June/July 2002

Encouraging Exploration

By Christine A. Wright-Ott, MPA, OTR; Richard J. Escobar, ATP; and Sharon Leslie, MS, PT

Children who are diagnosed with a physical disability or a developmental delay may not have the ability to move and explore their surroundings, particularly indoors where they spend 80% of their time. These children typically lie or roll on the floor, sit in a supported chair, or stand in a standing frame. They may use bath seats, braces, and special strollers. In spite of all this equipment, these children do not have the ability to access their environment or experience the stages of development that depend on hands-free, upright, self-initiated mobility.

Children who have a means for self-initiated mobility decide where, when, and how to move to explore their surroundings. Those who cannot move across a room to reach out to explore an object or place are at a great disadvantage. They do not experience a variety of sensory motor and developmental activities such as pushing or pulling toys, seeking and touching what they see, or moving around or under objects. If they do experience mobility, it is primarily passive, while being held or pushed in a stroller. Restricted experience and mobility during early childhood have a diffuse and lasting impact on development.¹ If a child's mobility continues to be one of a passive nature, never active or self-initiated early in life, the child is further disadvantaged in his development.^2-4 The significance of experiencing mobility in early childhood has been demonstrated.^5-7 The challenge then is to determine how children with developmental delays can experience upright, self-initiated mobility so they can access their environment, explore their surroundings, and experience developmentally appropriate activities.

DEVELOPMENTAL EFFECTS

Several researchers have studied the impact of early exploration on a child's development. A recent study demonstrated that children who seek stimulation in their environment at a young age demonstrate increased cognitive, scholastic, and neuropsychological test performance at 11 years.⁸ The study determined that "Young children who can physically explore their environment, engage socially with other children, and verbally interact with adults, create for themselves an enriched, stimulating, varied, and challenging environment."⁸

Recent guidelines released by the National Association for Sport and Physical Education warn that we are "containerizing" our infants and young children by confining them to strollers, playpens, and car and infant seats for hours at a time. This in turn may delay development such as rolling over, crawling, walking, and even cognitive development. They recommend infants interact with parents or caregivers in daily physical activities that are dedicated to promoting the exploration of their environment.⁹

If early exploration is being demonstrated as a key factor in a child's development, then is it not just as critical to provide the same opportunities for children who are mobility impaired? If families are containerizing their young children, then what are we doing to children with disabilities who spend time in static equipment like strollers, special chairs, and standing frames? Shouldn't these children have an equal opportunity to move about their environment and explore?

After Christine A. Wright-Ott, MPA, OTR, and Richard J. Escobar, ATP, made adjustments to Miles' walker, the 24-month-old with arthrogryposis can now experience self-initiated, upright mobility necessary for exploration.

THE MOBILITY CHALLENGE

Mobility devices, whether powered or manual, can provide children who cannot achieve independent or assisted ambulation using a handheld push walker with a means for self-initiated, upright mobility.¹⁰ If there are no precautions for weight bearing and the child can take reciprocal steps, a support walker may be appropriate, depending on the abilities of the child. A support walker includes a seat and may include pelvic, trunk, head, and arm supports. If a child cannot propel a support walker using leg movements, a powered stander may be appropriate. They are designed to enable children to move close to objects while standing to reach and explore.¹¹ The only movement required by the child is to operate up to four switches or a joystick.

Achieving self-initiated mobility, particularly for children under 6 years of age, is a challenging endeavor for many reasons. In the past, practitioners were reluctant to recommend a support walker for children, particularly for toddlers with cerebral palsy, if posture and tone were adversely affected while moving in the device. This concern has been overcome to a greater degree by the availability of various types of mobility devices with more options for positioning the individual. There are now more than 15 types of commercially available support walkers that offer a variety of positioning components to minimize undesirable postures. Many manufacturers and assistive technology suppliers will also make custom modifications for individual needs. A common custom modification that improves performance of children who adduct their legs during ambulation is a modified seat, which is padded, wider, and longer than standard seats.

Clinicians may be reluctant to consider methods for self-initiated mobility because using a device may infer that independent walking is no longer a goal, an unacceptable choice for most caregivers. When caregivers realize the significance of determining how a child can become more engaged in the environment by moving upright to experience the benefits of exploring, the means to do so becomes secondary. If mobility is presented in terms of accessing the environment and defined as transitional to future methods of mobility, use of an assisted mobility method becomes more acceptable. The benefits of achieving self-initiated mobility to access the environment and increase early exploration opportunities far outweigh the cost of a mobility device or the perception that use of a mobility device may be a deterrent to independent ambulation. On the contrary, we have observed several children, diagnosed with a developmental delay, walk independently after using a support walker for 6 months.

Acquiring funding for self-initiated mobility equipment may be another challenge. Costs for support walkers range from $800 up to $3,500 and a powered stander as much as $6,500. Justification for equipment should include the benefits the individual can achieve through use of the equipment such as accessing the environment, improving upper extremity development through reaching and manipulation, improving physical function, increasing opportunities for exploration, peer interaction, and dynamic weight bearing. Some families have chosen to acquire a support walker to achieve these goals rather than a standing frame-a more static option.

PRODUCT OPTIONS

There are several categories of upright mobility devices. Push walkers are intended for individuals who have a moderate degree of sitting and standing balance. Support walkers provide support around the individual's pelvis and trunk for those who do not have the balance to use a push walker. A few support walkers utilize a custom orthotics approach by fabricating a brace for the trunk and legs, which attach to a wheeled frame. Manual and powered standers enable the individual to stand and move either by pushing large wheels or by operating a joystick or switches. Motorized go-karts, modified toy vehicles, adapted tricycles, wheelchairs, and push pedal chairs can provide self-initiated mobility, but do so in a seated position rather than a standing position and are not practical to use indoors for accessing the environment (see Table 1).

CONSIDERATIONS FOR SELECTING A MOBILITY DEVICE

One must first define the purpose for using a mobility device and consider the environment(s) the child will be using it in. If the goal is for the individual to access the home environment, one should consider a mobility device that is highly maneuverable and allows the child to be upright. Children who have the ability and desire to use their upper extremities for reaching and exploring benefit from using a hands-free mobility device. Mobility devices that are designed with a minimal amount of hardware in front of the child are preferred. Large wheeled bases, trays, or arm supports that extend in front of the child will limit the ability to get close to objects for reaching and touching. It is ideal to evaluate use of a mobility device in the child's natural environment, particularly since most mobility devices work more efficiently on smooth hard surfaces than on carpet.

Once the mobility goals and environment have been determined, the individual's physical abilities need to be considered. Successful use of a support walker generally depends on the child's ability to step reciprocally with minimal hip and knee flexion spasticity or contractures. Children who are weak or hypotonic may do better in a lightweight, front-leaning support walker, which fully supports their weight. These children can typically move a support walker on a smooth surface like linoleum, but only if their legs have a minimal amount of weight bearing. The amount of weight bearing can gradually be adjusted in the walker to accommodate strength and tone changes.

HOW TO PROVIDE SELF-INITIATED MOBILITY EXPERIENCES

We have successfully utilized two approaches to determine which type of mobility device is the most appropriate for an individual. A side-by-side trial of at least three different categories of devices is recommended. It is most ideal to have an upright support walker, a forward-leaning support walker, and a motorized stander available at the assessment. A thorough assessment takes time. The average time for assessing a child in several types of mobility devices is 5 hours with an occupational or physical therapist and 5 hours with an assistive technology practitioner. This includes an assessment, a home loan trial, a report, and a fitting at delivery. This model works well for therapy centers with limited equipment budgets. Assistive technology suppliers or manufacturer representatives will often loan equipment to a therapy clinic for use in assessments.

We have also established the Mobility for Discovery Experience, a program funded through grants and donations. The Discovery Experience provides mobility-impaired children with an opportunity to try various types of mobility devices for exploration.¹¹ Two or three children, ages 15 months to 4 years, who have a variety of physical disabilities and are unable to walk, participate in daily, 90-minute sessions for 2 weeks. Mobility devices available to the children include support walkers, powered standers, tricycles, and adapted battery-operated vehicles. Once an upright mobility device is fit to the child, activities such as pushing and pulling toys, opening cabinets, moving themselves under and around objects, and exploring an accessible playhouse are introduced. Caregivers of children who have participated in the Discovery Experience reported positive changes in their children. The children slept longer at night, seemed to be happier during the day, became extremely excited when they realized they were returning to the Discovery Experience, and demonstrated increased verbalization attempts at language and interaction. One explorer went from speaking one word, which was not clear, to speaking two-word sentences such as "I do," "Go outside," and "Open door" by the end of the experience. The equipment is available for loan to the family to assure that it works in the child's natural environment.

THE TEAM'S RESPONSIBILITY

A child with a disability who sits in a stroller or an adapted floor chair with a tray over his lap must depend on others to bring the environment to him. A toy may be selected by his caregiver and secured to the tray. If the child attempts to interact with the toy, hand and arm movements are kept close to the body and elbows rest on the tray. A sibling in the room might ignore the child in the special equipment, which is not at peer height. The same child is taken out of the adapted floor chair and placed upright in a standing mobility device. He decides to move into the kitchen and reach for a drawer, which he successfully learns to open and close after several trials. Shoulder and arm movements are more frequent during attempts to reach and explore. The child begins to learn how to maneuver himself through the environment, manipulate objects, and accomplish new tasks he has discovered. Motivation is high and opportunities for learning and problem solving are everywhere. His sibling runs over to talk with him at peer level. Opportunities for peer interaction and social development emerge. A sense of independence and self-esteem develops as the adult tells the child to "come here" while he chooses to move the other way. He finally agrees and moves over toward his caregiver for a hug.

It is the clinical team's responsibility to determine how children with a mobility impairment can access and explore their environment. It is imperative that these children acquire upright mobility devices for self-initiated mobility. This is particularly critical for children 1-3 years of age in view of research in brain development and the importance of early exploration. The child who spends the majority of his day lying on the floor, positioned in static equipment, or being pushed in a stroller will be disadvantaged as compared to peers who can achieve some level of upright, self-initiated mobility. We must empower and enable children from a very young age to access their environment so they may participate in activities that encourage cognitive, social, sensory motor, and spatial relations development as well as peer interaction and a sense of self-worth.

Table 1. Self-iniated upright mobility devices at a glance.

References

1. Chiulli C, Corradi-Scalise D, Donatelli-Schultheiss L. Powered mobility vehicles as aids in independent locomotion for young children. Phys Ther. 1988;68:997-999.
2. Paulsson K, Christoffersen M. Psychosocial aspects on technical aids: how does independent mobility affect the psychosocial and intellectual development of children with physical disabilities? Presented at: 2nd International Conference on Rehabilitation Engineering; 1984; Bethesda, Md.
3. Butler C, Okamoto G, McKay T. Motorized wheelchair driving by disabled children. Arch Phys Med Rehabil. 1984;65:95-97.
4. Campos J. Locomotion and psychological development in infancy, childhood powered mobility: developmental, technical and clinical perspectives. Paper presented at: RESNA First Northwest Regional Conference; March 6, 1987; Seattle.
5. Butler C, Okamoto G, McKay T. Powered mobility for very young disabled children. Dev Med Child Neurol. 1983;25:472-474.
6. Kermoian R. Locomotor experience facilitates psychological functioning: implications for assistive mobility for young children. In: Gray D, Quatrano L, Lieberman M, eds. Designing and Using Assistive Technology: The Human Perspective. Baltimore: Brookes; 1998:251-268.
7. Dietz J, Swinth Y, Whiate O. Powered mobility and preschoolers with complex developmental delays. Am J Occup Ther. 2002;56:86-96.
8. Raine A, Reynolds C, Venables PH, Mednick SA. Stimulation seeking and intelligence: a prospective longitudinal study. J Pers Soc Psychol. 2002;82:663-674.
9. National Association for Sport and Physical Education. Early childhood physical activity guidelines and press release. Available at: www.aahperd.org/naspe/template.cfm?template=toddlers.html#. Accessed April 30, 2002.
10. Egilson S, Wright-Ott C. Mobility. In: Case-Smith J, ed. Occupational Therapy for Children. 3rd ed. St Louis: Mosby-Year Book Inc; 1996:562-580.
11. Wright-Ott C. The transitional powered mobility aid: a new concept and tool for early mobility. In: J Furumasu, ed. Pediatric Powered Mobility: A Developmental Perspective, Technical Issues, Clinical Approaches. Arlington, Va: RESNA Press; 1997:58-69.
12. Carnegie Corporation Report. Starting points: meeting the needs of our youngest children. Available at: www.carnegie.org/starting_points/startpt1.html. Accessed April 30, 2002.