“Kind of empowered”: Perceptions of socio-emotional development in children driving ride-on cars

Abstract

PURPOSE / Objective:

Early powered mobility (PM) experiences can be essential facilitators of self-initiated mobility, socialization, and exploration for young children with disabilities. Cerebral Palsy (CP) and developmental delay are two of the most common diagnoses associated with motor disability in young children with 1 in 345 children diagnosed with CP and 1 in 6 with developmental delay in the US. The purpose of this study was to explore the longitudinal experiences and caregiver perceptions of socio-emotional development in particular, in young children with disabilities during modified ride-on car (ROC) use.

RESEARCH METHOD/ DESIGN:

A qualitative, grounded theory approach was used. Semi-structured interviews were conducted with 15 families (children ages 1–4 with CP or developmental delay) at baseline, 6 months (as able due to COVID), and one year following ROC introduction. Data was coded independently by three researchers using constant comparison until data saturation occurred and themes emerged.

RESULTS:

Four themes emerged from the data: ‘Leveling the Playing Field’; ‘Breaking Down Barriers’; ‘Fun and Work: ROC as Toy and Therapy Device’, and ‘Mobility is a Pathway to Autonomy’.

CONCLUSIONS/IMPLICATION:

Children and caregivers viewed ROCs as both fun and therapeutic, consistently identifying perceived benefits for children’s socio-emotional development. This qualitative study provides a better understanding of the complexities and impact of ROCs on children and their families in the socio-emotional domain and may help facilitate clinical decision-making when introducing PM to young children with disabilities as part of a multimodal approach to early intervention.

Introduction

Mobility for all children is essential for growth and development. Children learn by exploring their environment and interacting with the people around them (Adolph & Hoch, 2019; Lobo, Harbourne, Dusing, McCoy, 2013). However, many children with functional limitations or neuromuscular impairments are unable to participate in self-locomotion (Huang & Galloway, 2012). Research has established that when young children are unable to mobilize independently, they are at a higher risk of secondary impairments to their communication skills, visual-spatial perception, cognitive and socio-emotional development (Feldner, Logan, Galloway, et al., 2016; Huang & Galloway, 2012; Jones, McEwen, Neas, 2012; Logan, Feldner, Galloway, Huang, 2016). The inability to move independently has also been linked to decreased interactions with caregivers and peers which increases feelings of isolation and learned helplessness in young children (Feldner et al, 2016). While evidence continues to emerge regarding developmental benefits of mobility technology use in young children, the literature suggests that some of the primary benefits of self-initiated mobility for children with and without disabilities include gains in socio-emotional development (Adolph & Hoch, 2019; Gudgeon & Kirk, 2015; Guerette, Furumasu, Tefft, 2013; Huang & Chen 2017).

Self-initiated mobility has been shown to have a direct relationship with socio-emotional development. A child’s desire for, and experiences with, social interaction is often a driving force behind concurrent development of mobility skills (Adolph & Hoch, 2019; Lobo et al., 2013). The development of self-initiated mobility also affords children and caregivers the opportunity for new and different means of exploration, communication, social interaction, and testing of boundaries (Adolph & Hoch 2019). Contrastingly, the inability to initiate self - directed mobility not only limits how children are able to explore their environment but also impacts they ways they interact with the people around them.

For children with disabilities, mobility technology (including canes, crutches, walkers, manual and powered wheelchairs) is often used to facilitate self-initiated mobility experiences. Each of these devices have their own benefits and barriers to implementation, among them the child and caregiver socio-emotional responses to, and outcomes of, device use. For example, older children often view their mobility devices as an extension of themselves and key contributors to their identities (Gudgeon & Kirk, 2015; Huang, Sugden, Beveridge, 2009). Literature has also demonstrated that children often have positive feelings towards mobility technology because of increased opportunity for social interaction and inclusion (Huang et al, 2009). However, feelings about mobility technology can be complicated by the powerful and persistent stigma that accompany device use. For example, mobility technology can be a very visible outward embodiment of a child’s physical disability. For caregivers, mobility technology, especially powered mobility (PM), can represent a failure or last resort when their child is unable to achieve traditionally expected locomotion (Wiart & Darrah, 2004). Healthcare providers may also be reluctant to incorporate or recommend such technology, adopting a ‘wait and see’ approach to a child’s response to therapeutic intervention, or may mistakenly fear that use of a device may preclude, rather than complement, the development of other motor skills such as walking (Feldner et al., 2016; Jones et al., 2012)

In current pediatric rehabilitation practice, PM devices are not often considered or prescribed for children under 5 years old, despite evidence that PM devices provide crucial opportunities for self-initiated mobility during critical periods of development (Jones et al., 2012; Keynon, Jones, Livingstone, Breaux, Tsotsoros, Williams, 2018). Further, early PM interventions have been shown to be safe and lead to improved visual and spatial perception, communication, memory, and socio-emotional competency in children as young as 7 months old (Feldner et al., 2016; Jones et al., 2012; Lynch, Ryu, Agrawal, Galloway, 2009). However, options to support early self-initiated mobility in children under 5 remain limited. Over the past decade, adapted toys like battery powered ride-on cars (ROCs) have become a potential avenue for an accessible, developmentally appropriate, and socially welcoming form of early PM (Huang & Galloway, 2012; Kenyon et al., 2018; Logan et al., 2016). ROCs are commercially available toys that can be purchased at a much lower cost than pediatric wheelchairs and easily modified by caregivers or professionals to fit their child’s size, support requirements, and other medical needs (Logan et al., 2016). Implementation of ROCs in the home and community has been reported to be feasible, socially appropriate, and fun (Hospodar, Feldner, Logan, 2021). Previous literature has hinted at the socio-emotional impacts of ROC use, but these studies have all been short-term and a more in-depth understanding of this specific domain over time remains unknown. Therefore, the purpose of this study was to explore the longitudinal experiences and perceptions of caregivers of young children with disabilities during modified ROC use to answer the following research question: How does ROC use impact caregiver perceptions of the socio-emotional development and experiences of children with CP or developmental delay over a one-year period?

Methods:

The current study was one component of an overarching, longitudinal, mixed-methods study examining the use of ROCs in the home and community over a one-year period. Forthcoming manuscripts describe the quantitative and participatory results of this work. For the current study, a qualitative, phenomenological approach was chosen to explore child and caregiver perspectives and experiences with the ROC’s over a one-year period. This research approach is useful when characterizing in-depth, lived experiences of a group of participants with exposure to a similar phenomenon, in this case, use of an adapted PM device in early childhood development (Merriam & Tisdell, 2015). Researchers utilized semi structured interviews to examine the relationship between modified ROC’s and caregiver perceptions of their child’s socio-emotional development over time. Semi-structured interviews were selected to allow in-depth examination of ROC perceptions and experiences in specific topical areas outlined in an interview guide while allowing participants the freedom to describe other, open-ended ideas and responses that might be important to them (Merriam & Tisdell, 2015). Ethics approval was received by the University of Washington Human Subjects Division and all study procedures were conducted with informed written consent and parent permission.

Transparency and Openness

This study was conducted and prepared using the Journal Article Reporting Standard for Qualitative Studies (JARS-Qual) checklist (Levitt, Bamberg, Creswell, Frost, Josselson, Suarez-Orozco, 2018). Further information regarding the semi -structured interview process is detailed and cited in the study procedures section below. The study’s design and analysis were not pre-registered. All data analyses, coding processes, and other research materials are available from the authors upon reasonable request.

Participants:

This United States-based study was open to children with CP or developmental delay and their caregivers, which were defined as one or both parents, grandparents, or other adult identified as the legal caregiver or guardian of the child. Participants were recruited across Western Washington area via convenience sampling through email and in-person distribution of study fliers to regional rehabilitation and early intervention clinics and local healthcare providers known to the research team. Potential participants self-selected to contact the research team and were then screened for eligibility. Inclusion criteria for the child were: 1) Age between 12–48 months old at study onset; 2) Medical diagnosis of developmental delay or CP with any level (I-V) of associated motor ability according to the Gross Motor Function Classification System (GMFCS) or communication ability according to the Communication Function Classification System (CFCS); 3) Ability to maintain a seated position with or without support; and 4) Ability to tolerate upright sitting with or without support while moving through space for 30 minutes; Inclusion criteria for adults were: 1) Age 18 years or older; 2) A legal caregiver for the child participant; 3) Reside in the same home as the child; and 4) Demonstrate proficiency in English to participate fully in the interview. Inclusion criteria was assessed via caregiver report using screening questions. If all eligibility criteria were met, participants were enrolled in the study on a rolling basis and remained in the study for a 1-year period.

Researcher Positionality:

The research team consisted of four physical therapy research capstone students at the University of Washingon during the time of the study. The senior author and principal investigator of the study was an experienced pediatric physical therapist with close to a decade of expertise in mobility technology research and specifically the Go Baby Go mobility and socialization program. The lead author had prior experience working with both neurotypically developing and medically complex children as a caregiver, and one author had background experience in early childhood education. This background positioned the team well to conduct all study procedures, however, also introduced the potential for bias.

To mitigate the potential for acquiescence bias, the research team engaged with the families using techniques such as unconditional positive regard throughout the study and particularly throughout the interview process. For example, specific research questions were generated with the aim of understanding the barriers and any negative experiences associated with the modified ROC in addition to seeking the facilitators and positive experiences (see Table 2 for examples of questions). During the interviews, all families were reminded that there were no inherently right or wrong answers and that all perspectives were valued. Further, the semi-structured interview guide was reviewed to ensure questions were open ended and non-leading, and that general topics of interest to the researchers were covered with additional opportunity for participants to express their perspectives on other topics they felt were important to their own experiences (Merriam & Tisdell, 2015). To minimize confirmation bias during data analysis and interpretation, research team members engaged in reflexivity and also conducted analysis procedures independently before reviewing results together and agreeing upon final themes.

Table 2.

Sample of Interview Questions

Sample of Interview Questions
Timing of Interview	Questions for Parents or Caregivers
Initial Interview	Describe your initial reaction to your child receiving his/her adapted ROC. Why are you interested in obtaining an adapted ride-on car for your child? How does this version of PM compare to other forms of PM, like a power wheelchair? Have you ever considered another PM device for your child? Where do you think your child will go in their car? What things will your child do or want to do? Describe how you see your child as they move around now.
Final interview	Describe the past year in terms of getting used to and using your child’s car. How would you describe the benefits of the ride-on car? How would you describe the drawbacks of the ride-on car? Describe any additional or unexpected situations (positive or negative) that have come up in the past few months in relation to your child’s ride-on car. Has having the car been the experience you have expected for you and your child? Why or why not? How have your feelings about the car shifted or changed over the past few months? How do others (friends/family) respond to your child in their car? Is this the same or different as when you first got the car?

Study Procedures and Overarching Context:

Within the overarching study, each family was provided a modified ROC, custom adapted to meet the different seating requirements of each child using easily acquired items like PVC piping, pool noodles, and harnesses to provide support. Each ROC had a large push button on the steering wheel to start the car as well as a data logger to track car use of the course the study. Two of the cars were outfitted with custom “trailers” to accommodate medical equipment like ventilators. All study procedures took place virtually or during in-person visits to the family’s home. Families were trained how to use the device to facilitate their child’s mobility and exploration, and were instructed to use the ROCs at a self-selected frequency and duration that worked with their individual schedules. Families kept the cars for one year, during which time data collection took place at three time points approximately 6 months apart to capture change over time: baseline, mid-study, and study completion. All children continued their routine care and therapies. Upon completion of the study, families could choose whether they wanted to keep the ROC (with data collection instrumentation removed) or recycle it back to the research team.

Semi structured interviews are often used in mixed methods or qualitative research “to explore participant thoughts, feelings and beliefs about a particular topic” using open ended questions. (DeJonckheere & Vaughn 2019). Interviews were conducted using a standard set of open-ended questions to explore caregiver experiences and perceptions related to ROC use, including potential impacts on socio-emotional development. A list of representative interview questions are provided in Table 2. All interviews were audio recorded and transcribed verbatim.

Data Analysis

Data from the semi-structured interview transcriptions were coded independently by three researchers using constant comparison until data saturation occurred and themes emerged (Merriam & Tisdell, 2015). A digital codebook was created in which researchers labeled and defined open codes, these were subsequently condensed by merging similar open codes, and re-labeled as focused codes. Independent coding took place initially using N’Vivo qualitative analysis software (QSR International, Burlington, MA, USA) but was transitioned to hand-coding when research facilities were closed due to the COVID −19 pandemic and shared software became inaccessible. After the initial independent coding process the data was discussed until themes were identified, refined, and 100% agreement was reached amongst the researchers. See Table 3 for an example of the thematic coding process. A copy of the final themes was presented to the participants as a form of member checking in order to solicit feedback, avoid misinterpretation, and ensure the accuracy of the data (Merriam & Tisdell, 2015).

Table 3.

Audit Trail Sample of Quotes and Coding Process

Quotes	Open Coding	Focused Coding	Theme
“He’s always watching people leave him, where this will allow him to go over there” (Initial, P05, father of 4 year old)	Opportunity for social interaction, ROC as play, Social power dynamics, inclusivity, Children with disabilities, siblings copy each other	Social interaction, power dynamics, inclusion	Leveling the Playing Field
“I don’t want her to like people to like take sympathy on her or like treat her different because she’s either in a wheelchair, or she needs a little extra time or- we want her to be able to stand up for herself and you know make her own decisions and if she wants to do this or if she wants to make her own choices” (Initial, P03, mother of 3 year old)	ROC as play, inclusion, disability perspectives, stigma against wheelchairs /AD, early PM seen as toy, opportunity for play with peers, technical difficulties, parents are blamed for not charging the car, car is popular with other kids, siblings want to play with the car, Exploration, wonder, ROC, building confidence	Not all early PM interventions are the same, stigma and play, inclusion	Breaking Down Barriers
“She is a kid that needs motivating. She’s not going to do something if it’s not fun.” (Midstudy, P08, mother of 3 year old)	Socio-emotional development, emerging independence, caregiver vs. Child-led play, child motivation and perseverance, play is hard work, cause and effect, balance between therapy and play, Avenue for socio- emotional development therapy device vs toy, Child enjoys being in the car, gaging ability level, opportunity, just right challenge, rising to the challenge, learning curve, perseverance, resilience, adaptation, parent pride	Socio-emotional development, motivation, emerging independence, Play is essential for motivation and independence, development requires challenge, gaging how hard to push is difficult, adaptation, the just right challenge	‘Fun and Work: ROC as Toy and Therapy Device’,
“When we got this car, you know, having him have the ability to make it go forward and backwards himself, and just to see how excited he was just amazing.”(Initial, P01, mother of 3 year old)	ROC as play, confidence, independence, freedom socio -emotional development, joy, self- directed mobility, no barriers, meaningful interactions, interacting with the environment, caregiver pride, independence is fun	Independence in mobility, ROC is freedom, Socio – emotional development, self- advocacy, children ask for what they need	‘Mobility is a Pathway to Autonomy’.

To ensure rigor and transparency, multiple methods were employed during analysis of this qualitative data. Triangulation of multiple data sources occurred as part of the overarching study, including the study semi structured interviews presented in this study, as well as the survey measures and automated car use data logger information presented in forthcoming study papers. This study also employed an audit trail, which included the shared digital codebook mentioned above, that also housed the data analysis procedures, researcher memos, and potential thematic connections to facilitate discussion among members of the research team and ensure transparency and accuracy (Merriam & Tisdell, 2015).

Findings:

Of the 19 families originally enrolled in the study, 15 completed all study procedures, with two participants withdrawing due to therapy schedules and an out of state move. Two additional participants were lost to follow up. All of the caregivers interviewed were the parents of the child; both mothers and fathers took part. In some instances, both caregivers participated together in study processes, in some cases, the research team only interacted with the primary caregiver. Three families had twins; in one set of twins both children had unique disabilities, in the other two sets the child participant had CP and their twin was non-disabled. In all families, this was their first experience having a child or children with a disability. Detailed participant demographic data are included in Table 1. It is important to note that several families (n=5) did not complete a mid-study interview as a result of the onset of the Covid-19 pandemic and the temporary pause in all research activities while modifications for alternative procedures were submitted and approved by the Institutional Review Board.

Table 1.

Participant Demographics

Participant Demographics
Variables	Children Participants*	Caregivers**
Number of participants (n)	n =15	n=22
Gender (Female, Male)	6 females, 9 males	12 moms, 10 dads
Racial Identification of Children    Caucasian    Mixed Race    Asian	66.67% 26.7% 6.67%
Highest Education Level of Caregiver    Some college    Bachelors    Masters    Doctoral	n/a	13.33% 40.00% 20.00% 26.67%
Socioeconomic Status of Household***    $26 −50K    $51–75K    $101–150k    $151–200k    $201–250k    $251–300K	n/a	7.69% 15.38% 30.77% 23.08% 15.38% 7.69%
Number of people in household with disability    1    2		93.33% 6.67%

^*Average age of children participating in study was 2.26 years old at beginning of study.

^**Caregivers were either mother of child, father of child, or both parents.

^***2 participants did not respond to survey questions regarding socioeconomic status, n=13.

The following four themes emerged from the data: ‘Leveling the Playing Field’, ‘Breaking Down Barriers’, ‘Fun and Work: ROC as Toy and Therapy Device’, and ‘Mobility is a Pathway to Autonomy’. These themes were central in caregivers’ perceptions of their children’s socio-emotional development and how this domain was impacted by ROC use. Though caregiver perceptions regarding other aspects of ROC use (i.e. barriers and facilitators to use) did evolve over time, responses related to socio-emotional development and well-being remained constant, therefore caregiver responses consistent with each theme are included from all data collection points.

‘Leveling the Playing Field’

This theme emerged from the families detailing a shift in ways their children were able to engage socially with others, especially with siblings and peers, while using ROCs. Caregivers described not only an increase in opportunity for their child to have social interaction, but also the importance of equity and inclusion in those experiences, resulting in a shift in the power dynamics at play when the children were using ROCs. As one caregiver remarked, “I think it’s a good way for kids to play with kids who have disabilities, cause it’s kind of an equalizer.” (Final, P01, mother of 3 year old)

Several families noted the socio-emotional impact of their children being on the same physical level as siblings and peers. Caregivers viewed their child’s ROC experiences as an opportunity to play or interact as a peer with equal amounts of autonomy:

Even bringing it to daycare, the kids can be at his eye level. And so he gets to start to be a little bit more of a peer rather than that kid that’s always to the side. (Initial, P17, father of 1.5 year old)

Caregivers also described how the modified ROCs allowed for inclusivity in a way than other assistive devices hadn’t previously offered their children:

It’s great that she can kind of also sit up and be a part of everything. Whereas the other toys we have down there, besides the stander, don’t really enable that same level as everybody else. (Midstudy, P02, mother of 2 year old)

Another family noted how the modified ROCs opened up a new realm of options for play and interaction with peers:

So it would be great to see their reaction, because they are always riding their bikes back and forth, and she can’t engage in that with them. So I was thinking, it would be a great way for her to get out and be with the other kids, the way that [participant’s brother] can be with them. (Midstudy, P09, mother of 4 year old)

Ultimately, caregivers felt that their child’s experiences with a greater variety of mobility experiences also contributed to an emerging sense of self, accomplishment, and expression, all of which are key aspects of socio-emotional development:

I think [ROCs are] such an important tool…to figure out how to help each kid that’s having some sort of a delay, find a way to help them or help them express themselves, or make them feel proud or important. You could just see that in him. It wasn’t every time we were in the car, but you could just see it was doing something for him, for sure, that we would have never thought of doing before. (Final, P15, mother of 1.5 year old)

‘Breaking Down Barriers’

The second theme captured perspectives surrounding the stigma that often impacts socio-emotional well-being of children who use mobility devices. Many caregivers drew a contrast between ROCs and traditional PM devices like wheelchairs or walkers that they believed negatively impacted a child’s experiences of moving through the world. Several of the families noted that they perceived the ROC as more of a toy, that enhanced play and socio-emotional engagement in their children:

It’s interactive where he can be with the other kids and it’s a toy. It is different than a wheelchair, right, where a wheelchair kind of gives a certain idea about a person. Whereas this is a toy and then kids forget about that… So, they were able to play all sorts of games with [our child] in the car. (Final, P1, mother of 3 year old)

Another family described a shift in the perceptions and interactions of others when their child used the modified ROC instead of a walker out in the community:

I think every day you don’t run into somebody with a walker, especially as a child. [With] older people, you see walkers are more acceptable from I think their viewpoints. So when we’re walking down the road [in the walker], [our child] will generally stop, cause he sees them looking at him, and he waits for them to go by and then he will go. So I think that really does show differently with the car, cause with the car, normally he’s just driving. I think they see a kid who’s having to fun compared to a kid with a disability who is using his walker. (Final, P05, father of 4 year old)

One family described how instrumental the modified ROC was in building up their child’s confidence and self-esteem:

[The car] really embraced his sense of wonder and excitement for the world, and I think it’s helped build his confidence too. I think he feels esteemed by people who see him in it. He feels that praise of, ‘Wow, that’s a cool little thing. Look at that dude cruising down the street in the car.’ (Final, P17, father of 1.5 year old)

It is important to note that there were some outlying perceptions by caregivers who described that they initially saw the ride-on car as a means to break down social barriers, but that this expectation was not met as it was for most families. For example, one participant, who resided in the same town with another study family, described:

I think I envisioned this as a point of social access, like relating to other kids differently. And that, because the car is really designed for the kid who it’s given to, it’s like other kids are curious, but the way that they’re curious is that they’d like to get in it and ride it. Right? And we never tried to ride with [the other child with an ROC]. We talked about it, but we never thought to do that. (Final, P13, mother of 3 year old)

‘Fun and Work: ROC as Toy and Therapy Device’

This theme described how caregivers perceived the ROC as something fun, challenging, and motivating for their child that impacted their learning and family interactions. For example, several families noted that the modified ROCs were fun and enjoyable experiences that simultaneously held therapeutic benefits:

I’m probably thinking [the ROC is] more of a therapy device…but it’s also a fun toy. It’s something fun. It’s work without…I think that a lot of the times he’s most successful when he’s playing but he doesn’t know he’s working. (Mid study, P01, mother of 3 year old)

Caregivers also noted that the cars were a fun way to interact with their child.

I think we use it more as a toy…The fun aspect really helps just to let him do it. So, it’s like, ‘Let’s go play with it’ and I get all excited with it and I try to be as loud as I can. He has fun and screams. Gets into it. (Mid study, P05, father of 4 year old)

To other families, the modified ROCs were both a reprieve from traditional therapies which can be frustrating for caregivers and children alike, and a way for the children to develop new skills.

She likes it… and it’s nice because not all of her therapy she enjoys, where this one… She’s still having to make those connections to make it go or stop it, or if she gets a little stubborn … she’s got to still do things correctly. It’s not just like, ‘Oh, we got the car and we have to do this, so here you go.’ It’s also like a reward thing too. (Mid Study, P03, mother of 3 year old)

Most families had a host of other mobility equipment in addition to the ROC, and families described how the learning process and experiences of self-initiated mobility carried over, including how these experiences contributed to autonomy and making mobility decisions for themselves:

When I think about what it was doing for him, it’s definitely more of a therapy toy. But I think of it kind of in a similar way that I would his walker. He uses his walker to get from point A to point B. He thinks it’s fun because he gets to move himself. But he’ll do the same thing with the [car that he does with his] walker. He’ll just say, okay, I’m all done. I don’t want to do this anymore. And when he’s across the yard, because well do it outside too, I say, “Okay, go put it back in the garage then”. And that’s worked in a similar way that it has with his car. He realizes, oh, I can go a little bit further. (Final, P15, mother of 1 year old)

‘Mobility is a Pathway to Autonomy’

This theme describes the caregiver perceptions of the ROC positively impacting their child’s opportunity to make choices, explore, and exercise their autonomy. For example, many of the families used descriptors like ‘freedom’ and ‘control’ that the ROC provided as their children were able to navigate independently through their environment, often for the first time.

She’s always smiling or giggling in it. It gives her a little sense of freedom or … I don’t like the word ‘normalcy’, but typical? Because she can’t ride a trike or anything…but it’s like she can control [the car]. She can go where she wants, she can start it and stop it… It’s her. She can do that. (Mid Study, P03, mother of 3 year old)

Another family detailed how using the modified ROCs gave their child the opportunity to make decisions and move independently.

He doesn’t get a lot of opportunity because he can’t walk. He doesn’t get a lot of opportunity to truly be independent and move independently away from us. And specifically, before he got his wheelchair because now he has a lot more opportunities. But I think [the ROC] gave him that opportunity to control and decide when he wanted to go and when he wanted to stop. I think that was really valuable in a different sense too. (Final, P18, mother of 2 year old)

Some caregivers noted that the while their child was in the ROC, their increased independence also provided new ways to interact other than having to hold them. This helped foster a sense of connection and excitement in the children and the caregivers alike.

She has more, so much more fun when she’s independent. And then we can interact with her more ‘cause we’re not having to position her-or hold her. Like I can actually face her and play with her-like with this car. Like you see how much more excited she gets when so that’s pretty cool. (Initial, P2, mother of 2 year old)

Many families described how their child’s ROC use opened up a world of decision making and exploration. The opportunity to make choices and explore lead to changes in communication between the children and their caregivers as well.

I guess what I was saying, was that I think the purpose of the car was to have that kind of… It’s like, I’m not sure I have the words for it, but it’s sort of like an executive thing for her. She has to make the decision to go and now she’s actively communicating with us, in the car. (Final, P10, father of 1.5 year old)

Overall, the families viewed the ROCs as a tool to promote not only mobility but a sense of agency and empowerment, which can be key components of socio-emotional development, “He was being silly but he thought he was just the king of the world I think because he was able to move it himself. Kind of empowered.” (Final, P6, mother of 5 year old)

Discussion:

This study was undertaken to develop a better understanding of how ROC use impacts caregiver perceptions of socio-emotional development and experiences of children with CP or developmental delay over a one-year period. Findings were consistent and overwhelmingly positive for this group of caregivers over time, indicating that ROCs employed as an early PM option for young children with motor disabilities have the potential to positively impact caregiver perceptions of children’s socio–emotional development, particularly related to independence and autonomy, play with family and peers, and self-efficacy.

Previous research demonstrates mobility technology increases opportunity for independence, social interaction, and inclusion, which is consistent with the findings of the current study (Feldner et al., 2016; Hospodar et al., 2021; Gudgeon & Kirk, 2015; Guerette et al, 2013; Huang, Chen, Huang,H.W., Shih, Hsieh, Chen, C.L., 2017; Wiart, Darrah, Hollis, Cook, May, 2004). For example, in a systematic review of ROC literature, Hospodar et al. (2021) reported that using modified ROCs increased functional mobility and opportunity for social interaction for children with decreased mobility in a variety of settings include home and community. Additional research with older children who use more traditional powered wheelchairs similarly found increased opportunity for participation in social activities as well as increased positive socio-emotional impact if the powered wheelchair fit the child and their environment well, however if these study found that the powered wheelchairs could also become a barrier to participation, locomotion, and a source of fear and anxiety if their environment was not easily accessible by PM (Gudgeon & Kirk, 2015, Guerette et al, 2013). Many of the families noted that the ROCs allowed their children to move through the world with increased confidence, wonder, and joy. This is consistent with previous research that demonstrated the use of PM facilitated meaningful relationships with peers and removed barriers to play or other age appropriate activities (Feldner et al., 2016; Jones et al., 2012; Wiart et al 2004).

Interestingly, in describing the social benefits of ROCs and contrasting them with more traditional powered wheelchairs, more negative caregiver perceptions of traditional devices persisted. By using a ROC, caregivers perceived an opportunity to shed a more stigmatizing outward reminder or indicator of disability, which was perceived to be both freeing and lead to increased opportunity for positive social interactions. This is also consistent with extant literature describing stigma, caregiver reluctance, and perceptions of PM as a ‘last resort’ for children with CP and other disabilities (Jones et al., 2012; Wiart & Darrah, 2002; Casey, Paleg, Livingstone, 2013; Feldner et al., 2016). While literature demonstrates that these negative perceptions do shift more positively over time, given the children’s young age and limited experience with PM prior to their participation in this study, these initial perceptions of more traditional devices are not surprising. Other early childhood research has demonstrated similarly evolving, more positive perspectives about a child’s abilities and assistive technology needs across this early stage of development (Kling, Campbell, Wilcox, 2010; Lee, Park, & Recchia, 2015).

Most caregivers perceived the ROCs as a way for children to also work on skill development in a fun context. In comparison to traditional therapies or other devices, which the caregivers indicated can be frustrating and challenging at times, the ROCs were perceived more like a toy that provided challenge, motivation, and an ability to build autonomy. Identifying opportunities that foster development of autonomy in young children with disabilities have been increasingly highlighted in the literature as crucial for optimizing quality of life, socio-emotional well-being, and participation in this population (Chu, 2018; Feldner, 2019; Hospodar et al., 2021; Shogren & Turnbull, 2006). Further, caregivers described the role of the ROC in augmenting their child’s social participation through mobility and exploration. Previous research has firmly established the connection between children’s development and the exploration and interactions with objects, people, and the environment around them, embedded within socio-cultural contexts (Adolph & Hoch, 2019; Lobo et al., 2013; Novak, Morgan, Fahey, Finch-Edmonson, Galea, Hines…& Badawi, 2020). The literature also indicates that interventions should be grounded more in participation, such as school, home, and play activities, rather than focusing the development of specific motor skills in isolation (Lobo et al., 2013). The ROCs allowed children to work on developing skills while being grounded in participation of daily activities in social contexts with their peers and family.

Finally, the findings from this study also add new elements to the literature. While caregivers described how their children were able to independently initiate and direct interactions with peers and siblings while using the cars, caregiver responses were situated in an equity framing that has only been hinted at in recent literature (Feldner et al., 2016; Sabet, Feldner, Tucker, Logan, & Galloway, 2022). The ROCs brought an element of fun as well as improved equity to the interactions with peers by allowing the children to be on the same physical level as everyone else. These findings suggest that the caregivers perceive ROCs as positively contributing to their child’s social capital and equitable engagement with peers during social interactions, which could significantly impact both caregiver and clinician decision-making to implement ROCs into a therapeutic plan of care. Continued research is important regarding how caregiver perceptions, expectations, and socio-emotional responses to mobility technology directly impact and influence the socio-emotional response their children have as well as their access to technology to support mobility.

This research fills an important gap in understanding families’ experiences with and perspectives of ROCs and their perceived impact on children’s socio-emotional development over a one-year experience with an early PM intervention. Results from this study mirror the existing evidence that socio-emotional benefits of self-initiated mobility are an important consideration for children and their families who use mobility technology as part of a multi modal approach to rehabilitation intervention. This study also identifies avenues and areas for further research. First and foremost, this includes future deployment of additional, objective measures of socio-emotional development in PM research, such as the socio-emotional and adaptive behavior domains of the Bayley Scales of Infant Development IV, a norm-referenced, standardized assessment for children 0–42 months (Balasundaram & Avulakunta, 2021). Additionally, further work should examine the feasibility of ROCs across different environments, such as schools, playgrounds, the home and community, and the unique ways these environments may contribute to aspects of socio-emotional development in children with a variety of diagnoses at various ages and stages. Findings from this study also point to the need for an expanded understanding of how caregiver perceptions, expectations, and responses to technologies that support mobility and exploration are shaped, and how they shift over time as they develop lived expertise around caregiving for a child with a disability. These shifting perceptions also likely influence their child’s identity development over time (Feldner, 2019). Understanding these processes requires further longitudinal work.

There are several limitations that impact the result of this study. Though data saturation was reached, the study was conducted using a small sample size of 15 participants, all recruited from the Western Washington area. While the participants were from a variety of socioeconomic, ethnic and cultural backgrounds, findings from this study may not be generalizable to a larger population. Relatedly, this study primarily looked at young children with a diagnosis of CP or developmental delay, therefore the results may not be generalizable to all children who may benefit from PM devices. Further, the research team in this US-based study did not have funding for translation services, so it is important to acknowledge that English language proficiency as an inclusion criteria, while necessary to ensure full participation in the interviews and accurate interpretation of the data, is a significant limitation that excludes non-English speaking populations. Future work must ensure representation of these voices, also.

A potential confounding factor that should be considered is that it is impossible to extract the impact of COVID −19 on the experiences of the families in this study. Several of the families were still participating in the study when COVID −19 emerged in the US, and research procedures as well as stressors for families may have led to decreased interactions and ROC use, which could have impacted our results. Further, it is important to note that socio–emotional development and the natural course of a child’s growth and maturation are inextricably linked and therefore difficult to isolate, which could affect caregiver perceptions of ROC impact. Additionally, the presence of researchers may have led to acquiescence bias, therefore the data, which was overwhelmingly positive related to perceived socio-emotional impacts of ROC use, may not fully reflect potential barriers and detriments associated with such devices. However, mitigating strategies were employed by the research team (described in detail in the methods section) to reduce this limitation. Finally, it is important to consider that caregivers’ proxy perspectives about mobility, disability, and technology directly inform children’s perspectives and thus may serve to facilitate or limit access to and use of devices such as ROCs depending on rehabilitative and mobility priorities.

Conclusion:

The findings from this study indicate that ROCs have the potential to be implemented as a form of early PM, with caregivers reporting positive effects for their children, particularly in the socio-emotional domain. Overall, children and caregivers viewed ROCs as both fun and therapeutic, consistently identifying perceived benefits for children’s socio-emotional development. Some of the positive effects include development of confidence and independence, growth, and increased opportunity for meaning interactions with people from parents to peers to strangers.

This qualitative study provides a better understanding of the complexities and impact of ROCs on children and their families in the socio-emotional domain. It may help facilitate clinical decision-making to introduce PM technology to young children with disabilities as part of a multimodal approach to early intervention.

Impact.

• Although the impact of motor skill development has been described in the literature, little attention has been given to caregiver perceptions of their child’s mobility using assistive technology in early childhood.

• This qualitative study is among the first to describe caregiver perceptions of the socio-emotional impact of an adapted toy ride-on car to facilitate self-initiated mobility in their children with disabilities.

• These results provide important data about the perceived positive socio-emotional impacts of mobility technology intervention as one of the key benefits of access to self-initiated mobility experiences for young children with disabilities. These lived experiences can help facilitate clinical decision-making and policy regarding the timing, urgency, and use of mobility-related assistive technology.