This hierarchy appeared to exist in contradiction to accepted standards of practice of rehabilitation. The strong emphasis of treatment of independent ambulation did include functional mobility and early on included the use of manual wheelchairs. It was a foundation of standard practice to recognize that ambulation and functional mobility were critical. In fact, occupational and physical therapists were the first professional groups to be looking towards adaptive equipment and treatment techniques which would assist children in mastering mobility.

However, when it came to powered mobility, this same standard of practice did not apply, it was not considered to be a viable treatment technique or even standard adaptive equipment. It was a "last resort" and only for those children who could prove in advance "readiness" skills.

With the microchip technology available today within powered chairs, the focus of "readiness" must change. The need for more bold and courageous treatment must include each child's ability to gain independent mobility through the use of power. This assumption then precludes that all previously held biases towards age, cognitive characteristics, or physical disabilities when considering a child as a candidate for power change. The only prerequisite to power now is the child's desire to be mobile.

In this session, I will demonstrate how powered mobility is both a treatment technique and adaptive equipment necessary for independent mobility (ambulation). It must be utilized as a standard of practice so that children can develop independent mobility.

Not only did we establish hierarchies of readiness, we also developed without thinking, I might add, methods of teaching, based on "driving."

We thought that giving someone a powered chair was most like giving them a car, and we proceeded to teach them as we were taught to drive. And when and how were we taught to drive? First of all, we were already experienced ambulators, and experienced hand users, and experienced task accomplishes. We came to driving with a rich past, and a capable, competent body. We had already mastered a bicycle, many riding toys, skating, dancing, and running. We also came with great desire, for the independence of control. Our teachers, however, came to this situation with great trepidation. They knew how much a "crash" could entail, not only in expense, but in dangerous bodily harm. Their primary job, was to try and ensure SAFE control.

In order to do that, they took the student and a vehicle to an open unfamiliar parking lot. The student was then taught some of what skills might be needed before approaching the environment to be managed, the ROAD. In this environment braking, turning, stopping short, starting quickly, looking both ways, all of this was considered. Windy roads, control of staying on the right, keeping the eyes forward, but also in the rear view mirror, all was emphasized.

Now, let’s consider an infant and toddler learning to walk. Do we set up cones and teach them right and left? Do we tell them to watch where they are going? Do we make them walk only on the right side? Do we instruct them the entire time they are walking, and do we stand over them, hovering, and instructing every moment? Do we insist that they walk over to us, first, and then on a predetermined pathway, we think is good? I am afraid if we did do this, no child would want to walk.

When teaching a child to ride a bicycle, are the same strategies used? Do we take them between cones? Do we tell them to look out, look behind, watch out? No, we stand with them, we work with them when both of us are ready to work, we work for short periods of time, and we hold onto the bicycle, making sure that the bicycle is managed, and the child is assured by our very presence, that she will not fall, and that the bicycle is under control. The child then slowly begins to take control as we allow it. We give up control as we see the child managing the bicycle. Most importantly, we also presume that the child will learn control of the bicycle. We never doubt her ability to learn, or to manage, we presume it takes an amount of time, and that time is specific to that child.

First and foremost we need to understand how to teach mobility. To a child who has never had control of her body before, this powered chair is going to be her legs. We need to encourage her and teach her as if she were learning to walk, using some strategies of teaching equipment like we would in teaching a bicycle, some like encouraging ambulation.

We need to totally change our approach in teaching driving to children. It must much more resemble the support required for ambulation. The powered chair to a young child, is a first form of independent mobility, walking some of the time. We must give up many of our ideas, past strategies and understandings of how we used powered chairs with adults. Our children are not going out by themselves onto a road, or off to work. Our children are learning to move.

These principles must be taken into consideration.

1. Familiar environment, small space, parents first

2. Immediate success and independent control

3. Control of Speed

4. Going and stopping, vs. forward (Turning as going, not circling)

5. Switch site/access

6. Forward Direction/ No reverse at first

In order to allow our mobility support to work, however, we need to have seating and chair performance which allows real independent control of the chair. This seating needs to be seating which promotes true task performance, not symmetrical passive control of the body. (Please read my other paper for a further discussion of this seating.)

The chair itself must be programmed to allow for simple control, moving to more complex situations as the child demonstrates increased competencies and interests. The adult is responsible for safety for all young children, not the child. The child will learn safe practice after having experience of control and with the adult’s assistance. When a toddler learns to manage a tricycle, we do not now teach them safety rules of the road. We stay with them, observing their judgment but not totally trusting them, and we are always nearby in an unfamiliar environment, or new situation. This, then, too, is how a new chair needs to be programmed. Slow speeds, but very maneuverable, not jerky movements must be adjusted through the programming of the controller. Reverse can be programmed out even in the use of a joystick, and not be provided for with single switches. Providing digital rather than proportional control is also important as a child learns to move, managing only one parameter of movement, direction, before complicating the situation and adding acceleration to it. Teaching subtle control by using zero pressure switches also allow the management of the driving controls to become automatic quickly. The joystick is not the first to be tried, when I work but rather the last. A child can do many methods of management of a chair, and accurate control of the chair and her body simultaneously is the foundation required for increased competence.

The use of single switches initially with children in powered chairs has really allowed an observable, easy progression, controlled by them, from the very beginning, to be ultimately, extremely successful. Many children progress easily and readily to a joystick. Others do not, but rather continue to progress to multiple switch access.

Who is a successfully trained child? Who is independently mobile? Independence must mean that the child is doing the act by all by herself. However, the level of independence varies greatly. If a child were able to drive a chair on a walk around the neighborhood, and her mother did not have to push her, and even if that child only controlled one switch which was forward, with the mother still responsible for the stops and turns, is this child independent? Yes, this child is independent at this task. Her mother can walk beside her, she is not pushing her, and the child is controlling the chair, independently. If a child could only do this, would this make her a candidate for powered mobility? Yes, yes, yes. However, I must now share with you, that after placing over 700 children in powered chairs, I have not yet met the one who only did this, all have continued to want to increase their independent control.

In closing, a lot more time could be spent on how the assessment process works, training strategies which have proven to be successful, and equipment which is preferred. In a few pages, this is impossible. Instead, as therapists, please think and try various types of mobility with children.

Remember, it is the point of delivery of the chair at which treatment really begins. Training is treatment. Use will define change, and functionality. Training must occur within the individual's environment. It should never be a "weekly" hour of training, but rather very short sessions, increasing in frequency rather than duration, over a longer period of time. The system ordered needs to be flexible to allow for change in use, and change in demand, both in seating, access, and chair performance.

Treatment and training need to come from reaction rather than control, expecting our children to tell us what they need and want, and by providing them with rich, and satisfying, successful experiences. Providing them with patience, and supporting them with faith in their own abilities to explore, and allowing them to be curious are the greater gifts. Wait for them to request what they need, wait before telling them how to use the equipment. Recognize that supporting an individual's own relationship with independence and subsequent mobility, is the task, not teaching an individual how to drive.

Continue to observe that mobility and the control of mobility is an interaction which provides opportunities for competence. Continue to promote the use of assistive technology, and to remember that powered mobility is crucial. Without independent mobility, it is difficult to interact. Without independent mobility it is almost impossible to be included. Remember that mobility is an inherent human desire, and trust it to show itself.