Therapists understand the important health benefits of standing for young children with physical disabilities, but we have also become increasingly aware of the critical importance of psychosocial benefits. In addition to improving skeletal development, managing spasticity and promoting trunk extension, standing can facilitate social interactions, stimulate play and help develop positive self-esteem. Standing also provides good proprioceptive input to young developing muscles and joints, helping organize a child's sensory system and increasing their level of alertness, so they can focus and be at their best for learning.

Universal Design

The universal design model has become central to the educational environment. It supports the intent of the Individuals with Disabilities Education Act (IDEA) that children with diverse abilities can learn and succeed with their peers. Therefore, it is imperative we have equipment within the educational environment for all children to stand and play side-by-side. When standers are available and embedded into the natural routines of a child's day, the opportunities for standing increase because the equipment is always available to the child. The more a child can stand, the more physical improvements will be made, and the more options that child will have to learn and interact with others.

Routines

Research has shown that successful outcomes happen when children learn in everyday routines, places and activities. Therefore it is our goal to integrate standing programs for young children into the meaningful routines of the child's day, whether it's art time, circle time, gym time or story time. We use a variety of standers based on the activity and child's needs. We are regularly evaluating and adapting standers to allow the best access to activities in the classroom and gym. For example, using stander trays that incline or a slant board on top of the tray to secure materials has been an effective way to help children access and visually attend to activities. We've noticed that once standing is incorporated into daily routines, the amount of time children are using their standers has dramatically increased. Being in a stander during the natural routine of the school day allows children to work on all areas of development, including language, cognitive and social skills, while also emphasizing their motor skill ­development.

Motivation

We know children stay motivated when they are having fun and playing. For some of our children with physical disabilities, standing can be challenging and not a preferred activity due to muscle stiffness and diminished strength. They need to gradually work on increasing their tolerance for standing longer in order to progress with standing and functional mobility skills. Children can be easily redirected from thinking about standing when they are singing at circle time, reading books, painting and playing with friends. Motivation is key to learning new motor skills and also increases the child's attention to stay with an activity.

Repetition

Repetition is very important with any standing program. There are differing opinions of how long a child should stand every day to get the recommended health benefits. Our goal is to work up to two hours of standing time a day. We also work closely with families to assist them with ordering a stander for home. As therapists, we believe our job is to teach school staff how to use the standing equipment safely and effectively so it can be used every day within the natural routine of the school day. We like to use standers that can move from sit-to-stand for the young children who are just starting to build up tolerance for standing activities. This way they can stand for a short period, sit down to take a 10-minute break, then stand again without having to be transferred in and out of the stander repeatedly. When the standing program is used on a consistent basis in the classroom, it also helps create a predictable environment for the child with clear expectations for optimal learning.

Social Interactions

Any activity can be an opportunity for social interaction between children when adults in the classroom set up the environment and become important facilitators of peer interactions. We focus on keeping children with disabilities in the classroom with their peers and incorporate therapy into that routine. When children are all standing next to each other, they have better eye contact and interactions increase. A game, book or art project can be set up on the tray of the stander so all the children can gather around to play cooperatively. In the gym, children using mobile standers can easily be included in movement activities with peers. When children with disabilities are standing and moving around the gym with friends, we often hear many more vocalizations and language since they are communicating.

Meet Lily

Lily is a 5-year-old girl who attends Normandy Park Education Center four afternoons a week in an inclusive classroom. She has a diagnosis of cerebral palsy and relies on assistive technology to access materials in the classroom. Lily arrives from the bus with a big smile on her face. She loves school and her friends. Lily's classroom is set up with a universal design model so adapted equipment and assistive technology are easily accessible to her. This enables her to participate in the same activities as her friends. Lily uses a voice output communication device to greet her teachers and peers. She has help to get out of her chair and sits on a bolster with her teacher, who has set up a road and toy cars for Lily and her friends to play together. Before long, Lily's peers have built a road up and over her bolster so she can "zoom" the cars down the hill. A great example of cooperative problem-solving and universal design in action!

For work-time, Lily gets into her sit-to-stand stander with the help of her paraprofessional. With all staff using the same words, for example "1-2-3-stand," Lily can learn through repetition to attach meaning to this functional language and knows the predictability of the standing routine. Once standing, she creates a beautiful art project working on the clear tray that is slightly inclined for better accessibility. A switch is secured to the stander so Lily can paint with her friends or family using a battery adapted spin-art machine. Afterwards, a step-by-step voice output communication aid, attached with an extension arm, is used so Lily can read a book. She reads by activating the switch with her head and her friend turns the pages. That's teamwork!

For circle time Lily needs a break from standing, so the stander can be lowered into a seated position in seconds and she can stay with her class while they sing songs, participate in interactive whiteboard activities and read a story. After a quick snack, she's off to the gym and standing again to play a bowling game with her friends. Once back in the classroom, Lily is transferred out of the stander for closing activities and her ride home on the bus.

Incorporating standing programs into the natural routines of the school day provides many important health and psychosocial benefits for children with physical disabilities. As therapists, we've had the privilege over the years of watching the same children we knew as preschoolers graduate from high school. We also have listened to families and discovered that in the end what really matters for all children is to be an integral part of their communities through meaningful relationships. The ability to develop friendships and relationships is at the heart of real success in school-and standing together can be the first step.

Laura J. Krueger and Mary J. Sullivan Coleman work together at Normandy Park Education Center in White Bear Lake, MN. They are also co-founders of Let's Play Together (www.letsplaytogether.org), a nonprofit organization that recognizes innate strengths and encourages friendships among children of all abilities.