Pediatrics Series

I Can Push Myself

We Cheer the Benefits of Independent Mobility for Young Children. But Does Dependent Mobility Get a Bad Rap?

Independent Mobility for Young ChildrenMobility milestones — from rolling over to crawling to pulling to a stand and walking — are among the most anticipated accomplishments of a young child’s life, in part because they accelerate the child’s ability to explore, learn and make their first moves toward independence.

Those potential benefits are no different for a child who uses assistive technology.

“Mobility is a natural human desire,” says Amy Bjornson, PT, ATP, Sunrise Medical Australia. “It also drives human development, including neuronal, motoric and social development.”

While adults tend to think of personal mobility in practical terms of transportation, Tina Roesler, MSPT, ABDA, director of sales & education for TiLite, says, “Mobility is about more than getting from point A to point B. At a young age, it is actually more about development of the sensory and motor systems and exploration.”

Independent mobility — the ability to decide for ourselves where we want to go, what we want to see and touch and explore, rather than having caregivers make those decisions — is especially prized by child development experts.

“The ability to be independent in your mobility is a critical element of growth and development for children,” says Tom Whelan, VP of product development, KiMobility. “Think about a baby learning to crawl and walk to access their environment. They are programmed to move themselves around. They are driven to vestibular stimulation for developmental purposes.”

“If children aren’t able to be independently mobile, they will fall behind developmentally,” Roesler says. But she adds, “Because our systems are so plastic at a young age, we may also give older kids the ability to ‘catch up’ once they are able to experience mobility.”

Fortunately, the evolution of pediatric mobility has yielded seating systems and wheelchairs that aren’t merely scaled-down versions of what adults use, but systems specially designed for the needs and adventures of childhood.

“Ultralightweight mobility technology provides the best opportunity for independent mobility for these children,” Whelan says. “The influx of rigid-frame ultralightweight wheelchairs optimized for pediatrics, especially for early intervention, increases the number of children that can have independent propulsion in a manual wheelchair.”

“It is imperative that children get every opportunity for independent mobility,” Bjornson agrees. “This can only happen in a chair that is configured and designed for a small child.”

The Role of Dependent Pediatric Mobility

Also on the assistive technology spectrum for infants and very young children is dependent mobility — wheelchairs that are propelled by a parent or caregiver, and that usually offer highly specialized postural components to support the child in a functional position.

For infants and toddlers, these chairs oft en resemble baby strollers, not only in basic design, but also in accessories and amenities, such as canopies and under-chair storage space. In fact, the stroller-type seating & mobility chairs introduced in recent years have been so attractive in design and function — for the children as well as Mom and Dad — that they’re getting harder and harder to tell apart from regular baby strollers at first glance.

That’s intentional, seating manufacturers say.

“Aesthetics have played a role for many years now and are continuing to become more important to consumers and caregivers,” says Mark Sullivan, product development manager, Convaid. “I’m not sure there has ever been a study, but historically the industry has always maintained that in many cases, the parents were not ready to accept their child needed a wheelchair, so they turned to a ‘strollerstyle’
mobility device.”

Sharon Sutherland, PT, Seating Solutions LLC and a consultant for Ottobock, says of the importance of aesthetics, “For parents and all family members, it is extremely important that the equipment being used to carry/position their precious and beautiful baby fits in — and therefore does not call attention to any differences — with mainstream equipment similar to that used for their other children as well as all other friends’ and family equipment being used for their children. It’s as simple as that, and a fact that I believe is very, very important for us to respect.”

At the same time, Sally Mallory, PT, ATP, Convaid, says it’s important that industry professionals, funding sources and consumers understand the many critical differences between consumer strollers and the highly specialized positioning wheelchairs that increasingly look like them.

Asked about current trends in these types of chairs, Mallory says, “The first trend is to try to not use the word stroller at all, as people tend to confuse that word [as meaning] something not durable or adaptable. In regards to positioning and functionality, we are seeing more features become incorporated into the designs, like tilt, recline, growth and more options like vent trays.”

Mallory adds, “The lines are beginning to blur between what people viewed as strollers versus a traditional wheelchair. Many years ago, wheelchairs started adopting stroller features like 12" rear wheels and stroller handles to make them more appealing to parents. Conversely, strollers started adding features as mentioned above.

“It is important to point out also that strollerstyle wheelchairs are also segmented like most products are. Some stroller-style chairs can be fairly basic and used for short-term use or as a back-up chair. The lines are becoming blurry as you move up into the variable positioning dependent mobility products. In the past they have also lacked growth capability, but that has changed. Now there are also dependent mobility stroller-style chairs that have the features outlined above. Using one term like ‘stroller style’ is no longer fitting.”

When Is Dependent Mobility a Good Option?

Pediatric mobility offers many independent choices these days, from infant-sized seating and infant-sized seat widths/depths on ultralightweight chairs, to kid-centric power wheelchairs with an array of alternative drive controls for children who are more efficient with switches than traditional joysticks.

All those options can seemingly push dependent mobility into the background. But Sutherland points out that for a certain time in their lives, dependent mobility for children of all abilities is routine.

“Firstly when thinking about ‘stroller-style’ mobility, one really has to consider the age of the child we are referencing,” she says. “For example, a child between birth to age 2 to 3 who is following the more ‘normal’ developmental milestones may utilize a stroller full time from 0-9 months, for example, until they begin to walk, and then parttime depending upon various factors such as fatigue, distance and safety, to name a few. It is less typical to see a child who is developing normally use a strollertype device for extended periods once they approach the age for preschool or school.”

Roesler looks to the expected timeline for a typically developing child, while also keeping in mind that child’s limitations: “If a child is at an age where they usually try mobility — independent mobility usually starts around 7 to 12 months, normally — we need to give them opportunities. Our expectations are going to vary based on age and motor development. While a 2-year-old may be able to propel short distances and interact with peers, we should not expect them to be independently mobile all day. We wouldn’t expect this from a child who was walking.”

At the same time, Shimono says she’s experienced cases in which parents prefer the child to use a dependent type of chair even if he or she is capable of operating a chair independently.

“Absolutely, this happens every day!” she says. “Parents want their babies to be their babies. While using a ‘stroller,’ they may feel like nothing is different, but when the word ‘wheelchair’ is mentioned, it starts that overwhelming feeling again — wondering if people will look at their child differently or treat them differently. They tend to want to keep the ‘stroller’ as long as possible.”

Shimono says she understands those feelings — “To me, this is as normal as not wanting my child to grow up too fast” — but adds, “It’s important to recognize if choosing to stay with a stroller or dependent mobility product is keeping the child from that next level of development or from accessing their environment. This can be a tough step for parents, but once they choose an independent mobility product, they are often happy to see their child’s new development, independence and access.”

“Many parents hesitate to move to independent wheeled mobility because they see it as ‘more disabled’ or they are afraid their children will no longer work on ambulation,” Roesler suggests. “It is important to emphasize to parents that mobility, in and of itself, is critical to overall development. Children can continue to work on multiple mobility skills — for example, ambulation and wheeled mobility — at the same time.”

Can Independent & Dependent Mobility Co-Exist in a Home?

Is there room — or reason — for a family to use both dependent and independent mobility systems for their special needs child?

“With kids, there really is a need for various modes of mobility,” Roesler says. “No very young child has the muscle strength or attention span to be independent with mobility all day.”

Though Roesler points out that the few studies done to date on manual wheelchair propulsion among young children “do not indicate that upper-extremity dysfunction is a significant problem with this population,” she adds that propulsion is something that little ones have to learn.

“They will not push like an adult,” Roesler says. “Most children will not extend to reach the wheel and will spend most of the time on the front third or so of the tire. As they mature, propulsion patterns and skills will also change with experience and development of muscle strength and coordination.”

Until that happens, very young children won’t be independently mobile for long periods, and “it is important that parents have some way to assist the child in these situations. The answer usually isn’t dependent vs. independent devices. A power chair or manual chair can be fitted with attendant controls or stroller handles that can be used by caretakers when needed. Many times, parents may have a dependent device as a backup in case a mobility system is not functioning properly.”

Another reason families may want two different systems: Transportability.

“In the case of powered mobility, the complexities involved in transporting the system may limit the child’s ability to be included in family life and certain social activities unless there is access to a second, more convenient mobility system,” Whelan says. “This can also be true when the child interacts with families that are not set up to accommodate powered mobility — e.g., sleep-overs — in order to provide a relief for the child. There is also the consideration of access to school, vehicles, and homes of friends/family, etc., that would require a second device set up for ease of transport to help facilitate participation and involvement in tasks and social functions.”

In addition to the potential convenience factor, having more than one type of mobility equipment can maximize the time that the child is properly positioned, Sutherland notes.

“It is often necessary for the family to have a stroller-type dependent mobility base as well as the primary mobility base that is operated independently by the child. Often the family will not be able to transport the equipment plus the child plus other siblings and their baby/kid equipment, so for convenience and safety and to ensure the child is correctly positioned at all times, the backup equipment is necessary.

“Sometimes it may be necessary if the home is not fully accessible. Then, the reality is that one piece of equipment stays with the kid for school and all activities where the equipment can go — but there may be a room or two in the house where the mobility base that provides independent mobility cannot go. The child will still need positioning, so a dependent mobility base may be essential for those situations.”

Sutherland says a detachable seating system may be a good answer for those families. “I try to recommend that the family consider a seating system that will interface with several bases — for example, one seating system will interface with a stroller-type dependent mobility system, or with a tilt-in-space dependent mobility system as well as with a high-low base for the home, as well as with a power base for independence when those milestones have been achieved. In essence, they could have one seating system that would interface with three bases, all of which could be essential for that child.”

Appreciating the Benefits of Each Mobility Type

While independent mobility may get more headlines than dependent mobility when it comes to child development, these pediatric mobility experts recognize how complex a child’s mobility needs may be, and they appreciated the role that each mobility type plays in helping a child to grow and a family to stay active.

“Clinically, a mobility device should always be seen as an adjunct to the child’s therapy goals,” Mallory says. “If the child is capable of independent self propulsion, whether manual or power, independent mobility should be considered as a therapy goal. As the child works toward achieving this goal of safe and independent mobility, a dependent device may be used until they are able to be independent in all settings throughout the day.”

Sutherland says, “Dependent mobility when age and ability appropriate is absolutely the best and only first choice. In situations where dependent mobility is selected when there is apparent potential for a child to exhibit age-appropriate locomotion, for example, and when this opportunity for moving through space is not explored, I believe this could be an unfortunate oversight for that child. A dependent mobility base may be a first choice when the child cannot manage any independent movement with assistance from any technology in sitting or standing — but the seating system set up within the base may give access to reach, exploration of their world through hands and eyes, for example. So even if the dependent mobility base is the first-choice solution, it can be very disadvantageous to not have the seating system appropriately fitted to that individual child. The seating that is provided in the dependent mobility system is critical for optimal function, tone management, respiratory function, visual field and postural support and alignment, to name a few.”

“Often there are compromises made between desired postural support and optimum position for self-propelling,” Whelan says. “As the child adapts to the chair, they may not be able to sit in the chair for long periods of time. So a second mobility device optimized for support and the need for change of postures may be necessary.”

Ultimately, the answer — dependent, independent or both — is as individual as the child it serves.

“Many complex products need a back-up product,” Shimono says. “Each situation is different, but I often see one product getting someone where another couldn’t. Every family and child is different, and the team has to look at all the different aspects of this case in order to determine what is best.”

This article originally appeared in the April 2014 issue of Mobility Management.

In Support of Upper-Extremity Positioning