occupational therapy or were PhD candidates, and three had a Master’s in occupational therapy. Using the Lawshe method, the content validity index (CVI) and the content validity ratio (CVR) were estimated. For this part, all items were prepared on a table and were studied by experts. Each item was scored in terms of its essentiality for assessing participation in children with ADHD. Three options were available for each item as the experts should answer them: it is essential, it is beneficial but not essential, and it is not essential. For assessing the CVR, the following formula (Equation 1) was used. In this formula, “Ne” denotes the number of experts who voted an item as being essential, and “N” indicates the number of experts who participated in the research [18].

The obtained answer will be compared to what Lawshe has introduced. According to his outcomes, each item needs a minimum score of 0.75 to remain in the questionnaire.
For the CVI part, experts scored each item for being clear, simple, and specific to the topic from 1 to 4, which shows the strongest score in 4 and the lowest score in 1. To calculate CVI, the number of experts who rated an item with 3 or 4 would be subtracted from the whole expert’s number [18].


Reliability
To estimate the reliability of the questionnaire, the test-retest reliability was done. The test-retest reliability shows the consistency of a questionnaire throughout the time [19]. Thirty parents of children with ADHD participated in the study [20, 21, 22]. Using the intraclass correlation coefficients (ICC), we compared the scores in the questionnaire, completed by 30 parents of children with ADHD twice, with an interval of two weeks. The inclusion criteria were as follows: Having a confirmed diagnosis of ADHD by a psychiatrist, being 6 to 12 years old, living in Tehran, and being able to write and read in Persian for parents responsible for answering the questionnaires. The exclusion criteria were as follows: having no tendency to participate or remain in the study and having any major mental (like Autism spectrum disorder or Down syndrome and so on) or neurological diseases (like cerebral palsy).

3. Results
Validity
Regarding the validity part, 8 experts took part. All the items asked in the I-CPAS are brought in Table 1.

As shown, all items scored 1 for the CVI part. In the CVR, parts 54, 62, 64, and 67 scored 0.75, and other items got 1. Table 2 presents the CVR values according to Lawshe’s definition.

This table indicates that scores higher than 0.75 would be considered acceptable in terms of validity. Therefore, all items remained in the questionnaire, and no item was added.

Reliability
In this study, the test-retest reliability was used to determine the reliability of the I-CPAS. Thirty children entered the study, but two could not participate in the re-test due to infection with COVID-19. They were excluded from the study, and 28 children stayed in the study, and their parents completed the test after two weeks. The absolute agreement and 2-way random were used. The ICC was calculated between the test and re-test and is presented in Table 3.

According to Munro, If ICC is higher than 0.8, the reliability is very good, between 0.79 and 0.8 is medium, and less than 0.6 is poor [23]. The ICC values show very good reliability in all dimensions of I-CPAS.


4. Discussion
Attention-deficit/hyperactivity disorder is a common disorder in childhood and affects children’s participation and many areas of their lives. Knowing the exact damage of any health issue is always important to provide a proper and beneficial intervention. The I-CPAS is an Iranian test for evaluating participation in children. The test was initially developed for patients with cerebral palsy. In this project, the main purpose was to assess this test’s psychometric properties for children with ADHD.
As this test was in Persian, no translation was needed. The first step was studying the content validity that showed good validity as experts ranked items. Regarding the validity part, no item was deleted. Although some comments on changing words were made, the test passed the validity test. These results were like other studies on children with cerebral palsy and cancer [12, 15, 16, 24].
Regarding the reliability part, all items were stable during the time. The ICC value was 1 for all items. This test also offered great test-retest reliability in other studies [12, 15, 16, 24]. I-CPAS showed good reliability for children with cerebral palsy, cancer, and other mental conditions. Although some participation scales exist for children with ADHD, none consider all the areas of participation in OTPF. For example, household task participation is assessed independently [9], and sports participation is studied in a different study [25]. Therefore I-CPAS sounds like a proper choice to evaluate the whole area of involvement among children with ADHD.

5. Conclusion
I-CPAS is a valid and reliable test for children with attention deficit with or without hyperactivity disorder and can be applied in clinical and research situations. 

Ethical Considerations
Compliance with ethical guidelines
This study was approved by the Ethics Committee of the University of Social Welfare and Rehabilitation Sciences (Code: IR.USWR.REC.1398.079).

Funding
The paper was extracted from the PhD thesis of Minoo Dabiri Golchin at the Occupational Therapy Department of the University of Social Welfare and Rehabilitation Sciences.

Authors' contributions
All authors equally contributed to preparing this article.

Conflict of interest
The authors declared no conflict of interest.

Acknowledgments
Authors would like to thank all the participants who devoted their time on the study.

References

1. Cashmore J. Promoting the participation of children and young people in care. Child abuse & Neglect. 2002; 26(8):837-47. [DOI:10.1016/S0145-2134(02)00353-8] [PMID]
2. Association AOT. Occupational therapy practice framework. domain and process. The American Journal of Occupational Therapy. 2020; 74(Supplement_2):7412410010p1–87.[Link]
3. Dehghanizadeh M, Akbarfahimi M, Zareiyan A, Yazdani F, Khalafbeigi M, Soleimani F. Predictors of interest in performing activities among iranian adolescents with cerebral palsy. Iranian Rehabilitation Journal. 2020; 18(4):377-86. [DOI:10.32598/irj.18.4.422.5]
4. Dehghanizadeh M, Khalafbeigi M, Akbarfahimi M, Yazdani F, Zareiyan A. Exploring the contributing factors that influence the volition of adolescents with cerebral palsy: A directed content analysis. Scandinavian Journal of Occupational therapy. 2021; 28(7):553-63. [DOI:10.1080/11038128.2020.1723686] [PMID]
5. Vessby K, Kjellberg A. Participation in occupational therapy research: A literature review. British Journal of Occupational Therapy. 2010; 73(7):319-26. [DOI:10.4276/030802210X12759925544380]
6. Association Psychiatric Association. Diagnostic and statistical manual of mental disorders. Washington, DC: Association Psychiatric Association; 2013. [Link]
7. Bélanger SA, Andrews D, Gray C, Korczak D. ADHD in children and youth: part 1-etiology, diagnosis, and comorbidity. Paediatrics & Child Health. 2018; 23(7):447-53. [DOI:10.1093/pch/pxy109] [PMID] [PMCID]
8. Mohammadi MR, Zarafshan H, Khaleghi A, Ahmadi N, Hooshyari Z, Mostafavi SA, et al. Prevalence of ADHD and its comorbidities in a population-based sample. Journal of Attention Disorders. 2021; 25(8):1058-67. [DOI:10.1177/1087054719886372] [PMID]
9. Dunn L, Coster WJ, Cohn ES, Orsmond GI. Factors associated with participation of children with and without ADHD in household tasks. Physical & Occupational Therapy in Pediatrics. 2009; 29(3):274-94. [DOI:10.1080/01942630903008350] [PMID]
10. Williams K, Jacoby P, Whitehouse A, Kim R, Epstein A, Murphy N, et al. Functioning, participation, and quality of life in children with intellectual disability: An observational study. Developmental Medicine & Child Neurology. 2021; 63(1):89-96. [DOI:10.1111/dmcn.14657] [PMID]
11. Joveini G, Zareiyan A, Khalafbeigi M, Lajevardi L. The comparative content review of the persian participation assessment measures: A systematic review. Iranian Rehabilitation Journal. 2020; 18(1):1-16. [DOI:10.32598/irj.18.1.928.1]
12. Amini M, Hassani Mehraban A, Haghani H, Mollazade E, Zaree M. Factor structure and construct validity of children participation assessment scale in activities outside of school-parent version (CPAS-P). Occupational Therapy in Health Care. 2017; 31(1):44-60. [DOI:10.1080/07380577.2016.1272733] [PMID]

13. Amini M, Mehraban AH, Haghni H, Asgharnezhad AA, Mahani MK. Development and validation of Iranian children’s participation assessment scale. Medical journal of the Islamic Republic of Iran. 2016; 30:333. [PMCID] [PMID]
14. Amini M, Hassani Mehraban A, Rostamzadeh O, Mehdizadeh F. Psychometric properties of the Iranian-Children Participation Questionnaire (I-CPQ) when used with parents of preschool children with cerebral palsy. Occupational Therapy in Health Care. 2017; 31(4):341-51. [DOI:10.1080/07380577.2017.1382753] [PMID]
15. Pashmdarfard M, Richards LG, Amini M. Factors affecting participation of children with cerebral palsy in meaningful activities: Systematic review. Occupational Therapy in Health Care. 2021; 35(4):442-79. [PMID] 
16. Alizadeh Zarei M, Mohammadi A, Mehraban AH, Ansari Damavandi S, Amini M. Participation in daily life activities among children with cancer. Middle East Journal of Cancer. 2017; 8(4):213-22. [Link]
17. Saljooghi F, Hassani Mehraban A, Amini M. [Construct validity and reliability of I-CPAS for children with mental disorders (Persian)] [MDThesis]. Tehran: Iran University of Medical Sciences; 2019.
18. Lawshe CH. A quantitative approach to content validity. Personnel Psychology. 1975; 28(4):563-75. [DOI:10.1111/j.1744-6570.1975.tb01393.x]
19. Weir JP. Quantifying test-retest reliability using the intraclass correlation coefficient and the SEM. The Journal of Strength & Conditioning Research. 2005; 19(1):231-40. [DOI:10.1519/15184.1]
20. Connelly LM. Pilot studies. Medsurg Nursing. 2008; 17(6):411-2. [Link]  
21. Hertzog MA. Considerations in determining sample size for pilot studies. Research in Nursing & Health. 2008; 31(2):180-91. [DOI:10.1002/nur.20247] [PMID]
22. Hill R. What sample size is “enough” in internet survey research. Interpersonal Computing and Technology: An electronic Journal for the 21st Century. 1998; 6(3-4):1-2. [Link]
23. Munro BH. Statistical methods for health care research. Philadelphia: Lippincott Williams & Wilkins; 2005. [Link]
24. Amini M, Hassani Mehraban A, Pashmdarfard M, Cheraghifard M. Reliability and validity of the children participation assessment scale in activities outside of school-parent version for children with physical disabilities. Australian Occupational Therapy Journal. 2019; 66(4):482-9. [DOI:10.1111/1440-1630.12569] [PMID]
25. Kiluk BD, Weden S, Culotta VP. Sport participation and anxiety in children with ADHD. Journal of Attention Disorders. 2009; 12(6):499-506. [DOI:10.1177/1087054708320400] [PMID]