Individuals presenting a variety of models and theories, including the systems, dynamical action, and task-oriented and ecological theories, have proposed that the environment acts as a mediator of movement expression. 1–10 Fischer 11 explains that minor alterations in the environment will change the skill being executed. The result becomes a new and unique movement, rather than slight variation of a movement. 12 For example, a child learning to pull-to-stand may demonstrate this movement successfully while using a sofa for assistance because it offers a supportive edge that is compatible to the child’s current morphological parameters. The same child may not be able to accomplish this action if presented with different environmental conditions, such as a taller coffee table without a supportive edge. Although the task is the same in both situations, environmental conditions are facilitatory in one situation while prohibitive in the other.
Environmental resources may be viewed as both opportunities for movement as well as constraints on behavior, dependant upon the environmental context for movement expression. 6,13 In the example previously discussed, the taller coffee table did not afford the child the means to pull-to-stand. The child consequently may consider other options afforded by the environment including crawling to a lower object (eg, sofa) that offers the opportunity or affordance to complete the task successfully.
The concept of affordance recognizes a direct relationship between motor behavior and the environment. Affordance is defined as a unique relationship between the potential actions of an animal and some aspect of its environment such as a place, object, or event. 14 Haley et al 16 explain affordance, in terms of clinical significance, suggesting that the human organism is designed to meet the challenges and tasks posed by the typical human environment. Therefore, the concept of environmental affordance suggests that movement is a direct response to environmental challenges. 1,6,12–19 In a study by Adolph et al 17,18 that explored the response of toddlers and infants to inclined surfaces, it was found that toddlers deliberately shifted from walking independently to more stable climbing and sliding positions before descending sloped surfaces. These results were considered evidence that toddlers actively perceive affordances. This example further supports the idea that children are active participants in their environments rather than passive organisms that are acted upon. 1,2,13,14,20
Given the importance of the relationship between the environment and motor behavior, pediatric physical therapists have an increasing responsibility to maximize the potential of the environment in both pediatric assessment and subsequent treatment of children. The literature suggests that if movement is highlighted for its own sake, without consideration of the context in which it will take place, then functionality is minimized and potentially ignored. 1,3,4 It has been proposed that children are presented with simple, contrived tasks as part of a functional assessment, rather than real-life tasks that would offer more valuable and accurate information. 1–4,15 In a study by van der Weel et al 21, it was found that children with neurological involvement performed better when presented with functional, concrete tasks. Children with cerebral palsy demonstrated greater forearm pronation when asked to bang on a drum than with the move-as-far-as-you-can abstract, pronation task. The authors proposed that concrete tasks, such as banging on a drum, offer greater visual, auditory, and tactile feedback.
Evaluation of a child’s choice of activities also adds valuable information to an assessment. Easley 19 ,p.64, in establishing the relationship between assessment and environment, suggested that “therapists could more accurately assess a child’s developmental strengths, not only by assessing functional activities, but through assessing the child’s choices and responses to extrinsic demands.” For example, if a child refuses to step on a balance beam, crawl through an expandable tunnel, or avoids loud noises during play, an impairment or disability related to sensory processing may be indicated.
Standardized tests are common in the assessment of the pediatric client. Although these tests provide the evaluator with vital information regarding the child’s performance in a standardized and measurable manner, they rarely highlight information about the child’s preferences, learning style, temperament, or social interaction skills. 22 In an effort to achieve the maximum outcome from standardized tests, children often are placed in controlled environments with minimal distractions. Furthermore, additional play items that may detract from the test are minimized because of potential interference with the standard process.
Although following standardized procedures is important, play and discovery also have been established as being vital in promoting a child’s best performance. 23–26 In a study by Field 25 of 200 children between one and five years of age, it was found that both the waiting room environment and the examination sequence influenced the behavior scores given to them by the examiners. It was concluded that children provided with toys, as well as those whose developmental test preceded their physical examination, received higher behavior ratings.
According to Linder 22, traditional examinations do not always provide an accurate representation of the child for reasons that include: unnatural environment, unfamiliar examiner, lack of identifying the child’s learning style and skill diversity, and lack of functional items. Conclusions based solely on results from standardized tests conducted under restrictive conditions may be inaccurate. 22 Consequently, the ideal intervention may not be prescribed for the child. The Bobaths 27,28 suggest that motor milestones presented in standardized tests, are useful in uncovering “abnormalities,” but should not be used exclusively to plan treatment programs. Standardized tests of milestones are not representative of normal development, in which motor activities are developed simultaneously to culminate in the expression of a motor milestone. 28–30
Observation of the child’s behavior in a stimulating environment that encourages exploration and play can complement standardized findings. The evaluator is provided with a more complete picture of the diversity of the child’s skills. Identifying activities that motivate a child becomes essential to the creation of a successful intervention process. Thelen et al 9 define motivation as the infant or child’s ability to recognize a task and desire to move toward a goal. According to this definition, emphasis should be placed equally on the movement and its consequences to provide motivation for additional movement expression and exploration. 1,2,12
All aspects of the environment should be considered when recognizing the role of the environment in movement expression. In addition to consideration of the physical environment, those involved with the child, including the parents, therapists, and other children, should be noted as well. 28 Together, all of these factors comprise the child’s environment. This holistic approach facilitates a family-centered, transdisciplinary assessment and intervention, culminating in greater goal achievement. 30
In an effort to explore the affect of a dynamic environment on the assessment process and subsequent individualized goal development, an interactive assessment room (IAR) was developed for the transdisciplinary assessment of children with developmental delays. A transdisciplinary assessment is one in which all team members observe the child simultaneously while a facilitator conducts the assessment. 31 In this approach, professionals from different disciplines may assess the child, but each is knowledgeable about the other disciplines and, therefore, tailor the assessment to fit the transdisciplinary team’s needs. 22
The creation of the IAR was in direct response to an assessment team’s need for a stimulating environment in which to conduct transdisciplinary pediatric examinations. The development of an IAR offered the opportunity for the exploration of a creative assessment environment that incorporated practice-based application of current theories and research. The room encouraged the completion of activities necessary for transdisciplinary, comprehensive assessment of the pediatric client, including both the examination of developmental milestones and functional activities targeted by standardized measurement tools.
From inception, six key points were identified as integral to designing the IAR and should be considered when attempting to reproduce and customize this project in other settings. These key points included the: 1) selection of a central theme; 2) creation of a versatile, multipurpose space; 3) provision of multisensory experiences; 4) maximization of environmental affordances; 5) provision of effective motivators and opportunities for goal attainment; and 6) facilitation of a transdisciplinary assessment.
Selection of a Central Theme
A farm theme was selected based on its potential for providing multisensory experiences, goal-oriented tasks, transdisciplinary assessment opportunities and its motivational impact on the children. Choosing an appropriate theme also introduced a cultural dimension to the project. For a child to identify with a theme and ultimately be motivated by it, one must consider a child’s life experiences, which are intricately associated with the child’s ethnic and socioeconomic background. At the IAR site, many of the children and families assessed are from surrounding rural areas. A farm theme was appropriate, because of its familiarity to a majority of children assessed at the Center for Development and Learning (CDL). The farm theme offered the opportunity to design five creative workstations for the children including a house, tree, cow, sheep, and pond (Table 1 and Appendix 1).
Creation of a Versatile Space
The IAR was designed for children from three years to preadolescence. However, the room was designed to be conducive to the examination of children older or younger than this age range. The room contained a basketball hoop, ball activities, and other activities for older children. In addition, the room contained mats, a mirror, toys and other items appropriate for infants and toddlers and general examination and treatment purposes.
The use of portable equipment added to the versatility of the room. For example, the “pond” activity mat can be rolled up for storage or transported to another location such as a client’s home or school setting. In addition, the objects attached to the walls throughout the IAR (apples, eggs, doorknob, mailbox, etc) are easily removed by detaching screws and Velcro.
Providing Multisensory Experiences
The activities in the IAR incorporated the senses of sight, touch, and hearing using bells, noisemakers, textured materials, three-dimensional accessories, and bright colors. These items provided a multisensory experience while encouraging the expression of gross motor and fine motor skills. Visual stimuli were achieved using farm animal paintings (cows, sheep, rooster) using high contrast colors such as black, white, yellow, and green. The sensory wall adjacent to the entrance to the IAR provided an excellent example of a multisensory experience. Auditory stimuli were available through the wind-up spider on a large web and a cowbell. The “barnyard” fence made of a five-foot-long foam roll provided tactile stimulation, as did the spots on the cow and the sheepskin made of textured materials. Finally, several three-dimensional figures were placed in the room, including a spider and butterfly.
Maximization of Environmental Affordances
The IAR was designed with a primary goal of maximization of environmental affordances to encourage optimal motor behavior from the pediatric client. Activity stations throughout the room were structured yet allowed the child the freedom to move from station to station and choose a desired activity. For example, when entering the room, the child has a choice of going to the tree or house station because they are visible immediately. If the child chooses the house station, the following scenario may unfold. Compelled by natural curiosity, the child ascends the steps to ring the doorbell, turn the doorknob, and check the mailbox. When the child feels that it is time, he/she may proceed to the next activity of choice (tree, pond, cow, etc). The child perceives this experience as play and exploration rather than assessment and, through play, will display his/her individual skills.
Environmental affordances also were provided by placing items of different shapes, sizes, and textures at varied levels to accommodate children with different morphological characteristics and skill levels. For example, the apples were placed 58 inches and 44 inches from the floor. Objects of different sizes (eg, apples vs eggs) also were included to accommodate the expression of diverse grasps and fine motor control.
Motivation and Goal Attainment
As mentioned earlier, the activities designed for the IAR were functional, concrete, and purposeful. In addition, the activities were self-explanatory and allowed parents or professionals to act as the facilitator for the child, depending upon needs unique to each individual situation. For this article, the term facilitator represents the individual (parent/professional) guiding the child throughout the assessment process. For example, the child may discover the apples and wander toward them to explore whether they can be picked off the tree. If the child is hesitant to explore, the facilitator may point out the apples to the child saying, “I’m hungry. Can you get an apple for me?” Children who refuse to enter the room with a facilitator may enter the room with a parent while the evaluators observe. The parent may facilitate the completion of activities in the room and allow free exploration. The evaluator represents the professional who, through observation or facilitation, will later use the results of this assessment for formal evaluation of the child.
Although not intended to mimic or substitute for standardized tests, the skills assessed through the completion of tasks in this IAR were designed to parallel those highlighted in standardized assessments such as the Peabody Developmental Motor Scales, Bayley Scales of Infant Development II, etc. These skills included, among others, stair climbing; ball skills demonstrated by playing with the ball and basketball hoop; jumping, hopping, and skipping encouraged by the trampoline and activity mat (ie, the pond station); balance beam activities inherent in the bridge-across-the-pond activity; and range of motion activities as assessed by such activities as reaching for the apples and eggs.
Facilitating a Transdisciplinary Assessment
An occupational therapist, a speech therapist, an educator, and a mobility specialist, who works primarily with children with visual impairments, were among the disciplinary representatives consulted to incorporate transdisciplinary activities at each station in the IAR (Table 2). This transdisciplinary collaboration generated creativity, excitement, and interdisciplinary interest.
Many discipline-specific needs and suggestions were communicated. For instance, the mobility specialist recommended that the colors in the room be bright and of high contrast for high visibility. Consequently, we chose to use bright farm colors in the IAR including reds, yellows, and greens against a white background. The lines of the paintings were designed to be simple and well defined.
The occupational therapist made many recommendations such as the inclusion of activities that allowed for observation of bilateral upper extremity skills. Some examples of fine motor and upper extremity activities incorporated throughout the room included reaching for apples and eggs located on an apple tree and operating a mailbox that required two hands to lift the lid and search for the letter contents. In addition, a fishing pole was added to the pond station to introduce a fishing activity that allowed the occupational therapist to evaluate upper extremity coordination.
The IAR was designed in accord with transdisciplinary requests and suggestions. The resultant IAR allowed other professionals to gain information from a unified assessment process. For example, the physical therapist may be the primary facilitator for the completion of the stations while the occupational and mobility specialists observe the child’s performance and gather information specific to their interests.
As is the case in many facilities, there was limited space available for examination and treatment. The room available for our project measured 13 feet × 13 feet and had previously been used as a multipurpose room for storage of equipment including balls, mats, boxes, etc. Before the project began, the room was cluttered and prohibited movement expression and a transdisciplinary assessment format. In transforming this room, we were presented with several challenges (Table 3) in addition to limited space.
Using the information from earlier pilot trials and from transdisciplinary assessments conducted in the room, multiple changes have been proposed and implemented (Appendix 2). Primarily, these alterations were because of durability, safety, and accessibility of the stations and activities in the IAR.
The completion of the IAR affected the children examined and also served to motivate professionals from multiple disciplines to conduct transdisciplinary assessments. During these examinations, other professionals, such as physicians, occupational therapists, etc, were free to enter and leave the IAR. They were able to gather information pertinent to their discipline-specific assessment through observation. Although some felt the need to further evaluate the child individually, observing such an assessment allowed the professional to gain a better understanding of the child before meeting with him/her to answer additional questions. It helped to determine the child’s skills and needs, assisted in focusing the subsequent assessment, or eliminated the need for an individual meeting with another discipline representative. Consequently, facilitating a transdisciplinary assessment may conserve time. Time management is essential in our facility because parents and children undergo long hours of detailed evaluation. Optimally, an observational window placed in the room would allow for observation by other professionals and students with minimal interruption to the child.
The reaction of the children assessed to the IAR became the most exciting aspect of the project. Repeatedly, a child entered the room and immediately proceeded to explore and complete the tasks available with minimal or no cues from the evaluator. We have coined the term invisible evaluator to describe this phenomenon. The feeling of being in a playful environment allows the child to relax and demonstrate natural abilities. Not feeling scrutinized, the child adjusts to the presence of an unfamiliar evaluator or facilitator. Thus, the child is provided with the most natural and/or least restrictive environment possible in a clinical setting.
This IAR provided the evaluator(s) with the flexibility to alter the environment, before or during the examination, to encourage optimal skill expression and result in the most comprehensive picture of the child’s abilities. For example, if the evaluator wished to examine a child’s ability to squat, she placed a toy frog on a lily pad on the activity mat and asked the child to “catch the frog.” If the evaluator wanted to observe the child’s ability to maintain his balance while reaching to pick an object up off the floor, she would ask the child to perform the same task (picking up a toy frog from a lily pad) while standing outside the activity mat using the cue “Can you get the frog? Don’t get your feet wet!”
In general, children responded very positively to the IAR. Most were motivated to explore and play in the room on entering. There were a few instances where a child was overwhelmed by the activities in the room. One child became frightened by the unexpectedly loud sound of the doorbell. In this case, a negative reaction to the activities offered valuable information as well. In addition to the observation of other behaviors throughout the examination, this reaction may be indicative of sensory integration impairment or sensory avoidance behavior.
We found that many of the activities served a dual purpose, that of an examination item and that of child motivator. For example, in some cases the physical therapist was interested in observing how a child ascended or descended steps. The child, because of fear or lack of interest, was not interested in climbing the steps, but was motivated to ring the doorbell at the top of the steps. Consequently, the child climbed the steps with minimal or no cueing from the physical therapist to ring the doorbell. Furthermore, task completion did not require incentives (stickers, bubbles, etc) to coax the child. The incentives and rewards for the child were inherent in the activities and environmental surroundings.
In addition, the tasks in this room encouraged the child to plan strategies for goal attainment. In one instance, a 27-month-old boy was not tall enough to reach the apples on the tree. Without direction from the facilitator, he found a stool that was in the room and placed it under the apple to reach it. This behavior provided information regarding the child’s ability to plan motor strategies, thus reflecting the child’s level of cognitive development and skill acquisition.
Finally, we found that IAR examination may also be successful with more than one child in the room. The children act as facilitators for each other, encourage task completion, and engage one another in play activities. This allows the team to observe each child’s psychosocial and interactive skills. Videotaping was found to be helpful when observing more than one child at a time. The evaluator can review the tape later and concentrate on each child’s unique environmental interactions.
In summary, we emphasize that each child and situation be considered when deciding whether to administer an examination via the IAR or standardized testing method. Although not intended to replace or mimic standardized tests, such examinations are complementary to other measurement tools. IAR examinations are appropriate in situations where: 1) the child refuses to follow the evaluator’s instructions; 2) the child is not comfortable with strangers; 3) the child has recently undergone standardized testing and retesting would be redundant and unnecessary; 4) as a screening tool; 5) as an aid in choosing the most appropriate standardized test compatible with the child’s needs; 6) as a form of encouraging the parent to take a more active role in the child’s assessment process by acting as the facilitator; 7) to facilitate collaboration among multidiscipline professionals; and 8) allow for the examination of other than physical skills (ie, psychosocial and cognitive). Standardized tests, on the other hand, may be more appropriate when: 1) an objective/numerical score is necessary (eg, qualification for services); 2) normative data are desired (eg, research, tracking treatment progress, obtain an age equivalence, etc); and/or 3) special attention is required to a specific impairment.
Part, or all, of this project can be adapted to other settings including school, clinical, and community settings. The central theme of the IAR may be customized to the population, examination, or therapy type, and objectives specific to the facility or therapist. It may also be made specific to an occupation or situation. The IAR may be designed in the likeness of a room in a house, such as a kitchen, or a situation, such as driving a car or shopping in a store.
Clinicians are encouraged to examine and collect objective data on the impact of the IAR environment on children with varying abilities and/or diagnoses. Future studies should focus on the impact of the environment on performance as compared with a control group. Studies should also investigate the results and subsequent development of individualized goals based on the results from an IAR examination as compared with standardized tests.
SUMMARY AND CONCLUSIONS
An IAR offers a stimulating examination environment for physical therapists and other professionals, incorporating practice-based application of motor control and behavioral theories. It provides a low-budget solution by maximizing available space and using inexpensive, readily available materials.
The room encourages the completion of task-oriented activities necessary for a transdisciplinary, comprehensive examination of the pediatric client, including the developmental and functional skills highlighted by current standardized instruments. IAR examinations may be indicated in certain situations and standardized tests in others. Although not standardized or normative, we would suggest that this type of examination motivates the child within the most natural environment possible within a clinical setting. When the results of the IAR examination are coupled with standardized test results, a more complete picture of the child’s abilities is ascertained. Although not all children will respond in the same way to the IAR environment, we would stress that it is in the execution of environmental choices that much critical information is found.
The authors would like to thank the CDL at the University of North Carolina, Chapel Hill, NC and all of the staff members who offered their time, ideas and encouragement to help make this project a success. Special thanks to Anne Hobgood for her artistic talent and wonderful sketches and Philip Weber for volunteering his carpentry skills. We would also like to thank Amy Thomas, Shirley Phillips, and their children for their time and willingness to participate in our pilot trial.
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Explantion of Alterations Made to the IAR
During the nine-month period after the completion of the room and initial pilot assessment session, we estimate that more than 60 children have been assessed in the IAR. Using the information from transdisciplinary assessments conducted in the room, multiple changes have been proposed and implemented. These alterations were primarily because of durability, safety, and accessibility issues related to the stations and activities in the IAR. Alterations included resecuring all Velcro with hot glue to increase durability, resecuring the doorknob because of repeated pulling and subsequent loosening, and adding a third apple 38-inches from the ground to provide greater accessibility for smaller children or children using wheelchairs for mobility. We also suggested choosing a different material other than wood (eg, plastic) for the apples and eggs. Although durable, wooden objects became a potential safety hazard secondary to the tendency of children to throw objects. Finally, using a basketball hoop with the capability of being placed at varying, adjustable heights was recommended to allow greater accessibility.