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RESEARCH REPORTS

Power-Up: Exploration and Play in a Novel Modified Ride-On Car for Standing

Logan, Samuel W. PhD; Lobo, Michele A. PT, PhD; Feldner, Heather A. PT, PhD, PCS; Schreiber, Melynda MS; MacDonald, Megan PhD; Winden, Haylee N. BS; Stoner, Tracy PT, DPT, PCS; Galloway, James Cole PT, PhD

Author Information
doi: 10.1097/PEP.0000000000000336

INTRODUCTION

Research increasingly supports the idea that everyday perceptual-motor experiences shape future developmental landscapes and abilities across multiple domains such as cognition and social skills.1–3 One way to view perceptual-motor experiences is through the lens of physical activity. Physical activity is defined as “...any bodily movement produced by skeletal muscles that requires energy expenditure.”4 Many studies describe physical activity levels of children without disabilities between the ages of 3 and 5 years.5,6 Often, physical activity is discussed in association to positive health outcomes,7 or achievement of daily, recommended guidelines of physical activity.8

Less is known about the physical activity levels of preschool-aged children with disabilities.9 This is likely due to several factors including measurement issues and recruitment challenges.

Lower physical activity levels have been reported for children with disabilities at school-age and throughout adolescence.10,11 Much less research has focused on preschool-aged children with disabilities. Research suggests that young children with disabilities such as autism spectrum disorder12 and cerebral palsy13 engage in less physical activity compared with their peers developing typically. One reason for the lack of research for preschool-aged children with disabilities is difficulty in validating physical activity monitors such as accelerometers and pedometers for this population.14 Although descriptions of physical activity have been reported for children with and without disabilities, very limited research has focused on how physical activity, and movement in general, is associated with engaging in play interactions with other children. Play and social interactions are critical experiences for learning and social-emotional development in young children.

Play interactions are defined as direct and indirect social interactions that are generally “purposeless,” occurring for their own sake without external considerations.15 A recent study reported that a large gap exists between 2-year-old children with and without disabilities in the amount and variability of physical activity and play behaviors within an early childcare setting.16 Key implications noted for future research and early intervention included (a) consideration of amount and variability of behaviors of children without disabilities as the “gold standard” when implementing technology and intervention strategies for children with disabilities and (b) embedding intervention goals and activities within dynamic, social settings such as classrooms, playgrounds, and other community spaces.

There were 3 purposes of this study: to describe the performance of physical activity and play behaviors for preschoolers without disabilities across 3 contexts of an early childcare center (gymnasium, playground, classroom), to compare physical activity and play behaviors of preschoolers without disabilities with those of 1 preschooler with physical disability across these 3 contexts, and to document how different assistive devices (forearm crutches or modified ride-on car) impacted play behaviors of the preschooler with physical disability in the gymnasium and playground. Ride-on car size did not allow for classroom assessment. We hypothesized that the behavioral landscapes of physical activity and play would differ between preschoolers with and without disabilities across contexts. We also hypothesized that the preschooler with physical disability would engage in more play interactions using a modified ride-on car compared with using forearm crutches in the gymnasium and playground, based on previous literature reporting increased social participation for children with ambulatory disabilities when using wheeled mobility devices.17,18

METHODS

Study Design

This study was a descriptive, prospective, and cross-sectional research design. A descriptive research design was used to report typically occurring physical activity and play behaviors of preschoolers. A case report research design was used to report typically occurring physical activity and play behaviors of 1 preschooler with a physical disability. A case report research design was also used to compare the play behaviors of the child with a physical disability during use of forearm crutches or a modified ride-on car.

Participants

Participants were 42 preschoolers without disabilities (19 males; mean age = 4.4 ± 0.8 years) and 1 preschooler with a disability (male; 4.5 years old; Asian ethnicity). They were enrolled from an early childcare center that serves approximately 230 children from the community. Please see the online supplemental files for a schematic and photographs of the classroom, gymnasium, and playground for more information about the space and layout of the early childcare center (Supplemental Digital Content 1, available at: http://links.lww.com/PPT/A120). Participants' parents reported their ethnicities as Caucasian (50%), African American (33%), Asian (14%), and other (2%). The preschooler with a physical disability is referred to here as “Child A.” His medical history includes diagnoses of ventricular septal defect, bilateral clubfeet, and bilateral peroneal neuropathy. At 44 months of age, he underwent surgery to treat a tethered spinal cord. He wore solid bilateral ankle foot orthoses and used forearm crutches for mobility.

Child A moved on the floor quickly and efficiently. He crawled using a reciprocal arm and leg pattern. He transitioned sitting to/from quadruped and pulled to stand with support from surfaces or his crutches. He primarily walked in the classroom using his crutches, only crawling on the floor when he needed to use his hands to move an object or when playing on the carpet. When standing at a support surface, he cruised right with bilateral arm support from the surface. Cruising appeared to be challenging for him. After 4 to 5 steps, he would lean his trunk as well as on his arms on the weight-bearing surface. He walked independently using crutches over a variety of surfaces including hallway, grass, mulch, inclines, and declines.

Child A received physical therapy services twice weekly from a school-based pediatric physical therapist who came to the early childcare center to deliver treatment. The focus of physical therapy was to improve trunk, upper extremity, and lower extremity strength in the context of working toward functional goals to increase Child A's access to education, completion of activities of daily living, and participation with peers. Child A's family received consultation once per month per his individualized education plan. Child A did not receive services through Part B coverage or otherwise, related to language, fine motor, or cognitive skills.

Description of Modified Ride-On Car

The primary researcher and Child A's physical therapist determined the ride-on car model for the present study based on consideration of the child's body size, hand reach, and ride-on car ability to travel across different surfaces including grass and mulch. Child A used a modified 12-V, Fisher-Price Power Wheels Kawasaki ($251.99) that traveled at 2 speeds forward, 2.5 and 5 mph, and 1 speed in reverse, 2.5 mph. A small activation switch (Honeywell switch, SPDT 250V 16A, $2.33, ordered from digikey.com) was installed directly underneath the seat so that activation of the ride-on car occurred when Child A pulled himself up from sitting to standing to unweight the switch (Figures 1 and 2). An electrical engineer inspected all modifications for safety. See a previously published technical report for more modification suggestions.19 The modified ride-on car was kept at the childcare facility where Child A chose to continue using it after completion of the study. The product (ride-on car) is not labeled for the use described here and the product (modified ride-on car that encourages standing) is investigational.

Fig. 1.
Fig. 1.:
A small activation switch was installed directly underneath the seat (Honeywell switch, SPDT 250V 16A, $2.33, ordered from digikey.com).
Fig. 2.
Fig. 2.:
Child A using the modified ride-on car in the gymnasium and on the playground.

Procedure

Approval from the university's Institutional Review Board and written parent/guardian consent on behalf of all 43 participants was obtained prior to data collection. Parent/guardian consent was obtained for photographs that included their children to be published in a peer-reviewed journal (Figure 2). Preschoolers without disabilities were video recorded for 28.3 ± 8.8 (total 1637) minutes in the classroom, 7.2 ± 3.3 (total 393) minutes in the gymnasium, and 6.6 ± 2.6 (total 545) minutes on the playground. Child A was video recorded for 449 minutes in the classroom, 61 minutes in the gymnasium, and 117 minutes on the playground while using forearm crutches and for 56 minutes in the gymnasium and 125 minutes on the playground while using the modified ride-on car. The modified ride-on car was not used in the classroom due to a mismatch between the footprint of the ride-on car and the space available to maneuver in the classroom.

Our goal was to describe as accurately as possible the behaviors of the children observed. We acknowledge that we video recorded more time in the classroom compared with the gymnasium and playground. Our rationale is that preschool children within this early learning center spend a majority of their typical day in the classroom and less time in other contexts. We decided not to shorten the minutes observed for Child A to match those of children without disabilities to provide as comprehensive as possible of a representation of behaviors. This approach seems appropriate because we did not conduct formal statistical analyses that rely on a set of assumptions about the data.

Data coding was performed through video analyses of each child using momentary time sampling to avoid excessive and unnecessary coding time while obtaining large samples of data. Video was divided into consecutive 15-second intervals and researchers coded behaviors in each category of physical activity and play the first 5 seconds of each interval. This is a well-established coding method commonly used in physical activity studies.16,20 There were 10 299 total observation intervals coded.

A mutually exclusive coding protocol was used within each assessment of physical activity and play behaviors. Within each category only 1 behavior was recorded for each observation interval. For example, if during a 5-second observational period a child sat for 3 seconds and stood for 2 seconds, only sitting was coded because that behavior was demonstrated a majority of the time.

Three trained coders analyzed all video recordings. Inter- and intrarater reliability of at least 85% agreement was established for each variable on 10% of the video recordings using the ratio of agreements divided by (agreements plus disagreements) multiplied by 100. For each assessment, the mean percent time performing each behavior is reported. Mean percent time was calculated by observed intervals for each behavior divided by total intervals multiplied by 100.

Assessment of Physical Activity

Physical activity was classified according to the Observational System for Recording Physical Activity in Children-Preschool version.20 This protocol has been used previously to measure physical activity in the childcare setting.21 Physical activity type was defined as lying down, crawling, kneeling, sitting, squatting, cycling, standing, walking, and running. Physical activity during modified ride-on car use was not coded because the ride-on car allowed only sitting and standing.

Assessment of Play

Play behaviors were classified according to Howes' Peer Play Scale22:

  • Solitary—child is more than 3 ft away from peers and teachers and is not engaged in verbal or physical interaction with anyone
  • Parallel—child is within 3 ft of a peer or teacher but with no direct verbal or physical interaction with anyone
  • Peer interaction—direct verbal and/or physical interaction with a peer
  • Teacher interaction—direct verbal and/or physical interaction with a teacher

Description of Data Presentation and Visual Analysis

In Table 1, we report means and standard deviations for each variable and context for preschoolers without disabilities and Child A's means for each variable and context. We describe Child A's behavior in any variable as different from preschoolers without disabilities if Child A's mean was more than 1 standard deviation above or below the mean of preschoolers without disabilities. We describe Child A's behavior in any given variable as different, while using a modified ride-on car compared with crutches, if the mean value of percent time was different by at least 10% because we believed smaller differences may not be meaningful.

TABLE 1 - Proportion of Time Observed of Physical Activity and Play Behaviors for Children Without and With Physical Disability
Percentage of Time Observed
Without Disabilities Child A Child A
Mean (Standard Deviation) CRUa CARb
Classroom
 Lying down 2% (3) 1% N/A
 Crawling 1% (1) 1% N/A
 Kneeling 14% (12) 8% N/A
 Sitting 56% (15) 63% N/A
 Squatting 1% (1) 0% N/A
 Cycling 0% (0) 0% N/A
 Standing 20% (12) 24% N/A
 Walking 8% (6) 4% N/A
 Running 0% (0) 0% N/A
 Solitary play 6% (6) 11% N/A
 Parallel play 43% (11) 38% N/A
 Peer interaction 17% (9) 13% N/A
 Teacher interaction 33% (12) 38% N/A
Gymnasium
 Lying down 5% (13) 2% N/A
 Crawling 4% (7) 12% N/A
 Kneeling 11% (14) 7% N/A
 Sitting 14% (18) 14% N/A
 Squatting 2% (3) 0% N/A
 Cycling 0% (0) 0% N/A
 Standing 23% (19) 39% N/A
 Walking 29% (16) 19% N/A
 Running 11% (10) 7% N/A
 Solitary play 13% (12) 31% 21%
 Parallel play 49% (20) 23% 34%
 Peer interaction 30% (22) 5% 6%
 Teacher interaction 8% (10) 42% 39%
Playground
 Lying down 2% (5) 0% N/A
 Crawling 0% (1) 0% N/A
 Kneeling 7% (17) 15% N/A
 Sitting 15% (16) 39% N/A
 Squatting 5% (9) 0% N/A
 Cycling 3% (11) 0% N/A
 Standing 31% (19) 28% N/A
 Walking 24% (17) 19% N/A
 Running 12% (10) 0% N/A
 Solitary play 21% (18) 24% 27%
 Parallel play 39% (19) 38% 34%
 Peer interaction 34% (23) 13% 23%
 Teacher interaction 6% (9) 26% 15%
aUse of crutches.
bUse of modified ride-on car.

It was not possible to conduct inferential statistical analyses because of the research design. The concept of social validity views intervention effects within a social context. One aspect of social validity is the importance of the treatment's effect.23 We chose 1 standard deviation or 10% difference as meaningful because it provides a standard to view whether or not the observed effects are likely to inform treatment planning via incorporating a modified ride-on car that encourages standing. We perceive 1 standard deviation or 10% difference large enough to establish social validity. The proportion of time observed in peer interaction was translated to the number of hours per year expected for the current sample to provide practical relevance and meaning to the results. Extrapolations were based on an average of 6 hours per day spent awake by preschool children in the early childcare center where the study occurred (excluding breakfast, lunch, and naptime). Hours per year were extrapolated based on an expected attendance of 20 days per month for 12 months.

RESULTS

Physical Activity

Classroom

When using crutches, Child A engaged in similar durations of physical activity types including sitting, standing, kneeling, and walking compared with preschoolers without disabilities (Table 1, Figure 3A).

Fig. 3.
Fig. 3.:
Each physical activity type reported by mean proportion of time observed in the classroom, gymnasium, and playground. Asterisk (*) indicates that Child A's mean is 1 standard deviation above or below the mean of preschoolers without disabilities. Physical activity was not coded during the modified ride-on car use because the ride-on car allowed only sitting and standing.

Gymnasium

When using crutches, Child A engaged in similar durations of physical activity types including sitting, standing, and walking compared with preschoolers without disabilities. Bicycles were not available for use in the gymnasium and thus no cycling occurred (Table 1, Figure 3B).

Playground

When using crutches, Child A engaged in similar durations of physical activity types including kneeling, standing, and walking. Child A engaged in more sitting and less time running compared with preschoolers without disabilities (Table 1, Figure 3C).

Play Interaction

Classroom

When using crutches, Child A engaged in similar durations of play compared with preschoolers without disabilities including solitary play, parallel play, teacher interaction, and peer interaction (Table 1, Figure 4A).

Fig. 4.
Fig. 4.:
Play interaction type reported by mean proportion of time observed in the classroom, gymnasium, and playground. Asterisk (*) indicates that Child A's mean is 1 standard deviation above or below the mean of preschoolers without disabilities. Plus (+) indicates that Child A's behavior is different while using a modified ride-on car compared with using crutches (mean value was different by at least 10%). The modified ride-on car was not used in the classroom due to a mismatch between the footprint of the ride-on car and the ambulation space in the classroom.

Gymnasium

When using crutches, Child A engaged in more solitary play and teacher interaction and less parallel play and peer interaction compared with preschoolers without disabilities. When using the modified ride-on car, Child A engaged in similar levels of solitary play and parallel play compared with preschoolers without disabilities. When using the modified ride-on car, Child A engaged in more teacher interaction and less peer interaction compared with preschoolers without disabilities. When using the modified ride-on car, Child A engaged in less solitary play (10% decrease) and more parallel play (11% increase) compared with when using crutches (Table 1, Figure 4B).

Playground

When using crutches, Child A engaged in similar durations of play compared with preschoolers without disabilities including solitary play, parallel play, and peer interaction and greater durations of teacher interaction. When using the modified ride-on car, Child A engaged in similar durations of solitary play, parallel play, and peer interaction and greater duration of teacher interaction compared with preschoolers without disabilities. When using the modified ride-on car, Child A engaged in less teacher interaction (11% decrease) and more peer interaction (10% increase) compared with when using crutches (Table 1, Figure 4C).

Extrapolation of Peer Interaction

One of the most striking results is the lack of peer interaction of a child with a physical disability in the gymnasium and on the playground, especially when extrapolated to the amount of hours per year. Preschoolers without disabilities are expected to engage in 432 (gymnasium) and 480 hours (playground) of peer interaction per year. In contrast, Child A while using crutches is expected to engage in 72 (gymnasium) and 187 hours (playground) of peer interaction per year. We found that the use of a modified ride-on car may help in closing the gap in peer interaction, especially on the playground. While using a modified ride-on car, Child A is expected to engage in 86 and 336 hours of peer interaction in the gymnasium and on the playground, respectively.

DISCUSSION

This is the first study to describe the performance of physical activity and play behaviors for preschoolers without physical disabilities and 1 preschooler with a physical disability across 3 contexts of an early childcare center. We hypothesized that the behavioral landscapes of physical activity and play would differ between preschoolers with and without disabilities across 3 contexts of an early childcare center. Our hypothesis was partially supported. In the classroom, Child A and his peers engaged in similar durations of physical activity types and play interactions. In the gymnasium, Child A and his peers engaged in similar durations of physical activity types; however, Child A engaged in more solitary play and teacher interaction and less parallel play and peer interaction compared with his peers without disabilities. On the playground, Child A engaged in more sitting and less running, as well as more teacher interaction and less peer interaction compared with his peers without disabilities.

This is also the first study to describe how one preschooler with physical disability engaged in play behaviors during use of forearm crutches versus use of a modified ride-on car, compared with preschoolers without disabilities across 2 contexts of an early childcare center (gymnasium, playground). We hypothesized that the preschooler with physical disability would engage in more play interactions during use of a modified ride-on car compared with use of forearm crutches while in the gymnasium and on the playground. This hypothesis was supported. In the gymnasium, Child A engaged in less solitary play and more parallel play while using the modified ride-on car compared with forearm crutches. On the playground, Child A engaged in more peer interaction and less teacher interaction when using the modified ride-on car.

Anecdotal observations of Child A's behavior offers insight as to why he engaged in more direct peer interaction on the playground while using the modified ride-on car. The sandbox is located directly outside of the exit from his classroom to the playground. While using crutches, Child A would often walk directly to the sandbox, sit down, and play for the duration of outdoor time. While peers interacted with him during this time, he was reliant on others to come to him rather than seeking out and initiating play interactions. In contrast, the modified ride-on car allowed Child A to travel further distances across the playground without appearing to become fatigued in the same way as when he used forearm crutches, increasing his ability to interact with peers engaged in a broader range of activities across the larger playground space. Furthermore, Child A's use of the modified ride-on car evolved over time. At first, there was a novelty aspect to the modified ride-on car that brought Child A's peers to him simply because they were curious and interested in it. As the novelty subsided, Child A appeared to use the modified ride-on car in new and varied ways to interact with peers. This included engaging in more complex social games such as tag and role-playing. In summary, when using forearm crutches Child A chose more isolated play experiences and relied on others to come to him for peer interaction while in the sand box. The modified ride-on car provided Child A with a novel means of independent mobility that allowed him to seek out and initiate interactions with peers.

Our results can be interpreted within the perspective of grounded cognition. Perceptual-motor experiences are situated within environmental, social, and cultural contexts that simultaneously interact to influence behavior.3 Child A has a physical disability and yet, he is proficient at using crutches to locomote. However, Child A engaged in substantially less peer interaction in the gymnasium and on the playground compared with preschoolers without disabilities likely because of higher energy demands and lower speed associated with his locomotion using crutches. Crutches did not afford him the opportunity to move long distances at high speeds to interact with his peers in the gymnasium or on the playground. One form of assistive technology to increase social interaction in large spaces is modified ride-on cars. Previous research has demonstrated the effect of modified ride-on car use on an individual's development.24–26 This is the first study supporting the use of a modified ride-on car to help a child engage with peers in a social context.

Clinical Applications

There are several clinical implications of this study. First, our study highlights the need for intervention techniques that can be incorporated throughout everyday activities to encourage and support higher levels of physical activity and play of children with disabilities. This contrasts with the “gold standard” of mobility intervention dosage, which at a maximum may reach 2 hours per week of “intensive” therapy service provision.27

Second, in order to optimally support the physical activity and play behaviors of preschoolers with disabilities, clinicians should challenge the standard of mobility device prescription. Current practice tends to result in an “either-or” dichotomized approach to walking versus the use of wheeled mobility, as well as a “1 child, 1 device” mentality about assistive technology, despite the natural tendency of children to self-select multiple modes of mobility and technology dependent on context.28 To our knowledge, only 1 previous study has compared the use of multiple assistive technology devices and included 3 children with myelomeningocele who used either a walking aid or a manual wheelchair.29 Results indicated decreased school performance while using a walking aid compared with a manual wheelchair, potentially due to the increased energy expenditure required while using a walking aid.29 Selecting the right mobility device in the right context is imperative for achieving full participation, and may result in augmenting physical activity and play for children with disabilities.

Third, our data emphasize the need for clinicians to partner with children, teachers, and other stakeholders in advocating for accessible and inclusive spaces. This will increase the opportunities available to engage in varied forms of physical activity and provide more natural opportunities for inclusive play for children whose mobility differences may leave them behind in inaccessible childhood spaces.

Future Research

The current study is descriptive and provides a general picture of physical activity and play behaviors. A limitation of the current study includes the descriptive study design that does not allow for causal inferences of differences observed between children with and without disabilities. We acknowledge that our decision that 1 standard deviation or 10% difference in behavior is large enough to establish social validity is subjective. The decision-making process in determining the social importance of effects is inherently subjective.30 A related limitation is the “differential effort” in collecting data across contexts and between groups of children with and without disabilities (ie, varied lengths of video recording). This may be considered a source of bias, itself explaining results. Another limitation is the low sample sizes of included children without disabilities (n = 42) and of a child with a disability (n = 1). Results should be interpreted conservatively without generalization to larger populations. Future research should use research designs that allow hypothesis testing through inferential statistical analyses. This would involve including more children with physical disabilities. It is important to determine how other forms of technology and training can continue to close the gap between behaviors of children with and without disabilities. Likely, a combination of several options of technology and training that is individualized to meet a specific child's needs will be most effective. An important direction for future research is to determine whether use of a modified ride-on car with a “standing” mode, such as the ride-on car described in the current study, can advance physical skills such as independent standing or walking as well as induce physiological changes such as improved bone density, muscle strength, and balance.

CONCLUSIONS

The results from this study help to improve our understanding of the relationship between physical activity and play for preschool children with and without disabilities, and how these are, in turn, impacted by mobility impairments and varying environmental contexts. This study provides evidence of the potential of modified ride-on cars to encourage peer interactions for children with physical disability. Further research that continues to directly compare the effect of use of different assistive technology devices may provide additional information regarding the advantages and disadvantages of each device. For children with disabilities who may use assistive devices, clinicians, families, and teachers are encouraged to embrace a “right device, right time, right place” approach.

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Keywords:

early childcare; environmental context; power mobility; socialization

Supplemental Digital Content

© 2017 Wolters Kluwer Health, Inc. and Academy of Pediatric Physical Therapy of the American Physical Therapy Association