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Gayle Wiens, PT, Assistive Technology Specialist Copyright 2014

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1 Gayle Wiens, PT, Assistive Technology Specialist Copyright 2014
Up; New Success for Young Children with Physical Disabilities and/or Multiple Challenges Gayle Wiens, PT, Assistive Technology Specialist Copyright 2014 Welcome! I am Gayle Wiens, I’m a PT/AT Specialist with 31 years of pediatric experience mostly with young children with significant neuromotor challenges. I’d like to know who you are, How many people have contact with young children under 5? Parents? Teachers? AT specialists? Social Workers? Speech therapists? OT’s? PT’s? Thanks!

2 Questions or Comments? Southwest Human Development is Arizona’s largest nonprofit dedicated to early childhood development ·         It includes More than 40 programs and services focused on young children ages birth to 5 ·         Serves more than 135,000 children and their families each year ·         Core Areas include: Child Development and Mental Health, EasterSeals Disabilities Services, Head Start and Early Literacy, Child Welfare ·         Professional Education and Training

3 ADAPT Shop- A Program of Southwest Human Development
I work at the ADAPT Shop, a program I helped create. Let’s get the details out of the way so we can talk about kids. ADAPT Shop is a non profit program dedicated to helping children birth thru 5 years, find new success in all areas of development by using Assistive Technology and custom adaptations. No ongoing therapy services are available. DDD covers the direct service time for consultation. Generally 12 hours/year are assigned (AT for Birth-3, PT for kids over 3 years old) The cost of the adaptations and modifications are covered by charitable donations, Easter Seals Walk with Me Fundraiser (whole agency), and grants. ADAPT Shop does not provide funding for commercial medical equipment but may help direct the family to systems that will. We have a limited amount of equipment for loan.

4 Who can access ADAPT Shop?
Arizona Children with DDD or DDD and Long Term Care Maricopa County-initial home visit Families from other counties in Arizona are seen at ADAPT Shop Families contact their DDD SC to request ADAPT Shop Services Contact Tina Martin, Senior Program Manager for Assistive Technology with new referrals or for appointments. Arizona Children with DDD or DDD and Long Term Care. Home visits can be provided for children in Maricopa County although most children will come to the ADAPT Shop to pick up their chair or items. When ready access to tools is needed to complete or adjust their adaptation, families come to ADAPT Shop. Please make sure families know there is a possibility that this may be necessary. Families in other counties in Arizona must travel to the ADAPT Shop for all their consultations and adaptations. We try to coordinate visits with other appointments the child has in Phoenix whenever possible. We have children coming from Yuma, Flagstaff, Tuba City, Lake Havesu and Pima County that travel to Phoenix for ADAPT services. Families contact their DDD SC to request ADAPT Shop Services Contact Tina Martin, Senior Program Manager for Assistive Technology with new referrals or appointments. Tina Martin is very knowledgeable about getting authorizations through DDD and she is very easy to talk to. sy to work with! Anyone can call that needs more information.

5 Assistive Technology For early SUCCESS!
People often ask me, How young is too young? No child is too young for ADAPT services IF there is a need. It can be a need for positioning and comfort. For example an infant with osteogenesis imperfecta (brittle bones) may need cushioning foam in everything they lay on. This child (age 14 months) is using a jelly bean to move our switch operated scooter to go to the bubble tube where her twin is playing with the remote. This is her first experience with powered mobility. See that focused look in her eyes? She’s ready!

6 ADAPT Shop helps with Assistive Technology:
Sitting supports and custom adaptations Help with beginning play and beginning to use hands. Also, switches when needed Beginning communication strategies for complex children Trials with various powered mobility; Go Baby Go, Our Multiple Switch Scooter, Power or Power Assist W\C Help identifying appropriate iPad apps Help identifying helpful medical equipment, including standing and moving for very weak children, and recommendations for orthotics that might be helpful What kinds of things does ADAPT Shop help with? People have heard we make Happy Chairs but many people don’t realize we offer a range of Assistive Technology options. We are continually working on new options to help children be successful, so, this is an ever changing list.

7 ADAPT Shop Model Search for unrealized potential
Look for the child’s strengths Discover the child’s interests to build meaningful activities Most of our professional training is focused on seeing deficits and documenting them. We are good at this! When you meet a child with significant neuromotor delays, sometimes their inabilities capture all our attention. We need new eyes to see. When I meet a new child, my focus is on searching for unrealized potential and looking for the child’s strengths and interests. This drives my intervention. This little girl had a horrible birth and the doctors told the family not much brain was left. Her vision is very poor but she has a surprising amount of comprehension, a desire to participate in activities, and she is willing to work very hard for meaningful activities. A week after they introduced a Step by Step and used it intermittently, she was able to use it to pray the family dinnertime prayer, line by line, without any cues or help, exactly on time with the rest of the family. There is a lot of girl inside that body! A medical history is helpful but I don’t assume it will necessarily determine the child’s potential. Even children with progressive diseases can often be better supported so they are able to do more with the abilities they presently have. We want to help them function as highly as they can for as long as they can. I don’t care what the chart says about their potential, I start high and move down. Many children exceed the level that would be predicted from their medical chart.

8 Find out what is meaningful to each child and their family and use it to plan your intervention.
How do I know what tasks are meaningful to each child? Here is where the listening and watching will lead you. Adults will inevitably talk while you are there. Even when you have finished directly interacting with the child, keep watching their responses to what the adult is saying. This can give you a window into their language comprehension! Is the child listening??? The listening child often has their eyes fixed to one side, they are holding still and not moving at all most of the time. They may glance in the direction of the speaker from time to time. As the adult tells a story or talks about family members, watch the child for their response. Sometimes a slight smile on one side is your cue, don’t miss it! Slight stiffening of their body as they are excited about the story. This little girl is usually positioned in her wheelchair, tilted back at a 45 degree angle. Her head is to one side and often falling off the large headrest. Her cortical vision is severe. I offered her a chance to walk outside. She is focused on her task, her eyes are turned on, she’s holding her head and upper trunk surprisingly well and doing her best to take steps and walk outside. This is how I know I found a meaningful task for her. By the way, I am pushing the KidWalk to advance with her gait and helping if her foot on the weaker side gets stuck and she can’t free it. Otherwise, I am not touching her so she knows she is doing it herself. I am NOT talking much. I am not telling her what to do. What human likes being told what to do!! If I am talking, it is often about the activity. Oh, it’s so nice outside today. Or the door is open, do you want to go out? Language comprehension is usually closely linked to cognitive skills

9 Ideas for Finding Meaningful Tasks
Use things any child would like: Increased participation in play with someone they love/like e.g. using Step by Step to direct the play and make comments. At school, kids want to play with other kids. At home, play with family members. Going outside This is a big one! Position them near an open door. Being in charge of the activity e.g. using an iPad app that is interactive and that they do themselves. Telling other people what to do. Making choices among things they usually don’t have access to e.g. things from the kitchen for pretend cooking, choice of their brother’s Hot Wheels cars, choices of family members, clothing and accessories to try on and look in the mirror. This is GREAT for vocabulary development and FUN. Anything mega fun! These kids are putting out a huge amount of effort so activities need to be extra fun to be worth it! e.g. squirting your brother with a switch operated water squirter, yelling out (on device) DANCE PARTY and kids start dancing, turning the music on and off for the Dance Party. I’ve been very fortunate to work with young children with physical or multiple challenges my whole career but I’ve learned so much seeing these children every day! Out of 350 children, only about 10 seemed to have little potential for significant functional improvement! We are missing so much potential, personality and fun that is inside each little one, waiting for us to help them bloom! And bloom they do, if we provide, stable, comfortable active positioning and meaningful tasks for function. Finding meaningful activities for each individual child is key to unlocking a child’s potential. Most tasks we ask them to do are not worth the huge effort it requires. If you had to use every scrap of your physical ability to go to the grocery store, how often would you go? Not often! Only when it was really necessary or you wanted something important to you. Keep that illustration in mind as you ask children to do tasks!

10 ADAPT intervention often starts with custom seating
ADAPT intervention often starts with custom seating. The child needs a stable position with his body supported and items positioned rather exactly for him to be successful and able to make consistent responses and progress. These are photos from initial data collection for research study with Dr. Kathleen Ganley. We are working on the Case Report and looking for funding for a pilot study. This child had a number of commercial seating options. He hated sitting in all of them! His max tolerance was 5 min and then he would cry inconsolably until they lay him on the floor. This little boy has mitochondrial disorder and cortical vision impairment. I think he also has athetoid cerebral palsy with strong extensor thrust. Here he is a few minutes later in brand new chair. No one had ever seen him focus his eyes before. His PT had never seen his arms relaxed while sitting. His mom called the next day to say he was happy sitting in his chair 2 hrs/day and he was HAPPY. At the final testing appointment, he went from 95% of the day on the floor to 30% of the day on the floor and he had developed a new relationship with his brother. That fall, he went trick or treating, using the Step by Step. His brother wanted to record the voice messages on the Step by Step and then they went trick or treating together. Flailing, constant movement Child only tolerated sitting anywhere for 5 min max; wheelchair, Child Life, therapy chairs so 95% day laying on floor. 5 minutes later in his new chair, Notice the visual focus on iPad

11 What’s a Happy Chair? They got the name from the first family I used one with in Arizona. I left the foam support for them to try to support their son in sitting. He had muscular dystrophy and normal cognition. He wasn’t strong enough to prop up in sitting like his sister so he was often fussy. It’s really hard to play much laying down. The kids were sick so I didn’t see them again for 3 weeks. When I saw them again, I asked if they tried the little foam support . The mom said, “we call it the Happy Chair, because when the boy in in there, he is happy”. The name just stuck. Usually, once I get the support right for them, they spontaneously smile. This is so much so, that if the child seems uneasy at all, I know that I am not finished. Something else needs to be adjusted. The child will usually point it out to me by moving towards the problem, then looking at me as if to say, Fix it!. When I am done, it should be their favorite place to be. This little girl received her first Happy Chair about 6 months ago. It was a tall back chair and we had to add extra side support because she typically fell to one side and her head fell to the same side. She wasn’t visually focusing well or really playing. What a difference 6 months later. Here she is without the tall back and head support and without the side support. She is actively playing with toys and her posture and her vision are tremendously better. We are moving on to standing.

12 I like it! Here is one of those Happy Chair moments. We just placed him in his new chair. Notice, no straps are holding this child that wears a harness in all his seating options and now he is upright instead of reclined or tilted back. He may need straps in a wheelchair or car seat, when his body is less active but playing with out those supports in an active way will help him build strength, endurance and postural control. So what are the seats doing: Hold sacrum in erect position Provide lateral and posterior stability to pelvis Ramp to raise distal end of femur to reduce sliding Neutral Adduction/Abduction Provide a stable foundation to allow good spinal alignment and spinal extension, lateral weight shift through the hip and beginning trunk rotation. Also positions the legs for standing up from sitting in a raised chair. Provides positioning previously only possible with therapists hands. This means longer periods in treatment each day which leads to greater strength

13 A Happy Chair is a custom designed and constructed chair made of foam and plastic.
So, now you have seen some photos of a Happy Chair. A Happy Chair is custom designed and constructed chair presently made out of foam and plastic. Some do look similar but some are quite different. Some look similar

14 Some look quite different
I design the chair for each child’s needs. If the child has different needs, different features are built into their chair. Sometimes they get a very different looking chair. That is the Happy chair for this child, exactly as she needs it to be. In this chair, the back height is adjustable and the arms raise up so we can put gradually larger foam triangles under the arms to move towards shoulder flexion. The little bump is for her hyperextended knees and there is an extra cushion under her feet. The black piece is a diaper harness so she wouldn’t slide down in her chair. This child had almost no active movement so there was no need for sides to prevent her from falling off.

15 This is the child for the unusual chair I just showed you
This is the child for the unusual chair I just showed you. At the initial visit, this child is almost immobile. Her elbows, knees, and neck are hyperextended, her back is arched and her head is tilted back. This was not just a momentary position, she was always like this. She had two leg fractures from therapists trying to gently bend her hips. So, we designed a Happy Chair that works for her.

16 Same child at first follow up
Same child at first follow up. I had raised the arm rests and the back of the chair so she could continue to get new motion. Her mom said that from the day we delivered her chair, that is the place she wants to be. They said she loves the chair and relaxes as soon as she is placed in it. Flexion in her hips and arms were increased and she remained relaxed. In this photo, I had just talked to the mom about how to help her play with her doll. I placed it with her and asked if she wanted to hold her dolly. She worked for 20 minutes to move her arm from hyper extended to slightly flexed to hold her doll without any help or cues at all. I was writing my note, just watching, and her mom was in the other room so it was quiet. Her Family had never seen her move out of hyperextension. So, what kind of task is this? A meaningful task for her. Most people would see her severe physical condition and history of near drowning and be sure no one is home. If she focuses for 20 minutes and works with no cues for 20 minutes and her meaningful task is holding her babydoll (she is 5 years old), what do you think about her potential for cognitive growth? When professionals met the child on the first slide, do you think she was getting good cognitive teaching? What about this child? Good seating can not only improve the child’s functioning but it also often changes peoples perceptions of the child.

17 We make free standing chairs and also do adaptations such as high chairs. We adapt high chairs mostly for tiny children. By the time the child is 18 mo or 2, there is not enough room for the contour seat and other supports and still have the tray fit on safely. In this case, we did add our own way for the tray to attach but usually we would move them to a free standing Happy chair or commercial chair with seating inserts.

18 Blocks illustration for sitting AND Standing
Simulating pelvic tilt in sitting or unstable, pronated foot in standing Here is my explaination of why the Happy Chairs work so well. When blocks are aligned or nearly aligned, it is easy to balance the top block (head) When the bottom block (or pelvis is tilted), it is impossible to keep spine and head straight and very difficult to hold even some of them together. When the bottom block or pelvis is tilted and unstable, it is IMPOSSIBLE for them to balance their head on top. This is why the children can’t sit! Similarly, In standing, when the foot collapses, it is IMPOSSIBLE for the child to balance the pelvis, spine and head over the feet for standing with good posture. They have to compensate for the lack of stability by stiffening their body trying to hold it together (fixing), using muscles abnormally for that purpose (e.g. crouch gait). There will be abnormal changes throughout their body but if we stabilize the bottom block (feet), then it becomes possible.

19 The Solutions: The custom contour seat stabilizes the bottom block (pelvis) for sitting and the back of the chair helps them to align their spine. Then, they can balance their head on top. You know you have achieved alignment when you see intermittent chin tucks. Similarly, Cascade Orthotics stabilize foot (bottom block) for standing.

20 What happens in the commercial chairs we use ?
Unless the chair includes support directly at the sacrum, a ramp that lifts the femur at the end of the knee that holds the legs in line with the hips, and lateral leg support to keep them aligned with the hips, the child’s bottom slides forward. You see this all the time, when someone “pulls up” the child in his chair it is because the bottom slid forward. The only thing I know that really works for this problem is the custom contoured seat. Commercial contour seating often fails to provide support at the sacrum, and sometimes fails to keep the legs aligned with the hips. The ramp that is needed near the knee gets broken down with use and sometimes slopes down instead of up.

21 350 Happy Chairs later….. I’ve learned that normal alignment leads to normal development. Children that don’t display any balance reactions, suddenly do in their new Happy Chair Swallowing gets easier. Muscles in the throat are the same length on each side and gravity assists food going down into the right place. Talking is easier in normal alignment too. A few children have started saying words in their chair.

22 Sitting but poor functioning, pelvis unstable so many compensations.
Little boy sitting alone but look at his pelvis and back. Can’t see much pants or diaper at the back? Then the pelvis is probably tilting back. He was not using his vision very well and playing was impaired by hand use for support. Let’s talk about all the problems that occurred due to his unstable pelvis; kyphosis in back, where is his neck? His shoulders are elevated for stability, arms not in a good position to play and they have to be used intermittently for support, upright head and upper trunk control cannot develop, and his legs are rolled out and apart (which will eliminate balance reactions and development of the abdominal obliques.

23 This is the same day, when we placed him in his new chair
This is the same day, when we placed him in his new chair. The blue tape is to hold it until the adhesive is fully dry. Now you see his neck! His ear is over his shoulder, He is weightbearing on his left arm in a natural position and look at the visual focus! Bringing the toy up to eye level and keeping the stimulus in a consistent posiition is Really helpful for children working on developing their vision! Now, when he reaches for the toy, his eyes and hands will be together.

24 Seating for Prevention!
Begin supported sitting at 5 months. Gets them off their head! Less torticollis and plagiocephaly. Can provide positioning before 5 months if needed. NICU grads and infants are welcome if there is a need. (must have DDD) Good supportive seating can prevent the development of scoliosis. If a child is hanging to the same side, tilting the head to the same side, let’s intervene before the problem occurs! Bumbos are not the answer for kids with significant muscle tone differences. We all know that it is much easier to prevent a problem from occurring than to treat it. I also use seating for prevention.

25 Infant with Down Syndrome age 4 months. See kyphosis already
This is the child that taught me that lesson. This is an infant with Down syndrome at 4 months of age. He was on the low end of the range of muscle tone for kids with Down Syndrome. If his mom did not Hold him together with two hands, he collapsed fully forward to the ground. Although he looks pretty good in the first photo, he could not stay sitting like that, even with his mom using both hands. So, we made him some seating which he started using when he turned 5 months.

26 3 months later- child sitting alone, pelvis stable with sacrum at 90, kyphosis completely resolved.
3 months later (at 9 months), he was starting to sit alone but now with the pelvis stable and sacrum erect and back straight. He is using a little scapular retraction to help him stay upright but he was Very successful with sitting alone. You can tell how well he is doing by the positions on the adults in the photo- no ones sitting close or has hands ready to catch.

27 Why not just use commercial equipment?
Young children with significant neuromotor delays aren’t very successful with commercial equipment, which is designed to fit an age or size RANGE and strap the child in so they don’t fall out. We want more than just safety, we want normal alignment (for comfort and health) and for the child to be able to function. The more severe the physical challenge, the more perfect the chair has to fit for the child to be able to function. I do use commercial equipment when the children are starting to get too big or too old for Happy Chairs. I often will put in a custom contour seat to stabilize their pelvis if they still need it. Some children don’t still need it, they have learned how to hold their body in good alignment. Occasionally I meet children that already have commercial equipment and sometimes I do both; add a contour seat to their equipment and make them a Happy Chair. It depends on their needs and the needs of the family.

28 Seating to make functioning possible
Kids need seating to be functional. We don’t want to wait until they can sit alone before they start functioning! This bright little girl is unable to anything on the floor except flail arms and legs and occasionally she can momentarily touch and fling something. Here she is in her chair making choices with a dear friend, Dr. Caroline Musselwhite, writing a social story to use with her brother. She just turned two that week.

29 ADAPT Shop is about ……increasing quality of life for children and their families.
I was asked to see this child because she was unstable in every position and equipment they put her in. They could no longer contain her in her umbrella stroller and they wanted some help. She lay on the floor most of the time, and though she did some movement, she could not maintain a toy in her hand, she was not sustaining her gaze for any length of time on anyone or anything. This is 4 months after she had her seating. She was sitting alone, using her hands to play and great improvement in her vision. The family could face her for interaction and communication instead of being behind her and spending all their energy trying to contain and support her body. They could really play with their little girl. You can see, she is purposefully playing with toys then also. Unstable pelvis, couldn’t stay in umbrella stroller, takes 2 hands to hold in sit. Constant movement. 3 months later; sitting to play, vision better

30 Who needs a Happy Chair? Kids with high tone Kids with low tone Kids with poor pelvic stability or fluctuating tone Really, any child that is not being successful physically with head control, trunk control or sitting. A child that has a body out of alignment, either because they don’t know where everything goes or they are unable to get it there.

31 Children laying on the floor or tilted back in wheelchairs
Children laying on the floor or tilted back in wheelchairs. They need seating too! No child is too severe! We help lots of children with severe disabilities and those with severe deformities too.

32 But they have nice tilt in space wheelchairs….
The Lazy Boy effect; How well do you pay attention when fully supported and leaned back? Tilt in space is good for the bus or a nap! If I was giving a lecture on your favorite area of interest. You were loving it! After the break, you come back and the seats were replaced with Lazy Boy Recliners. What happens to your level of attention and engagement? This is your favorite subject!!! I call this the Lazy Boy effect and this is what happens with those tilt in space wheelchairs. It is also very difficult to see forward. When tilted, you have a great view of the ceiling. Tilt in space is nice for the bus. Move the child to as upright as he/she can manage (more upright than you think) for meaningful activities.

33 I’ve learned that almost all children want to be upright after about 6-8 months old.
You can’t always tell this when you interact with them. Some children are so frustrated with being trapped in equipment that they will fight even flexing their hips! Normal alignment is comfortable. Childdren with significant neuromotor deficits are almost NEVER in normal alignment! Not in their wheelchair either. When I get the children aligned normally and supported comfortably, and able to move a bit, they get so happy! Even with trial parts and pieces, I can often position a child well enough that they smile and turn to look at me.

34 Upright doesn’t just mean sitting!
As the children started to get stronger from sitting in their Happy Chairs, I noticed that the contour seat held them in the correct position to stand if their trunk was moved forward (nose over toes). I talked to the children first and asked them if they wanted to stand up. Boy, did they! The look on their face is priceless! They are so proud and happy! I’m so sorry I don’t have photos of this facial expression because my hands are busy helping them stand. Remember when your young child did something for the first time? That look of joy is unmistakable.

35 Standing for kids in wheelchairs
This is our stand up bar that we use to help children begin to pull to stand. This child isn’t sure yet whether he likes it. He is in the minority, most kids grin! Let’s talk a minute about spatial awareness of their body map. Children are not born with a spatial map of how their body is connected together. It is as they move, bump against things and bear weight on parts of the their body that they put together a map of their body. The children at the ADAPT Shop, generally didn’t have enough strength to access these experiences. As a result, we see lots of incoordination when we try to help them do things with their body. This is most commonly seen in the legs. You try to stand a child up and they have no idea what to do with their legs and feet. Some children don’t even put them on the floor. Sitting in a raised Happy Chair puts weight on the feet. As the child moves in the chair, weight shifts through their now flat feet. This helps them connect their legs to their trunk in their body map. Many children that were not near standing when they received their chair, can easily stand up from their chair when prompted a month or two later.

36 All by myself! Standing, even if your hands don’t know what to do yet.
85% of the children start using the stand up bar while they require hand over hand to keep their hands from falling off the bar. This child is standing alone at the bar for the first time. You can see my hand ready to catch but she didn’t need it. This child has vision impairment, hearing impairment, motor impairment and cognitive delay. She is 2 ½ in the photo. She stood here for several minutes by herself. You can’t see her face but her eyes are focused and she is paying close attention to her task. Thus, it’s a meaningful activity for her! I’ll share a funny story. I took a stand up bar into her classroom. I had a number of ADAPT clients in the same classroom. I had done some standing with her with the bar and she was still on my lap while I was trying to do some teaching with the staff. She started kind of bouncing on my lap. Finally, I said to her, are you getting tired of waiting while I’m talking so much? Here’s the bar- and she practically jumped out of my arms standing up! It was a good lesson, this child was cueing me to do my part of the job so she could do hers. This was early in the school year, and the staff had never seen her take initiative in anything so it was a good eye opener that there was more going on inside this little girl. Standing, even if your hands don’t know what to do yet.

37 Helping with Standing-Orthotics
For low toned feet 1st AFO’s for standing For children with increased tone or moderate to severe physical challenge If the child is weak enough to need help to be able to begin to stand, they almost certainly need decent orthotics. I have the best luck with Cascade orthotics, they have a patented plastic that is much thinner and more flexible (but not too flexible). Hanger provides these upon request. They are more comfortable and allow more normal weight shifts and movement. I do ask for some special features, if you are interested, ask. When I use the stand up bar, I usually put my hands over theirs on the stand up bar. Few of the children have an effective grasp when we begin. 2nd articulated AFO for stepping

38 Kids like standing This child stands to look out the patio door at his dog outside. He stands for up to 30 minutes at a time and lowers to sit to rest for a bit, then stands again to continue his activity. Previously, this child spent the day laying on the floor with his hands in his mouth. He had severe CVI, hearing impairment, motor impairment and cognitive delay. He now uses the iPad effectively to interact with books and do interactive activities. He is working on using a walker.

39 Standing is exciting

40 Standing?? Our therapist says they aren’t ready for standing yet.
Yep! Children that roll in the door, tilted back in their wheelchairs, head falling off the headrest, yes, those children. But, they don’t even have good head control! Standing with good support makes it easier to hold your head, not more difficult. More than 80% of the children that I use the stand up bar with, pull to stand the first time we try it. Almost all the children enjoy standing in the KidWalk and the majority take some steps. My first goal for them is standing for transfers but if a child keeps progressing, we help them keep moving! Crawling comes up when we start to talk about standing weak children. Children that spend their day either laying flat or tilted back in their chairs most often have non functional arms and hands. Crawling requires a great amount of stability in the upper extremity. These children will not have this anytime soon, if ever! Furthermore, people have been making them work in prone for years and they HATE it! It requires a ridiculous amount of work for a tiny amount of reward. Children have been failing in this position for years. Humans don’t like to do tasks that they fail at! Working in standing is a way to gain core strength in the head and trunk which ALL these children need. It helps develop the shoulder and hand and gives the child an experience of learning to use their upper extremities for support. Weightbearing on their hands/arms increase their awareness of them and some children being reaching for something for the first time EVER!

41 What is standing good for?
Benefits from using the stand up bar include: Significantly improved core strength in neck and trunk Grip begins to happen and they are more successful with toys Longitudinal arch of the hand starts to develop Shoulders relax and muscles elongate, improving functional reaching Attention span increases because if they space off, they start to fall. New visual perspective on their environment leads to better use of visual skills

42 Kids like moving too!

43 This is the KidWalk, it works nicely for children that need a lot of support. It is unique among gait trainers because it allows the hips and seat to move to the side to unweight a foot for stepping and allows a little movement up and down to prevent locking of knees and to reduce spasticity. It holds them in good alignment and I see less sitting. I use it as a dynamic stander (child can stand and play in it) and as well as a gait trainer. Children find it very comfortable and like being able to move and experimenting while feeling safe. 9 months ago, this child had no head control and lots of extraneous mvt. He came today to try the Kid Walk. His neurologist was shocked at his progress, and said he never expected the child to improve EVER.

44 Child’s posture before
This child has very severe cortical vision impairment. He keeps this head down position in all equipment. This is what he looked like playing ball with his grandmother. His head didn’t go down until he was totally physically exhausted. He was in and out of the KidWalk but he lasted an hour. Vision was turned on, his was attention focused, that means we found? a meaningful task found for him. Child’s posture before Child’s posture after

45 Standing but not Standers
The standing we do is DYNAMIC. It involves moving and using their own power to stand or move. The skill I want to teach with standing is weight shift to one side so they can pick up a foot to take a step. This means moving and asymmetry. Standers lock kids into standing symmetry and the straps do all the work below the chest. They couldn’t move a leg if they wanted to. This teaches kids that they can lock their body or collapse but not how to shift weight and step. Standers are appropriate for children with paralysis, for most other children, there are better options.

46 The Purpose of Happy Chairs: Getting Stronger Increasing Function Better Quality of Life
Happy chairs are for getting stronger! Any human strapped into a reclined position or where the straps provide all the support will not get stronger, they will get weaker! Happy Chairs allow at least a small amount of movement so the child can build strength. Happy Chairs are for increasing function! NO human can give consistent responses if their body is not stable and comfortable. This includes heads falling off headrests, and trunks falling to the side, feet falling off footrests. When we are uncomfortable, it’s distracting! Mommy and Me

47 Red Rocket Scooter-up to 4 directional switches

48 Purpose of use of Red Rocket
1) Give movement experiences to children that have not had success with moving in an upright posture Allow the children to learn by making mistakes, as all children learn as they begin to move. E.g. crawling children bang their head repeatedly on a coffee table before they finally learn to duck. Move at a slow enough speed that they can work on visually processing WHILE they are moving.

49 Purpose of Red Rocket cont.
Help the child visually and cognitively begin to anticipate obstacles and use problem solving skills to figure out how to avoid them. Allow the child to begin to explore their environment and all the sensory motor experiences that come with it. Increasingly, speech therapists and assistive technology specialists tell us movement comes before communication. As the child moves themselves, communication is stimulated. They have something to talk about! As the child is able to move themselves, steer themselves and solve problems, others begin to see the child’s true abilities and potential. Humans are more likely to talk to someone who is moving.

50 Social Scripts for Young Children by Dr. Caroline Musselwhite
Our first workshop by Dr. Caroline Musselwhite was a huge success! We are encouraging families to use a Step by Step with Levels to help their child interact with their siblings, friends and families. I often share Caroline’s handout about how to make a social script with a child that can be recorded onto the Step by Step and used by the child for interaction. Remember-the child MUST choose the messages or else it will not be their voice and their self expression. Sometimes I help them create a first script about something meaningful to the child such as a script to interact with a sibling when they arrive home from school.

51 Switch toys, Other Resources
We have a limited number of switches and battery interrupters available for ADAPT Shop clients. Various other beginning level aug comm. options are also available for ADAPT Shop clients. We can help families find appropriate iPad apps to use with their child Sometimes we arrange for trial equipment when it is particularly needed. We believe in, “try before you buy” as much as possible.

52 Referrals? 602-633-8686 Tina Martin, Senior Manager for AT Under 3 years old:
Team needs to determine that the child has a need that the team feels they cannot meet without outside resources. Child needs a relevant goal on the IFSP. For example, child will sit and play with support or explore possible switches for active play with toys or explore some beginning aug comm activities. Service Coordinator gives us permission to proceed Simple, one page referral form We try to schedule to visit with one or more team members

53 Referrals- 3+ Service Coordinator adds 12 hours of PT for the ADAPT consultations. This is IN ADDITION to any ongoing therapy and will not interfere with ongoing therapy. Same simple, one page referral form We try to schedule to include the child’s ongoing therapist whenever possible.

54 Questions?

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