Self-directed mobility is a fundamental human right, especially for young children with disabilities who rely on adults to provide them access to mobility experiences. Self-directed mobility is defined as movement that is initiated by an individual and may include independent locomotion such as walking, the use of mobility technology such as gait trainers, standers, or the use of powered mobility devices including motorized wheelchairs, battery-operated ride-on toy cars, or other similar devices. Children without disabilities experience developmental gains in cognition, language, and social skills as a result of the onset of independent locomotion that occurs between 10 and 14 months of age (Campos et al., 2000; Uchiyama et al., 2008; Anderson et al., 2013).

Regardless of ability, the grounded cognition framework (aka embodied cognition or embodied development) (Thelen and Smith, 1994; Thelen et al., 2001; Smith and Gasser, 2005) suggests that learning occurs through movement as bodies and minds interact with and within environments and experiences of particular cultural or social contexts (Lobo et al., 2013). Research in developmental psychology and pediatric rehabilitation demonstrates that active (i.e., self-directed) movement experiences are fundamentally different and more advantageous compared to passive movement experiences (Held and Hein, 1963; Libertus and Needham, 2010; Jones et al., 2012; Lobo et al., 2013). Thus, the relatively passive lives of young children with disabilities who experience limited mobility are especially disturbing.

Over 30 years of research has demonstrated that young children with disabilities who experience the most severe delays in mobility can use powered mobility devices for self-directed mobility (Butler et al., 1983; Galloway et al., 2008; Lynch et al., 2009; Livingstone, 2010; Ragonesi et al., 2010; Jones et al., 2012). Equally important, using this technology results in some of the developmental gains associated with the onset of crawling and walking (Butler et al., 1983; Galloway et al., 2008; Lynch et al., 2009; Livingstone, 2010; Ragonesi et al., 2010; Jones et al., 2012). Unfortunately, the reality is that many if not most of the children who could benefit from powered mobility do not gain access to this technology until after 5 years of age (Nicholson and Bonsall, 2002). Given the importance of self-directed mobility, we believe that this lack of access is nothing less than a form of human rights violation—but a violation that is readily eliminated as the barriers to access and solutions are both known and being addressed by our work and others (Feldner et al., 2016).

One significant barrier that prevents widespread acceptance of access to self-directed mobility experiences is the absence of commercially available powered mobility devices that are specifically designed for young children with disabilities and accessible to all. For example, the Wizzybug© manufactured by designability© is commercially available but is not available for purchase in North America. Another example is the Skippi© manufactured by Ottobock© but starts at a base price of $10,000. Furthermore, the cost of other available powered mobility devices can be up to $30,000 or more (Cooper et al., 2008). Insurance companies routinely deny funding requests based on cost, environmental accessibility, or a child’s young age (Nicholson and Bonsall, 2002; Staincliffe, 2003). Modifying off-the-shelf, battery-operated ride-on cars has emerged as an alternative to traditional powered mobility devices (Huang and Galloway, 2012; Logan et al., 2014, 2016).

Go Baby Go is a community-based outreach, research, and clinical treatment program that works with families, clinicians, service providers, and industry to provide pediatric equipment to children with disabilities for movement, mobility, and socialization. The modified ride-on car technology, which was explored intermittently in the late 1980s and early 1990s, re-emerged from the Go Baby Go program in 2012 (Chiulli et al., 1988; Cooper et al., 1992). Commercially available, battery-operated, ride-on cars are adapted by installing a large, accessible activation switch. Common materials such as PVC pipe, swimming kickboards, and Velcro are used to build a customized seating system for support. Modified ride-on cars offer a low-cost, powered mobility device that is affordable, accessible, and fun. Because the device is a mainstream toy, caregivers and clinicians can address child and family goals without the social stigma of a medical device (Gibson et al., 2012). Not surprisingly, evidence is emerging that suggests positive developmental gains for children with disabilities who use modified ride-on cars for self-directed mobility (Huang and Galloway, 2012; Logan et al., 2014, 2016).

The purpose of the current technical report is to describe two innovative and novel extensions of the initial modified ride-on car technology that encourages self-directed mobility, participation, and function for young children with disabilities. The general features, modifications, and clinical applications of the modified ride-on car technology are described in a previously published technical report (Huang and Galloway, 2012). One major feature of the initial modified ride-on car technology is that the activation switch is pressed while a child is seated. A child must use their hand, trunk, or head in order to press the activation switch (see Figure 1). The current report extends that work to describe “sit-to-stand” and “throw-baby-throw” ride-on car technologies.

One limitation includes that modifications range from relatively simple (sit-to-stand technology) to complex (throw-baby-throw technology). It may be difficult for individuals without prior engineering or electrical experience to complete the modifications on their own. Another limitation is the level of noise that ranges from minimally (sit-to-stand technology) to potentially distracting (throw-baby-throw technology). Finally, while families and volunteers can complete the modifications using step-by-step instructions, many people are hesitant to attempt the modifications themselves, citing intimidation, or a lack of perceived confidence in their technical abilities.

A limitation of both technologies is that often, a caregiver still may be required to provide assistance with steering (sit-to-stand technology) or helping to retrieve the foam balls (throw-baby-throw technology). However, it is hoped that incorporating the throwing device on to the car will also provide increased opportunities for peer-to-peer interaction in all aspects of ball game play, where a peer might engage in ball retrieval rather than a caregiver. In addition, children with disabilities may not have the coordination and bilateral upper-extremity function to simultaneously use both technologies at the same time. Children with disabilities may need to stop the ride-on car before activating the switch for throwing. However, the skill level required to run and throw at the same time is often beyond the capabilities of young children without disabilities. The throw-baby-throw technology is designed to emphasize social interaction, rather than proficiency of sport. Future research will examine the use of both technologies by children with disabilities in natural contexts such as early learning centers and within the home.

There are several advantages to the sit-to-stand and throw-baby-throw technologies. One advantage is that both technologies were developed using developmentally inspired principles of powered mobility technology (Feldner et al., 2016). These principles include: adaptive, flexible, durable, low-cost, esthetic, and accessible [see Feldner et al. (2016) for a full description of each principle]. Another advantage is that both technologies are designed to be simultaneously “assistive” and “rehabilitative.” For example, a wheelchair is an assistive device that supports participation, but typically does not contribute to increasing function. By contrast, a treadmill is a rehabilitative device that supports function, but typically does not contribute to increasing participation. The sit-to-stand technology is assistive as it provides a means of self-directed mobility. This technology is also rehabilitative because embedded within its use is encouragement of the physical skills of pulling from sit-to-stand and dynamic-assisted standing and balance. The throw-baby-throw technology is assistive because it provides a means of throwing. This technology is also rehabilitative because embedded within its use is encouragement of the physical skill of reaching. The activation switch can be moved closer or further away, or on the left/right side or in midline in order to encourage reaching in a way that promotes physical strength and coordination.

Another advantage is that both technologies are lightweight and portable which promotes use within a variety of real-world contexts, such as the home, early childcare center, playground, and other community spaces. Due to this design feature, the technologies may be used much more frequently and for longer durations than traditional pediatric technology. Another advantage is the relatively low-cost of modification supplies that will enable greater access to all families. Finally, these toy-based technologies are inclusive and socially welcoming for children of all abilities, promoting further integration and participation of children with and without disabilities within the same play contexts.

Another advantage of the throw-baby throw technology is that it may foster independence. A majority of switch adapted toys focus on sensory consequences such as lights, sounds, and vibrations, rather than an emphasis on participation that may be provided by the throw-baby-throw technology. Typically, switch adapted toys are simply placed next to a child with a disability. This does not allow a child with a disability to move within the environment to initiate social and play interactions with others. The attachment of the throw-baby-throw technology to a modified ride-on car provides the potential of more independence in participating with others by allowing a child with a disability to make their own decisions with regard to exploring the environment and engaging in the skill of throwing.

Over the past 15 years, pediatric rehabilitation professionals have widely adopted a modern health framework, the World Health Organization’s International Classification of Functioning, Disability, and Health (ICF), as a model of holistic practice (World Health Organization, 2001). The ICF includes three health domains: (1) body structure (anatomical parts of the body) and function (physiological functions of body systems); (2) activity (execution of a task or action by an individual); and (3) participation (involvement in life situations). The ICF also considers environmental factors that make up the physical, social, and attitudinal environment in which people live and conduct their lives (World Health Organization, 2001).

The ICF was generated out of concern that previous classifications of the various domains of health and functioning neglected to recognize the social and environmental barriers to function that exist external to an individual, thus situating disability as solely an individual problem (Wiart and Darrah, 2002; Ostensjø et al., 2005; Gibson and Teachman, 2012). The ICF model, as a response to these concerns, contains body function and structure domains as well as activity and participation domains, all of which can influence or be influenced by personal factors and environmental contexts, but which are not meant to be linear or to imply causal relationships (Law et al., 2007; Gibson et al., 2009; Gibson and Teachman, 2012).

Despite the adoption of the ICF, the current culture of pediatric rehabilitation and caregivers alike view the use of powered mobility devices as a “last resort,” once all other efforts toward the skill of walking have been exhausted (Bottos and Gericke, 2003; Wiart et al., 2004; Rosen et al., 2009; Feldner et al., 2016). This represents a dichotomous view of thinking suggesting that self-directed mobility should be achieved by either a powered mobility device or walking. This dichotomous view may persist, in part, because researchers and caregivers have observed that the inability to walk is considered the most visible signifier of disability (Wiart et al., 2004; Daudji et al., 2011; Gibson and Teachman, 2012). For example, when comparing a walker device to a wheeled mobility device, a caregiver expresses

Especially the kids at school, they think it’s pretty neat that he’s walking like they are. He seems to be more of a boy than more of a, ah, than you know someone with a disability (McKeever et al., 2013, p. 386).

This view reinforces traditional emphasis on body structure and function goals of the ICF, which focuses on walking as “normalcy,” undermining other forms of mobility, and implying that participation is a lesser goal. Moreover, it equates disability with being less than a boy, or, to put it bluntly, less than human. Emerging research indicates that this sentiment is the consequence, in part, of a lack of positive disability narratives that challenge walking as the only means of “normalcy,” which, left unmitigated, often results in children with disabilities’ internalization of stigma and low self-worth (Gibson et al., 2011; Gibson and Teachman, 2012). Several studies cite the role of rehabilitation professionals as key in either maintaining or challenging these established normative views on disability and walking (Wiart and Darrah, 2002; Bottos and Gericke, 2003; Wiart et al., 2004; Gibson et al., 2011; Gibson and Teachman, 2012).

The sit-to-stand and throw-baby-throw technologies presented in this technical report embrace the holistic view of the ICF by placing equal emphasis on the body structure and function, activity, and participation domains. The sit-to-stand technology specifically targets the physical skills of pulling from sit-to-stand and assisted standing, skills that contribute to the onset of independent locomotion. The throw-baby-throw technology specifically targets the physical skill of reaching. These aspects of the technologies emphasize the body structure and function domain by encouraging the advancement of specific physical skills.

The sit-to-stand and throw-baby-throw technologies presented in this technical report simultaneously embrace the medical and social models of disability. The ICF represents an attempt to find balance between dominant disability models. In certain academic or advocacy circles, there is a broader, on-going societal conversation regarding different ways of thinking about disability. However, knowledge of disability models themselves, and their implications, has yet to be translated into most of the lay-public’s daily community life. Disability models are sets of beliefs about the cause, nature, and treatment of disability. The medical model views disability as an individual pathology that is determined through diagnostic criteria based on deviation from a statistically determined norm for the purpose of treatment or cure (Olkin, 2002). An alternative view is the social model of disability. In this model, the “problem” of disability is primarily socially constructed and society’s lack of accommodation for people’s differences is the cause of the disabling experience (Olkin, 2002). Therefore, while impairment may exist at an individual level, disability occurs because societies are structured under the assumption that everyone is healthy, without disability, and fits a culturally constructed norm or ideal (Wendell, 1996). The social model encourages the formation of an identity inclusive of disability as a positive experience, akin to a minority group, one that can help to improve an individual’s quality of life and adaptability (Dunn and Burcaw, 2013; Bogart, 2014).

Both technologies presented in this technical report emphasize impairments at the individual level by advancing physical skills. These aspects of the technologies align more closely with the medical model. However, encouragement of physical skills is embedded within ride-on cars, a daily play, and exploration and participation experience of millions of children without disabilities. Both technologies provide a means for children with disabilities to engage in similar childhood experiences. The low-cost, low-tech, and do-it-yourself aspects of the technologies promotes increased access for children with disabilities and supports inclusion and full participation in society. These aspects of the technologies align more closely with the social model. Both technologies embrace that treatment and rehabilitation are important while simultaneously creating an interface in the form of modified ride-on cars between children with disabilities and their environment as a means to reduce barriers and support social participation. Perhaps the social model of disability needs even further influence in rehabilitative practices surrounding self-directed mobility. Although commonly cited as at odds with rehabilitation frameworks, the ICF incorporates psychological and social (environmental) factors of the social model, and provides a framework to engage these models in a complimentary way as demonstrated in the current technical report (Wiart and Darrah, 2002; Gibson et al., 2009; Gibson and Teachman, 2012; McKeever et al., 2013).

There is a growing alternative culture within pediatric rehabilitation that highlights a social model of disability and embraces “effective mobility,” defined as “locomotion that is functional, timely and energy-efficient” (Butler, 2009, p. 5). Effective mobility emphasizes a multi-modal view, suggesting that individuals, including young children, may need several options for locomotion to provide opportunities for participation in daily life depending upon the environment and situation (Feldner et al., 2016). The multi-modal view of self-directed mobility more closely aligns with the social model of disability because it does not view a lack of independent locomotion as a disability, but rather embraces alternative ways that society may accommodate for people’s differences by supporting access to powered mobility devices.

As a practical application of the shift in thinking to effective mobility, pediatric rehabilitation professionals can engage in more value-neutral modes of caregiver education, describing the benefits of self-directed mobility at all levels, whether generated via activation of a child’s own body or via a mobility device, and emphasizing that both modes should occur as early as possible. Adjustments in service delivery can also include an explicit commitment to a paradigm of “right mode, right time” decision-making, in which all modes of self-directed mobility are considered equally valuable, dependent on environmental contexts and needs of the child. Doing so further reinforces the value of multi-modal self-directed mobility, and weakens a walking vs. wheelchair dichotomization by considering other forms of locomotion like bicycles, ride-on toys, the Segway, go-carts, and scooters (Feldner et al., 2016). Moreover, a team approach should be utilized to ensure that the child himself or herself is at the center of these modal decision-making processes, at the earliest possible opportunity.

There are currently no plans to pursue commercialization of either technology presented in this report. It is critical that any electrical and structural modifications to a ride-on car or toy-based pitching machine be fully tested and checked by an engineer with the appropriate expertise to determine safety. The technologies described in this report may or may not be appropriate for any individual child. It is important that families work with their child’s clinical team in order to reach appropriate decisions of treatment on an individual basis.

SL, JG, WS, HF, and KB created the idea and were significantly involved in writing and reviewing manuscript drafts. BG, SR, MC, AW, and ZS were involved in the design, prototyping, and testing of the technologies, as well as reviewing manuscript drafts.

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.