Johnny stands in the kitchen pulling magnets off the refrigerator, while mom gets the dinner meal prepared. While this may sound like a typical event at any household, the difference is that Johnny has physical delays and cannot stand on his own. Johnny is 15 months old, and is standing for the first time without help from an adult. He just received a stander (with casters) that allows his mom and family to have him upright and nearby while they are anywhere in the house.
Johnny is not sitting, crawling, standing or walking like his typical peers; he is, however, entertained and happy to be in his stander allowing mom to prepare dinner without worries.
How do you begin to assess the needs of a child for standing while also considering what is best for the family and meeting their needs?
When assessing a child for a stander in early intervention, it is important to consider not only the needs of the child, but also the emotional and physical ability of parents to use the equipment and carry over a standing program at home.
The readiness of the family needs to be considered when determining how soon to begin standing and what equipment to choose to ensure a smooth start with good carryover.
Just the Right Fit
At the beginning stages of working with children in early intervention, much of the parent's emotions are tied to dealing with their child's disability and grieving over the diagnosis or the unknown of what is to come. As practitioners, we need to be sensitive to the family's emotional state so we aren't overloading them with too many expectations, yet at the same time gently pushing for the child's best interests.
Beginning a standing program with knee immobilizers and orthotics during therapy to assess the child's (and parents') response to standing is an inexpensive way to initiate standing. If carryover is good on the parent side outside of therapy sessions, advancing to the next stage can involve trials of equipment through medical vendors.
With the availability of the Internet, it is helpful to show parents various standers that could potentially work for their child; this allows the practitioner to get feedback on what standers the parent might want to try first.
Consideration of the size of the stander, the accessibility/size of the family home, ability of parents to physically help their child into and out of a stander, ability to easily move a stander to many areas of the home, and the cost of the stander all play a part in how a stander might fit into a family's home life.
For Johnny's family, it was important to have a stander that was smaller for the size and limited open space of their home, but with casters so he could move easily within the home to be near his siblings. It was also important to have the stander be easy to use so that many caregivers could be trained to help establish a routine for him to use it regularly.
Dealing with the expense of a stander is an important factor to consider. Some families have insurance co-pays to consider when purchasing large equipment.
Growth and progress in early intervention can make it difficult to predict an ongoing need for a stander, and even make it difficult to sucessfully justify to insurance companies. Some children will progress to walking and may not need such equipment for the long term.
As a practitioner, I have seen the benefits of early standing on a child's progress even if they outgrow the need for the equipment long term.
Standing for typical children begins at approximately 9 months; children with disabilities need to be working toward standing for hip development and bone density along the same timelines if possible.
Many children who do end up walking can still benefit from early weightbearing on their hips with implementation of a standing program.
When purchasing a stander through insurance, knowledge of the benefits of standing can help practitioners with writing letters of medical necessity. Research shows that 7.5 hours of standing will help improve bone density.1,2
Research also supports sustained stretching of 30 minutes or longer as preferable over passive range of motion in improving range of motion in children with spasticity;3 thus, standing can be a beneficial means of sustained stretching. In addition, there is evidence to support temporary decreases in spasticity shown on EMG with 30 minutes of static weightbearing.2
If possible, look toward strategies that will allow loaning equipment during the early intervention years when children outgrow equipment so quickly.
Fortunately for Johnny and his family, they are able to use his stander on loan from his school district and will not need to purchase one-at least for now.
Establishing good carryover of a standing program is important if we want the equipment to get used after we teach the families how to use it.
Routine-based intervention has become popular with early learners, engaging the parents with what routines to work on in therapy sessions. This routine model works well for fitting in the standing needs of our youngest learners.
If the parent identifies dinner time as a difficult time to juggle their family needs, perhaps having the child stand in a stander during this time will work the best for the family, helping them establish a routine they can follow through with.
It is especially important to engage parents in the decision making so that they feel they have ownership, thus leading to better carryover.
As practitioners, we can begin with good education for why standing is important, and then turn it back to the parent for their input on how or when they think this might work for their family.
When establishing Johnny's standing program, older siblings were involved in his care, in addition to his parents. It was important to the family that adequate training be available to allow the siblings to also be involved with his standing program.
Siblings were present at home visits, allowing hands-on training and practice. Use of videotaping has also been a good technique to train family members who cannot be present at therapy sessions.
As you initiate standing programs with this young population in early intervention, remember to make the experience fun and meaningful for the children. Being able to stand and play with the magnets at the refrigerator was certainly fun and meaningful for Johnny, and the freedom Mom felt seeing him play independently made the experience a success for the family.
1. Katz, D., Snyder, B., Dodek, A., Holm, I., & Miller, C. (2006). Can Using Standers Increase Bone Density in Non-Ambulatory Children? Abstract as published in the American Academy of Cerebral Palsy and Developmental Medicine (AACPDM) 2006 Conference Proceedings.
2. Pin, T. (2007). Effectiveness of static weight-bearing exercises in children with cerebral palsy. Pediatric Physical Therapy, 19(1), 6273.
3. Pin, T., Dyke, P., & Chan, M. (2006). The effectiveness of passive stretching in children with cerebral palsy. Developmental Medicine and Child Neurology, 48(10), 855-862.
Mary Miles received her bachelor's in physical therapy from College of St. Scholastica in 1986, returning for her doctorate in 2008. She is NDT certified in pediatrics and currently works in White Bear Lake School District in birth to 21.