assistive technology for children with disabilities

Assistive Technology for Childrenwith Disabilities

Selena Isabelle, OTRS. Fiona Bessey, OTR

Kathryn Lawrence Dragas, OTRPatricia Blease, OTR

Jayne T. Shepherd, MS, OTR/LShelly J. Lane, PhD, OTR/L, ATP, FAOTA

ABSTRACT. Through The Rehabilitation Act, the Technology RelatedAssistance for Individuals with Disabilities Act (The Tech Act), the Indi-viduals with Disabilities Education Act (IDEA), and the Americans withDisabilities Act (ADA) of 1990, the federal government broadened thestates’ roles in increasing awareness and accessibility of assistive tech-nology (AT) devices and services to children with disabilities. As amember of the AT team, the occupational therapy practitioner plays anintegral role in selecting the most appropriate device, and working withparents and other professionals to integrate the device into a child’s dailyroutines. This literature review presents a summary of available informa-tion on AT materials and strategies that assist infants, toddlers, and

Selena Isabelle, S. Fiona Bessey, Kathryn Lawrence Dragas and Patricia Blease areemployed respectively by: Sheltering Arms Physical Rehabilitation Hospital, Chester-field County School System, Children’s Hospital of the King’s Daughters, and theMedical College of Virginia Hospital.

Jayne T. Shepherd and Shelly J. Lane are faculty of the Department of OccupationalTherapy, School of Allied Health Professions, Medical College of Virginia Campus,Virginia Commonwealth University in Richmond, VA.

This article is based on a full-length literature review, in partial fulfillment of the re-quirements for the Master of Science degree in Occupational Therapy at Virginia Com-monwealth University.

Occupational Therapy in Health Care, Vol. 16(4) 2002http://www.haworthpress.com/store/product.asp?sku=J003 2002 by The Haworth Press, Inc. All rights reserved.

10.1300/J003v16n04_03 29

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school-aged children with disabilities. We begin with a brief look at leg-islation affecting the provision of AT. Issues concerning the use of Elec-tronic Aides of Daily Living (EADL), and strategies for successfulmanipulation are presented; followed by a discussion of play and leisure,mobility, and communication devices. Finally, we conclude with a dis-cussion concerning the importance of measuring the effectiveness of ATdevices and services. [Article copies available for a fee from The HaworthDocument Delivery Service: 1-800-HAWORTH. E-mail address: <[email protected]> Website: <http://www.HaworthPress.com> © 2002 by TheHaworth Press, Inc. All rights reserved.]

KEYWORDS. Occupational therapist, assistive technology, school,early intervention, children, disabilities

Assistive technology (AT) enhances the development of infants, tod-dlers, and children with disabilities by providing them with a means toplay, communicate, move, and control their world. AT includes adap-tive, mechanical, computerized, and electrical tools, devices, and toysthat enable children to improve learning, mobility, communication, andpositioning within the home, school, and community environments(Attermeier, n.d.). The following excerpt, based on a comprehensive lit-erature review, emphasizes what we feel are critical concepts to under-standing the effectiveness of AT, and optimizing its usage with infantsand young children with disabilities.

OCCUPATIONAL THERAPY UNDERPINNINGS AND AT

“Occupational therapy is the art and science of helping people do theday-to-day activities that are important to them despite impairment, dis-ability, or handicap” (Neistadt & Crepeau, 1998, p. 5). Occupationaltherapy practitioners address a child’s engagement in meaningful andpurposeful occupations and activities. They focus specifically on per-formance areas (i.e., activities of daily living, work and productive ac-tivities, and play and leisure activities), and performance components(i.e., sensorimotor, cognitive integration, and psychosocial skills andpsychological components) of a task as they relate to children’s tempo-ral and environmental contexts (American Occupational Therapy Asso-ciation, 1998). As trained health professionals, occupational therapistsprovide AT devices and services to children with disabilities, enabling

30 OCCUPATIONAL THERAPY IN HEALTH CARE

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them to be more independent and to participate in activities in theirhome, school, and community environments. Federal legislation iscompatible with the focus of occupational therapy, and further estab-lishes the relevance of the occupational therapist’s involvement in pro-viding AT devices and services to children with disabilities in collabora-tion with the team.

THE LEGAL ASPECTS OF AT

Providing AT devices and services to young children with disabili-ties and their families is an integral part of early intervention (EI) andschool-based programs, and is governed by law. The Rehabilitation Actof 1973 was the first law to mandate that children with disabilities haveaccess to AT devices and services within EI and school programs. Sub-sequently, the Technology Related Assistance for Individuals with Dis-abilities Act (The Tech Act) of 1988 as amended in 1994 and 1998, andthe Individuals with Disabilities Education Act (IDEA) of 1990 and itsamendments of 1997, modified and broadened the role of the govern-ment in the provision of AT devices and services to children with dis-abilities. According to The Tech Act, an AT device is defined as “Anyitem, piece of equipment, or product system, whether acquired com-mercially off the shelf, modified, or customized, that is used to increase,maintain, or improve functional capabilities of individuals with disabil-ities.” Further, The Tech Act defines AT service as, “Any service thatdirectly assists an individual with a disability in the selection, acquisi-tion, or use of an AT device.” Additionally, the Americans with Disabil-ities Act (ADA) of 1990 gave civil rights protection to older childrenand adults with disabilities by guaranteeing equal opportunities and rea-sonable accommodations in employment, transportation, state and localgovernment services, and telecommunications. This legislation sup-ports the occupational therapist’s involvement in providing AT accom-modations to children of all ages with disabilities within the leastrestrictive environment. Table 1 summarizes the various laws that gov-ern the acquisition of AT devices and services and their significance.

THE TEAM AND IT’S APPLICATION OF AT

Through the use of AT, children with disabilities are given the meansto play, move, communicate, and control their world like other children

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their age (Attermeier, n.d.). More important than the technology are thestrategies, techniques, and implementation of services that accompanythe use of AT for children and their families (Armstrong & Jones,1994). According to Hutinger and Johanson’s (2000) findings from theEarly Childhood Comprehensive Technology System project, success-ful implementation of AT for children is reliant on the provision of anAT team. Without the leadership and support of an AT team, the bene-fits of technology are seldom fully explored, and children in need maynot have the opportunity to engage in the most effective educational ex-periences.

Swinth (1996, 2001) offers considerable guidance as to the make-upand function of AT teams. She states that the first and most important


TABLE 1. Summary of Legal Mandates Affecting Assistive Technology De-vices and Services

Year Title of Law Significance

1973 The Rehabilitation Act of 1973 All individuals have a civil right to accessfederally funded programs.

1988 Technology Related Assistance forIndividuals with Disabilities Act

Defined AT device and service. Providedfederal funding to states for thedevelopment of consumer responsiveinformation and training programsdesigned to meet the AT needs ofindividuals with disabilities.

1994/1998

Technology Related Assistance forIndividuals with Disabilities ActAmendments of 1994 and 1998

Acknowledged that individuals participatein many different types of activities in avariety of contexts, and highlighted thenecessary role and therapeutic benefit ofAT devices and services. Defined federalexpectations regarding a state’s ATprograms affecting consumer responsiveactivities, advocacy services, and systemschange.

1990 Individuals with DisabilitiesEducation Act

Identified AT devices and services includedin public education. Stipulated that ATdevices and services be detailed on theindividualized education program (IEP) ona case-by-case basis.

1997 Individuals with DisabilitiesEducation Act Amendments of 1997(1999)

Required that AT devices and services beconsidered for each child.

1990 Americans with Disabilities Act of1990

Intended to make American Society moreaccessible to people with disabilities byrequiring equal opportunity and reasonablepublic accommodations.

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step when determining the need for an assistive device is to form an ATteam. Potential members of an AT team include the child, the child’sfamily, teachers, teaching assistants, therapists, school nurses, rehabili-tation engineers, and social workers (Swinth, 1996). Prior to selecting adevice, the team evaluates what tasks the child needs to perform, andthen considers whether adaptations to the environment will sufficientlymeet the child’s needs. If the team determines that the child will benefitfrom an assistive device, they then consider when the device should beselected, and what kind of device is needed (Swinth, 2001). The SETTFramework is a popular guideline used to determine the most appropri-ate technology required for a given task together with the individualchild and context in mind (National Center to Improve Practice [NCIP],1998). Each member involved in the selection process helps to guaran-tee that the selected device will be appropriate within each environmentthe child encounters (Swinth, 1996).

The main question for the team is to determine what the child needsto do to perform their roles now and in the future. To facilitate the deci-sion-making process, a functional needs assessment is conducted toevaluate the child’s medical and physical functioning and identify theiractivities of daily living (Swinth, 1996, 2001). It is important to initiatethe assessment by talking with the family, caregivers, teachers, and oth-ers who interact with the child regularly. Sociocultural factors may af-fect the implementation and use of the device, and may include: Thefamily’s educational level and knowledge of the disability, emotionalreadiness, roles, the extent to which independence is important to thefamily, goals and expectations for using the device, and the family’s fi-nancial resources (Judge & Parette, 1998; Swinth, 1996). When select-ing a device, the team also considers the child’s physical and cognitiveabilities and limitations. Further, if the child is able to communicate, itis important that he or she is given the opportunity to express his or herneeds or preferences (Swinth, 1996, 2001).

Team members consider the context in which the technology isneeded by observing the child in all settings (e.g., indoor and outdoor)where he or she will be using the device. In addition to cognitive and so-cial capabilities, the child’s positioning, developmental needs, strengthand endurance, and functional features of the device also need to beevaluated before making a recommendation (Swinth, 1996). The teamconsiders specific adaptations and functional features of the device(e.g., ability to fit under the table during meals, ability to be easily trans-ported) that will improve its use in home and school activities (Swinth,1996; 2001). In addition, Judge and Lahm (1998) indicate that consider-

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ation must be given to the future needs of the child, and whether the de-vice can be adapted as the child grows and matures. Many informalassessments have been developed through the Wisconsin AssistiveTechnology Initiative (WATI). Interested readers are referred to theWATI Website (www.wati.org/). Thoughtful planning and careful analy-sis ensure that the child and family receive the best possible device.

After completing a functional needs assessment to determinewhether AT is needed, the team is ready to identify various AT devices,and select the device that will best meet the child’s needs. This processinvolves answering logistical questions such as: Who will change thebatteries in the device? How can the device be mounted (Armstrong &Jones, 1994; Swinth, 2001)? Once the child’s needs and abilities arematched with a particular device, the members of the team train thechild and other individuals who will assist with the use and care of thedevice. The use of AT during the evaluation process assists children,families, and service providers in choosing the best fit for the child. Thisprocess helps to ensure that the form of technology chosen will besomething that the child will use in their home, school, and communi-ties over a period of time (Armstrong & Jones, 1994).

Once the appropriate AT is chosen, team members are responsiblefor working with parents, teachers, and other professionals to integratethe device into the child’s daily routines (Judge & Parette, 1998).Finally, the device is continually evaluated for function and it’s abilityto meet the family’s goals and objectives (Swinth, 1996, 2001). Supportservices such as curriculum integration and maintenance, ensure thatthose working with the child are trained and competent at using the de-vice, and that modifications are made when necessary. Thus, it isthrough the combination of carefully selected technology, committedtraining, implementation by parents and professionals in appropriatesituations, and maintenance of a device, that AT teams ensure a child’ssuccess with the device is long-lived (Hutinger & Johanson, 2000).However, without the proper match of technology and service provi-sion, one can expect that there may be abandonment. Interested readersmay wish to examine Wehmeyer’s (1999) article “Assistive Technol-ogy and Students with Mental Retardation: Utilization and Barriers,”for more detailed information.

AT Application: Positioning. Both clinical reasoning and researchsupport the importance of AT for proper positioning of the child. In or-der to actively play, move, and communicate, children with physicaldisabilities may need assistance with positioning to access assistive de-vices and other objects in their environments. The role of the occupa-


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tional therapist in EI is to structure the environment to optimize playopportunities for the child (Missiuna & Pollock, 1991). Within theschool environment, emphasis is also placed on the occupational thera-pist’s skills in positioning and modifying the physical, cultural, and so-cial context of the classroom in order to give the child the opportunity tobenefit from instruction (Lowman, Simons, Shepherd, Fiocca, Ernouf, &Hundley, 1999). As a result of environmental considerations and equip-ment modifications, appropriate and functional positioning createsgreater opportunities for play, work, and learning.

Positioning may take on various forms throughout the day dependentupon the child’s age and tasks to be performed. Like their typically de-veloping peers who change positions frequently during play and schoolactivities, children with disabilities need the opportunity to change po-sitions many times throughout the day. For example, a child with a dis-ability may be positioned in a wheelchair for transportation to and fromschool and while on the playground. However, during a classroom ac-tivity, such as circle time, it is also important for a child with a disabilityto be included by being positioned on the floor with their peers. Whenpositioning a child with physical disabilities, external supports maymaintain head control, trunk control, and allow the child to use theirarms to access objects; thus facilitating the emergence of motor, cogni-tive, and perceptual skills (Lane & Mistrett, 1997).

When a child needs to learn a new task or use existing skills, a func-tional task ready position enables the child to use controlled movementsto access and participate in activities they enjoy (Kangas, 2000). Afunctional task ready position aligns the pelvis, spine, and head. A sta-ble pelvis enables movements to occur above and below the waist, andenables shoulder mobility. Combined, pelvic stability and shoulder mo-bility provide a foundation for head and upper extremity control(Kangas, 2000; Swinth, 2001). In a task ready position, the child’s headand shoulders are slightly in front of their pelvis and their feet are flat onthe floor and bearing weight (Kangas, 2000). This position enables thechild to reach and manipulate objects such as toys or writing utensils,and observe their hands and arms while playing or working. Childrenwith disabilities are able to participate more effectively in their educa-tional programs when seated upright in a functional position with theassistance of various positioning aids (e.g., wedge, round pillow, largetowel roll, Boppy, triwall insert, seatbelt, wheelchair, or other mobil-ity device) (Lane & Mistrett, 1997).

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Beyond these clinically based reports, there is some empirical sup-port for the importance of proper positioning. Seating for task perfor-mance has been shown to be essential throughout the school day whenstudents attend to blackboards, videos, other visual aids, feed them-selves or be fed at lunch, and participate in various classroom activities.In a study by Trefler and Hobson (1983), 10 children with cerebralpalsy (i.e., six boys and four girls), ages 13 and younger were providedwith specialized seating and positioning aids. When compared to base-line measurements, children fitted with custom seating systems madesignificant improvements in their ability to maintain head and trunkcontrol for the duration of the school day (e.g., an average of 7 hours). Inaddition, arm control, measured by recording the number of times chil-dren were able to hit a ball using a bat within one minute, was substan-tially improved when students played from their customized seatingsystems. These results demonstrate the powerful effect that specializedseating and positioning devices can have on the performance of chil-dren with physical disabilities.

In addition to task performance, the ability to maintain an upright andstable position also has important implications for socialization withothers. Hulme, Poor, Schulein, and Pezzino (1983) provided 41 chil-dren with multiple handicaps and developmental disabilities adaptedseating devices (e.g., wheelchairs, travel chairs, strollers) and assessedthe impact of correct positioning on behavioral changes. Caregivers re-ported a significant change in socialization when the seating device wasused for an average of 4 hours per day. Before receiving the equipment,children spent an average of 50 percent of their time during the day withsomeone else, as compared to 58 percent of their time after receivingthe device. The results of this study indicate that with adequate supportand stabilization, the ability to maintain an upright sitting position isimproved, thus increasing the frequency of socialization in childrenwith disabilities. However, based on these results, one can also assumethat if technology was inappropriate within the environment than so-cialization would not have increased. When provided with appropriatepositioning aids and supports, children with disabilities can not only sitlonger, therefore, spending more time attending to pre-academic or aca-demic tasks, but also interact more, and successfully manipulate objectsin their environments.

AT Application: Access. Environmental control for children with dis-abilities begins with switch access. Through switch use, children aregiven access to mobility, communication, and play both at home and atschool (Behrmann, Jones, & Wilds, 1989). When selecting a switch for


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a child with a disability, the following characteristics should be consid-ered: Force required to operate the device, portability, size, weight,safety, and the need for multiple switch access. Other considerations in-clude the amount of fine motor control needed to access the switch, fre-quency of use, safety, training required, optimal positioning, andaesthetics (Angelo, 1997a). When properly positioned, infants less than12 months of age, may benefit from manipulation of switches to controltoys and access objects in their environments (Angelo, 1997a; Sullivan &Lewis, 1993).

Appropriately, adapting an electrical device with a switch provideschildren with increased independence and control over their environ-ments (Angelo, 1997a; Behrmann, Jones, & Wilds, 1989; Sprigle &Lane, 1995). For children, toys adapted with switch interfaces provide ameans to learn about cause and effect, time, space, direction, engage inindependent play, and participate in group activities (Angelo, 1997a).Adapted input devices, integrated with educational computer software,enable children to learn and explore concepts of shape, color, number,object identification, event sequencing, words, phrases, and sentences(Wershing & Symington, 1998). For example, Swinth, Anson, andDeitz (1993) studied computer access with 40 boys and 40 girls withoutdisabilities between the ages of 6 and 18 months. Based on age, childrenwere grouped into categories in three-month intervals. In this study,children had to press and release a switch to play music using computersoftware. The results indicated that children as young as six monthscould manipulate a switch to control a simple cause-and-effect computerprogram. Although this study focused on typically developing children,it has potential implications for children with disabilities in EI and schoolprograms. Like their typically developing peers, an environment equippedwith multiple switches enables children with disabilities to exploremany stimuli and develop individual preferences.

A wide range of computer software is currently available to facilitateaccess by children with disabilities, in conjunction with the use ofswitches to control single objects (e.g., toys, radios, blenders, lights), aswell as scanning programs to assist with choice making (Behrmann,Jones, & Wilds, 1989; Judge & Lahm, 1998). Through the use of switchesand other input devices, children with disabilities are able to demon-strate their competency and understanding of age appropriate activitiesand educational instruction. These same switches are precursors to us-ing more complex Electronic Aids of Daily Living (EADL) to operatetelevisions, radios, lights, telephones, emergency systems, and other elec-tronic devices. Enabling a child to control aspects of their environments

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advances their knowledge of the world and their role in it (Behrmann,Jones, & Wilds, 1989; Wershing & Symington, 1998). Thus, when oc-cupational therapist’s use switches and other input methods with chil-dren with disabilities, they may observe many gains.

AT AND OCCUPATIONAL PERFORMANCE

When children with disabilities use appropriately selected AT de-vices, proper positioning, and EADLs, they have increased access to theworld around them. They are able to communicate with others, play,move, and explore like their typically developing peers. Their ability tobe active participants in these activities of daily living is crucial to theircognitive, physical, social, and psychological development. This devel-opment, facilitated by AT devices, gives children with disabilities astrong foundation to participate successfully in their educational envi-ronments.

Play and Leisure. Central to the field of the occupational therapist isan emphasis on productive activities. Two primary productive activitiesof children are play and leisure. All children need time and space to playin order to develop and practice the social, cognitive, and physical skillsneeded to be active participants in the role of student (Takata, 1969).These play and learning experiences are as critical for the healthy devel-opment of children with disabilities as they are for their peers withoutdisabilities. However, due to barriers created by the nature of their dis-ability, infants and toddlers with special needs are often deprived of ex-periences that support successful development of play skills (Takata,1969). It is, therefore, important to provide methods through whichchildren with disabilities can develop, learn, have fun, and experiencesuccess in play, in ways similar to their typically developing peers(Swinth, 1996).

As previously discussed, early learning through switch use and bat-tery operated toys facilitates the development of skills such as objectpermanence and cause-and-effect. Further, by adapting age appropriatetoys with switches, children with disabilities are provided with the op-portunity for integrated play with their siblings and peers, thus facilitat-ing the development of social skills (Locke & Levin, 1998). Whenchoosing toys for children with disabilities, important characteristics tobe considered include method of activation, capacity for adjustment,potential for self-expression and interaction, multi-sensory appeal, cur-rent popularity, safety and durability, and opportunities for success


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(KidSource OnLine, 1997; Langley, 1985; Let’s Play! Project, 1999).The wide range of toys and devices now available can augment existingplay skills, compensate for limitations, and reveal and enhance the learn-ing capabilities of children with disabilities (Lane & Mistrett, 1996;Swinth, 1996).

Adapting toys for children with disabilities is an effective way to pro-vide novel options for play and leisure activities. Moreover, the need tohave a variety of accessible toys in order to maintain a stimulating andfun play environment has been documented using case study methodol-ogy. Working with a five-year-old girl with spastic tetraplegia, corticalblindness, and moderate bilateral hearing loss, Facon and Darge (1996)demonstrated that providing this child with a variety of toys resulted inan increased switch press response rate, and prevented satiation duringa single intervention session. Additionally, these same investigatorsfound that the provision of a variety of toys across several sessions pre-vented a decrease in switch press frequency in a 13-year-old boy withspastic quadriplegia and profound mental retardation. The results ofthese studies support the importance of varying toys for children with dis-abilities to sustain their interest and active engagement in play activities.

Through the use of AT, children with disabilities are able to accesstoys and play objects, increasing their opportunities to engage in playand leisure activities in their home, school, and community environ-ments. This helps to develop a child’s sense of self-confidence, prob-lem-solving skills, and promotes independent thinking (Alessandrini,1949). These skills build the foundation for children to successfully par-ticipate in the role of student.

Mobility. Locomotion and other motor skills, typically developingthroughout the first three years of life, enable infants and young chil-dren to explore and interact with their environments (Judge & Lahm,1998). With each mobility milestone, children build upon their knowl-edge of their environments, and begin to understand concepts such asdirection, space, and body scheme (Case-Smith, 2000). However, forchildren with physical disabilities, inhibited mobility reduces their op-portunity to explore and interact with their environments (Swinth,1996). Without exploration, children are denied important experiencesthat will influence subsequent development (Neeley & Neeley, 1993).For these reasons, AT is necessary to make mobility possible for chil-dren with disabilities (Judge & Lahm, 1998).

A number of devices, both high and low technology, have become in-creasingly available to help children move about their home and schoolenvironments independently. Typically, low technology devices are

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less expensive, more easily accessible, and are often tried before using ahigh technology AT device. Comparatively, high technology deviceshave greater complexity, involve multiple components, are usually op-erated electronically, and require training (Mistrett & Lane, 1995). Ulti-mately, the choice of a device depends on the family’s goals, needs,preferences, and the abilities of the child (Lane & Mistrett, 1996;Sullivan and Lewis, 1993).

Research using AT with infants and young children has primarily fo-cused on the effects of high technology with young children with dis-abilities (Judge & Lahm, 1998). Research has shown positive effects ofpowered mobility with children who use these devices. In a study byButler, Okamoto, and McKay (1983) nine children with various disabil-ities, between 20 and 39 months of age, were taught to drive poweredwheelchairs at home under parental supervision. Eight of the nine chil-dren became independently mobile; repeated illnesses limited the re-maining child’s opportunity to learn. However, their parents reportedthat independent mobility had increased their children’s interest inother styles of movement (e.g., riding a rocking horse), and in activitiesthat involved movement within their wheelchairs (e.g., hiking, playingbaseball). In addition, six children, between the ages of 23 and 38months, with severe disabilities, participated in a study by Butler (1986)designed to assess the effects of independent mobility on self-initiatedspatial exploration, interaction with objects, and communication withcaregivers. Three children showed increases in all three behaviors; onechild increased in self-initiation and communication; and two had in-creases in spatial exploration only. This research is further supported bymore recent findings in which Deitz, Swinth, and White (2002) observean increase in the number of self-initiated movements, and initiation ofcontact with others, in two five-year-old children with developmentaldelays when using a powered mobility riding toy during free play. Thus,it appears that early independent mobility experiences are linked to thedevelopment of certain cognitive and psychosocial skills, and an in-crease in overall activity level.

Since early provision of mobility experiences can positively impact achild’s cognitive and psychosocial development, it seems only naturalthat young children be offered the means to independent mobility.However, it may be difficult to determine when a child is cognitivelyready to operate a powered device safely. In a study by Tefft, Guerette,and Furumasu (1999), 26 children (i.e., 20 males and 6 females) withphysical disabilities, between 20 and 36 months of age, were evaluatedusing a cognitive assessment battery to determine what skills predicted


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powered wheelchair performance. Cause and effect and object perma-nence were found to be highly important skills necessary for successfulpowered mobility operation, and the majority of children who becamesuccessful functional drivers demonstrated high scores in these areas. Inaddition, cognitive problem solving and spatial relations mastery werealso good predictors of successful functional mobility. This study estab-lished the need for the development of certain cognitive skills to enablefunctional operation of a powered wheelchair, and suggested that earlyassessment of a child’s cognitive abilities can be used to aid therapistsin determining whether the child is capable of safe and independentpowered mobility. However, with sufficient cognitive ability, Deitz,Swinth, and White (2002) suggest that early powered mobility experi-ences assist in facilitating a transition to other adapted movement de-vices and wheelchair use in school-aged children.

In an educational setting, numerous high and low technology devicesare available to school-aged children to compensate for a variety ofmovement difficulties. The types of assistive devices used in the class-room to help children with these difficulties include positioning equip-ment and mobility devices, such as mobile standers, prone scooters,walkers, and wheelchairs (Shuster, 1992). Examining 53 students withspinal cord injury induced motor disabilities, Dudgeon, Massagli, andRoss (1996) found that 29 students used manual wheelchairs, while 17reported using power chairs, and 7 students used walking aids such ascrutches and braces at school. Devices such as powered wheelchairsbenefit students not only for mobility, but also for improved positioning,which enhances visual pursuit, and manual dexterity within the class-room; thus providing secondary educational benefits (Shuster, 1992).These devices also enable mobility to other locations within the school,increasing opportunities for communication and reducing the time ittakes for some students to get from class to class, therefore, maximizingthe amount of time they are engaged in instruction. Ultimately, mobilitydevices enable students to participate in classroom tasks with less ef-fort, thus improving their educational performance within the schoolenvironment and occupational performance in the role of student.

Communication. In addition to mobility needs, AT is used to increasethe expressive and written communication abilities of children with dis-abilities, thus enhancing participation in home life or an educationalprogram. AT facilitates communication through the use of assistive andaugmentative communication (AAC) devices, which enable children tocommunicate expressively. Further, written communication is en-hanced through computer software and hardware that facilitates the

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child’s success for completing assignments, both at home and at school.As with other types of AT, early provision of AAC devices for childrenwith communication delays can promote cognitive development andsocial interaction, thus preparing the child for later participation in anacademic setting (Van Tatenhove, 1987). Through the use of technol-ogy for both expressive and written communication processes, childrencan interact with, learn from, and grow in the many contexts in whichthey communicate.

AACs, such as adapted keyboards, communication boards, eye gazeboards, vocal output devices, and computers, are devices that enrich thecommunication abilities of a child. In choosing the most appropriateAAC device, the occupational therapist’s assists in deciding on a vari-ety of communication techniques, including access methods for foster-ing effective communication. Accessibility is paramount to the designof an AAC, as it forms the basis for the child’s ability to use a particulardevice (Angelo, 1997b). Gaining an understanding of a child’s learningstyle, participation in activities and routines, home and school environ-ments, and supports in a child’s life are all additional issues to consider whendetermining appropriateness of AAC devices (Doster & Politano, 1996).

The goals of AAC use focus primarily on enabling the child to inter-act socially in a variety of community and academic settings (VanTatenhove, 1987). In a study designed to investigate whether com-puter-based activities foster social interaction, Howard, Greyrose,Kehr, Espinosa, and Beckwith (1996) examined changes in social playbehaviors, communication, and affect of children engaged in computerand non-computer play activities. The investigators studied 22 childrenwith developmental disabilities between 18 and 60 months of age whoused microcomputers within their school’s daily curriculum. Interac-tions involving these children were compared to a control group of 15children who were not exposed to microcomputers. The authors con-cluded that children exposed to microcomputers in the classroom dem-onstrated more social and positive interactions with peers, as assessedthrough observation of behavior in five categories: social interaction,social play behaviors, social pretend play, vocalizations, and affect.Earlier work with microcomputers by Spiegel-McGill, Zippiroli, andMistrett (1989) also suggested that integrating computers into pre-school settings facilitated social interaction between children with dis-abilities and their typically developing peers. Further, research byHutinger (1996) supports the effectiveness of computer technology inimproving social interaction and communication skills within a class-room environment.


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Although the goals of AAC use focus primarily on social interactionbetween the child and their caregivers, teachers, and peers, a currenttrend in the literature is using AACs as tools that facilitate language andliteracy, rather than merely social interaction. Musselwhite (1996) dis-cussed the merging of communication and the ways in which AACs canbe used to facilitate language and literacy. She proposed an active, cre-ative, and fun approach centered around the theme of a storybook to as-sist students in sharing and communicating. This approach, used inconjunction with requests for page turning and other interactive compo-nents, enhances the child’s ability to learn. Additionally, Wershing andSymington (1998) identified ways in which emerging literacy can beencouraged: (a) offering children opportunities to experience concep-tual information; (b) helping children understand that they can use pic-tures and words to communicate; (c) helping children understand thatpictures have meaning; (d) telling stories; (e) helping children un-derstand that words have meaning and can be used to tell stories; and(f) helping children create their own stories using words and pictures.

In addition to AT aiding children in expressive communication, con-ventional computers, and organizational and specialized math softwarefacilitate children’s ability to complete note taking, projects, assign-ments, and research (Anderson-Inman & Knox-Quinn, 1998). Further,word prediction and speech synthesis are ways in which technology canassist students with disabilities. These programs convert text intospeech, enabling students to read without asking for help, as well as pro-viding a combination of auditory and visual components for learning.An additional benefit is recognition of spelling errors, which may other-wise have been missed without speech output to supplement reading(MacArthur, 1998). Middle-school students with learning disabilitieshave benefited from computer-based study strategies such as these de-veloped by the Center for Electronic Studying at the University of Ore-gon. After learning the computer-based strategies, children were moresuccessful in school and pursued vocations that would have been diffi-cult to attain without improved academic success (Anderson-Inman &Knox-Quinn, 1998). Thus, technology also has an important place in fa-cilitating written communication.

OUTCOMES RESEARCH

Whether AT is used at home, school, or in the community, the effectsare far reaching and have the potential to yield benefits and carryover to

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other environments. This generalization is critical, as children’s dailylives are intertwined within these contexts. Research regarding the spe-cific aspects of environmental contexts is necessary to determine the ef-fectiveness of children’s AT use within their home, school, and commu-nity environments.

Outcomes are the clinical end-results of patient care for individuals,families, and communities (Polit & Hungler, 1999). In measuring spe-cific outcomes, occupational therapist’s document the value of servicedelivery, and justify the need for devices and services in terms of im-proved patient care and cost (Abreu, 2000; Minkel, 1996; Ottenbacher &Cusick, 1990; Polit & Hungler, 1999). Outcomes measurement alsoprovides manufacturers and third-party payers with information con-cerning the difficulties and successes associated with AT device use,documentation about device durability, longevity, and insight into dis-continuation and replacement (Kohn, LeBlanc, & Mortola, 1994).Thus, outcomes research becomes essential to identifying the greatestbenefits of AT, and cost-effective ways of providing services.

Outcomes measurement with children offers a unique set of chal-lenges. Children grow, mature, and develop quickly, and as they do,their needs for assistive devices and services change. They may physi-cally outgrow their AT device, or surpass it developmentally. Anothercomplicating factor is that a child’s disability status may be emerging,leading to the suggestion that outcomes measurement with this popula-tion is “like trying to hit a moving target” (Smith, 1996, p. 76). Thus,within the realm of AT, there are few empirical studies documenting theimpact of AT on children.

Some of the information presented thus far falls under the rubric ofempirically based outcomes research, but much of it does not. Few in-struments exist that measure the impact of AT on quality of life and thedevelopment of life skills. Various outcomes studies examining the useof AT with children have been presented earlier in this review, inte-grated within other sections. Others are presented in Table 2. What isavailable indicates that AT as an intervention can be effective in chang-ing the lives of infants, children, and their families.

Much needs to be done in this area. The scarcity of well-designedoutcomes studies is likely in part related to the scarcity of well-validatedoutcomes tools. In the absence of well-validated outcomes tools forchildren, other documentation methods must be sought. One suchmethod receiving current support is goal attainment scaling (GAS).GAS is a method for measuring the impact of interventions, and evalu-ating clinical changes in individuals (Ottenbacher & Cusick, 1993;


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mos

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sw

ere

whe

elch

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(n=

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s(n

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and

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eats

(n=

36).

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ironm

enta

lcon

trol

and

inde

pend

-en

tliv

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=53

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ting

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(n=

12).

The

barr

ier

toA

Tus

em

osto

ften

men

tione

dw

asco

st,a

sm

osto

fthe

fund

ing

sour

ces

used

topu

rcha

seA

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vice

s,w

ere

pers

onal

fund

s.La

ckof

info

rma-

tion

was

also

aba

rrie

r.

46

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Ottenbacher & Cusick, 1990). Using GAS, an individual’s goals are de-veloped through team collaboration. Subsequently, behaviors are de-fined, demonstrating emerging goal attainment and progress. BecauseGAS uses individually developed goals, it lends itself well to applica-tion with Individual Family Service Plans (IFSPs) and IEP goals.

Methods of documentation such as GAS, enable occupational thera-pist’s to recommend devices, and implement services that are most ap-propriate for the children they serve. It is incumbent upon occupationaltherapists, as providers of AT devices and services, and users of thispowerful intervention tool, to get serious about the development andimplementation of well-designed AT outcomes studies with children.Without these, occupational therapists run the risk of losing their fund-ing for AT.

SUMMARY

In sum, through legislation affecting AT devices and services, thefederal government broadened the states’ roles in increasing awarenessand accessibility of AT to children with disabilities. This literature re-view has presented both clinical reasoning and empirical research, indi-cating the importance of AT devices and services to a child’s ability tomaster various skills, move, communicate, and engage in exploration oftheir environments. Consequently, it is evident that AT has becomemore readily available in EI programs and schools. However, further re-search is necessary concerning the types and extent of technology usedwith children in EI and school-based practice, how it is being used, howintegral it is to the development of a child with disabilities, and how ef-fective it appears to be. Now is the time for such research to take place.

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