Final Word version accepted for publication by British Journal of Occupational Therapy
TITLE
Electrically Powered Indoor/Outdoor Chair performance for children aged seven to nine
years.
ABSTRACT
Introduction: Northern Ireland Wheelchair Guidelines state that wheelchair users who
wish to drive their National Health Service (NHS) provided powered wheelchairs
outdoors must complete an electrically powered indoor/outdoor chair (EPIOC) test.
Within the same guidelines children in Northern Ireland (NI) under the age of ten are not
permitted to complete this assessment. Research was completed to evaluate how
children under ten years would perform in EPIOC training and testing under adult
supervision.
Method: A case-study design was utilised with three children aged seven to nine years
to evaluate if: these children can complete EPIOC training/testing safely with adult
supervision; length of time using an electric powered indoor chair (EPIC) correlates with
performance on EPIOC training/testing; the current NI guidelines on age restriction
should be re-evaluated so that each child is assessed on an individual basis rather than
age.
Findings: Paediatric powered wheelchair users aged seven to nine years can become
competent EPIOC users with adequate training and adult supervision. Length of time
(years) driving an EPIC may not correlate with improved EPIOC performance.
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Final Word version accepted for publication by British Journal of Occupational Therapy
Conclusion: Regional NI criteria relating to EPIOC provision for children should be
revised in order to consider an individual needs assessment, rather than imposing an
age restriction.
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INTRODUCTION
Within Northern Ireland (NI), when a service user is being prescribed a powered
wheelchair clinicians are required to follow the regional wheelchair guidelines for NI
(2012). These Guidelines, which are not imposed elsewhere within the United Kingdom
(UK), have criteria which dictate both the lower age for whom an outdoor powered
wheelchair can be provided as well as the speed at which the powered wheelchair can
be driven. When the service user is provided with their first National Health Service
(NHS) powered wheelchair, it has a maximum speed of two miles-per-hour and can only
be used indoors. If the service user wishes to drive their wheelchair outdoors they then
undertake an assessment called the Electrical Powered Indoor/Outdoor Chair (EPIOC)
test. Once successfully completed they are permitted to use their NHS powered
wheelchair outdoors as well as indoors with an increased upper speed limit available of
four miles-per-hour, reflecting typical walking speed (Mohler et al. 2007). Further these
Guidelines only permit service users who are ten years of age or over to complete this
test. This imposed age criterion has no evidence supporting its foundation, and appears
to have been introduced to correlate with the age that children in NI complete their
cycling proficiency training within schools and are deemed to have acquired some level
of road safety. These criteria, unique to NI with no similar criterion presently being used
elsewhere in the World, were initially put in place as a means of reducing potential road
safety risk for the child and their caregiver.
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Rationale
Subsequently, due to the current age restriction on driving speed, application of the
Guideline imposes several limitations on both the child under ten years, and their
family/caregiver. Specifically, where the child is reliant on a powered wheelchair for
mobility, then they are unable to independently join the family in everyday outdoor
activities, such as shopping and visiting other relatives. Furthermore, they may be
unable to partake in outdoor games and social activities with their friends, or simply to
go ‘for a walk’ up their street or to visit a neighbour.
Literature Review
Provision of powered mobility for children with mobility limitations has several benefits
including improvement in general development, (Ragonesi and Cole, 2012; Lynch et al.,
2009; Galloway et al., 2008; and Jones et al., 2003); psychosocial skills and inclusion,
participation, independence and function, (Guerette et al., 2013; Evans et al., 2007;
Tefft et al., 2011; Jones et al., 2012; Rodby-Bousquet and Hagglund, 2010).
Additionally, it can afford these children with a greater ability to socialise with their peers
and their family (Evans et al., 2007).
Tefft et al. (2011) evaluated powered wheelchair provision for twenty-three children,
aged between eighteen and seventy-two months. They found that powered wheelchair
provision can improve independence and social intervention for young children, and had
an overall positive impact upon the family, reducing the impact of caregiver stress.
Indeed, there is evidence to suggest that children with restricted mobility may have
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passive, dependent behaviour and this can have long lasting consequences (Jones et
al., 2012). These children have been found to often fall behind in other developmental
areas because they cannot independently explore and act on their environment (Jones
et al., 2003). Further these children are at risk of participation in fewer activities (Bult et
al., 2011), and their mobility limitations are often key barriers to their participation in
everyday activities (Shikako-Thomas et al., 2008).
In the USA there are no age restrictions on children’s usage of powered wheelchairs for
outdoor mobility, with early intervention for those aged 0-3 years being federally
mandated. Each state has its own mechanism for service delivery and funding which is
similar to Canada where each province has its own fiscal criteria (Paleg et al., 2015),
and variations in provision are consequently evident within the USA. Conversely, in
Sweden there are no financial restrictions for the provision of powered wheelchairs,
however, powered wheelchairs are not routinely provided to children. Further, Rodby-
Bousquet and Hägglund (2010) reported that no child with cerebral palsy with mobility
impairments and under the age of four had independent wheeled mobility outdoors. This
may have been a result of the reluctance of parents to accept powered mobility (Rodby-
Bousquet and Hägglund, 2010), or the resistance of the therapist to prescribe to young
children (Wiart and Darrah, 2002). Moreover, in some countries children are only
afforded the opportunity to access powered mobility once they have acquired skills that
demonstrate a readiness to drive, however, as Hardy (2004) points out, these skills
often can only be attained through having opportunities to experience mobility.
Although the affirmative impact of early powered mobility on overall development is
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recognised (Paleg et al., 2015) there continues to be variations worldwide in both
accessing and providing powered wheelchairs for young children. In N.I, children can
currently access wheelchair services from three years, with manual wheelchair
provision generally still being the first option considered, and powered wheelchairs
given to these children for indoor only use. However, similar to the rest of the UK,
should the parents wish, it is possible to obtain a powered wheelchair for indoors and
outdoors use through self-funding or through charitable organisations.
In 1991, the UK Government ratified the treaty of the United Nations Convention of the
Rights of the Child. This gives all children and young people comprehensive rights on
all matters that affect them, including the right to leisure and play, to be safe, and to rest
(Stancliffe, 2003). Within the treaty, disabled children are given additional rights to
ensure that they have special care and support so that they can lead full and
independent lives without discrimination. These rights are further enhanced through the
Disability Discrimination Act (1995); the Human Rights Act (1998); and the Special
Education Needs and Disability Act (1998, 2001). The first referring specifically to the
supply of goods and services, and includes provision of children’s equipment to promote
independence. Together the UK’s adoption of these legislative acts and policies means
that the UK is committed to the provision of services and equipment for all children in
the UK, including those with mobility challenges.
The introduction of the World Health Organisation’s (WHO) International Classification
of Function, Disability and Health – Child and Youth version (ICF-CY) (WHO, 2004)
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identifies three levels of human functioning: (1) health condition; (2) body structure and
functions (BSF), activities and participation; and (3) environmental and personal factors.
Within this model, body structure and function (BSF) and limited independent mobility
(activity) and participation are described as the major components of health and are
influenced by environmental and personal factors (Casey et al., 2013). Children with
gross motor impairment (BSF) and limited independent mobility (activity) may have
participation restrictions unless an appropriate mobility device (environmental
intervention) is provided. Mobility devices, whether powered or manual, can provide
children with limited mobility with a means of self-initiated mobility allowing them to
independently explore their environment (Fernandes, 2006), provide them with a sense
of autonomy, the opportunity to participate in a range of activities and to pursue the
interests of their choice (Frank and De Souza, 2013).
At present children who live in Northern Ireland who have been provided with a NHS
powered wheelchair must be ten years of age before they are eligible to drive their
powered wheelchair outdoors. This criterion, which does not appear to have an
evidence base, essentially compounds young children’s limitation in accessing their
environment, as well as participation in everyday life with family and friends. Despite a
growing body of research on powered mobility exploring wheelchair training
programmes, readiness to drive or the type of powered mobility, there is a paucity of
work on whether very young children can safely drive their powered wheelchairs
outdoors. Therefore, this study was completed to evaluate how children aged four to
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nine years who are already indoor powered wheelchair users, would perform in EPIOC
training and testing.
Aims and Objectives
The aim of this study was to evaluate the readiness of children (aged between four and
nine years), who already use a NHS powered indoor wheelchair to drive an EPIOC
under supervision of an adult caregiver.
The objectives were to explore:
If children between the ages of four and nine years can safely complete EPIOC
training/testing with adult supervision;
If exposure (time in years) to having an EPIC correlates with performance on
EPIOC training/testing;
If the Guideline should be reviewed so that each child is evaluated on an
individual basis, rather than age in regards to accessing EPIOC training/testing.
Methodology
This study used case study design. A review of existing records showed small numbers
of children in NI using powered wheelchairs. With small numbers of young children
using powered mobility case study methodology can facilitate exploration and in-depth
understanding (Crowe et al. 2011; Yin 2009) of the child’s ability to drive a powered
wheelchair outdoors, and offer the potential of analytic generalisations to be made (Yin
2009). Previous studies relating to children’s powered wheelchair have also used low
sample sizes (Lynch et al., 2009; Jones et al., 2003). Research Governance was
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obtained from the Belfast Health and Social Care Trust Research and Development
office. Ethical approval was obtained from Ulster University and nationally from the
Office for Research Ethics Committees Northern Ireland (REC14/NI/0055). Consent
was obtained from the parent, and assent was obtained from each child. Anonymity and
confidentiality of all participants was assured throughout all phases of this study.
Sample
All children who lived in NI who had been provided with a NHS powered wheelchair,
and who were aged between four and nine years, were invited to participate in the
study. Potential participants were identified by an administrator at the Regional
Disablement Services (RDS) with access to this regional data. This administrator was
not involved in the study therefore limiting the threat of selection bias. A total of twenty-
one children were identified as being potentially eligible to participate in the study. Due
to this low number a power analysis to determine sample size was not completed. It
was anticipated that recruitment for this study would be low in line with other studies
exploring the relationship between children and powered mobility which had sample
sizes ranging from one to ten, (Ragonesi and Cole, 2012; Lynch et al., 2009; Galloway
et al., 2008; Jones et al., 2003).
The first author provided the RDS administrator with an information pack, permission
slip, copy of the EPIOC route map and the EPIOC points system to post to each of the
parents of potential participants. If the parent agreed for their child to participate in the
study they signed and returned the permission slip in the stamped-addressed-envelope.
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They were then contacted by telephone by the first author to discuss the study further
and determine if their child met the inclusion criteria.
Inclusion Criteria
Eligible child wheelchair users had to have an NHS provided powered indoor wheelchair
for at least six months; be aged four to nine years; be able to travel to the EPIOC
test/training site with their parent; and both child and parent able to understand and
speak the English language. Parents gave informed written consent and the child gave
their assent by writing their name or ticking the relevant box on the consent form.
Exclusion Criteria:
Children were excluded if they had a medical/educational diagnosis of a severe learning
disability or cognitive disability; had any problems with eyesight (that could not be
corrected with glasses); any hearing impairment (that could not be corrected with a
hearing aid; or had a diagnosis of uncontrolled epilepsy (had to be seizure free for one
year before commencement of the study).
Participants
A total of fourteen parents returned the permission slips. Of these nine did not meet the
inclusion criteria; two children had not yet received their wheelchairs; for another the
parents were non-English speaking; and the other six children had a diagnosis of
severe learning disability.
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A total of five children were eligible to participate, however due to medical reasons two
of these children withdrew before commencement of the study. The total study sample
was three children (two boys and one girl) aged seven to nine years, with diagnoses of
cerebral palsy with spastic quadriplegia (n=2) and Duchenne Muscular Dystrophy (n=1).
All three children were aged seven to nine years.
Data Collection
All training/testing was completed in the Belfast Trust on the grounds of a large regional
hospital site, the workplace of the first author. Participants were provided with two
appointments, both with their parent present; one for EPIOC training completed by the
first author; then a second appointment two weeks later to complete the EPIOC
assessment as per the current NI EPIOC assessment protocol for those aged ten and
above. In order to minimise the risk of assessor bias and potential issues with inter-rater
reliability the EPIOC assessment was completed by this second occupational therapist,
also an accredited EPIOC trainer/tester. Further, all interventions were completed using
the standardised Belfast Health and Social Care Trust route thereby reducing the threat
of measurement bias.
To date, there is no standardised outcome measure available relating to child or adult
performance in EPIOC use. Performance on EPIOC training and assessment was
captured using the EPIOC score sheet developed by Trust staff. The EPIOC is a
pass/fail test scored out of 500 points and contains twenty-five categories based on
obstacles and manoeuvres the powered wheelchair user must face along the training
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and test route. Each category has a risk factor of low, medium or high. An optimal
score is zero, however if participants accrue 120 points they fail the assessment and
are not eligible to progress on to complete the EPIOC test as further training would be
required. It is used to determine an individual’s ability to safely and competently drive
their powered wheelchair outdoors. Additionally, parent comments regarding their
child’s performance during training/testing were recorded; along with any verbal
prompts to manage the child’s safety during driving were noted.
EPIOC Training
The participants attended the Belfast site to complete EPIOC training using their own
powered wheelchair thereby ensuring user familiarity with the wheelchair functionality
and settings. The original speed settings of the participant’s powered wheelchair were
noted and then re-programmed to a maximum speed of four miles-per-hour. EPIOC
training was then completed along the pre-determined EPIOC route, through hospital
buildings, along an outdoor footpath and crossing several traffic junctions within the
hospital grounds. An average EPIOC training session takes one to one-and-a-half
hours and once training was completed, the participant’s wheelchair speed was
returned to its original setting.
EPIOC Test
The child returned with their parent two weeks after the EPIOC training for the EPIOC
test, which lasted approximately one hour. The second assessor, blinded to their
training performance, completed the EPIOC assessment. The two week period enabled
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determination of whether the participant had retained information from the training
session.
FINDINGS
Child number one (child #1) was male, eight years and nine months old and had a
diagnosis of cerebral palsy with spastic quadriplegia. His parents reported that he had
not achieved functional mobility prior to wheelchair use. He was issued with a NHS
powered wheelchair when he was four years of age and had been using the powered
wheelchair for independent indoor mobility for four years at the time of the study. He
used his powered wheelchair for all indoor mobility at home and at school. He was
issued with a manual wheelchair for outdoor mobility, however, he did not have
adequate upper limb function to self-propel this wheelchair, which meant that he was
reliant on others for all of his outdoor mobility.
Child #1 accrued a total of 40 points out of a potential 500 in the EPIOC training,
gaining points in not stopping and looking before crossing the road. This was because a
car driver waved him forwards, although he stopped immediately when verbally
prompted and was able to return to a safe position. Throughout the training the child
displayed an acute sense of road safety awareness and of the ‘Green Cross Code’, a
UK pedestrian road safety awareness campaign (RoSPA 2005) integrated into primary
school curriculum to promote the safety of children when using footpaths and roads in
the community. He was able to adjust the speed of his wheelchair appropriately,
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especially reducing speed when traversing through hospital corridors. He demonstrated
an awareness of traffic and an ability to judge when it was safe to cross roads. During
completion of his EPIOC test two weeks later he accrued zero points. He had retained
all of the instructions and advice provided during the EPIOC training, passing the
EPIOC test successfully under adult supervision and with no errors.
Child number two (child #2) was aged nine years and seven months and had a
diagnosis of Duchenne Muscular Dystrophy. He walked independently until he was six
years of age and had received a NHS powered wheelchair two years prior to the
commencement of the study. His parent commented that prior to his diagnosis he was
‘climbing trees and riding a bike’ outside with friends and receiving his powered
wheelchair for mobility he has become restricted to indoor play. Child #2 did not
accrue any points out of the potential 500 during the EPIOC training and throughout the
training he too displayed an acute sense of road safety awareness and of the ‘Green
Cross Code’. He was able to adjust the speed of his wheelchair appropriately, again
reducing speed when driving along hospital wards. Similarly to child #1, he
demonstrated both an awareness of traffic around him and an ability to judge when it
was safe to cross roads. During his EPIOC test he accrued 40 points attempting to
cross the road when waved forward by a car driver. Despite this error he passed the
EPIOC assessment successfully with adult supervision. Additionally, his parent
commented that since child #2 had become wheelchair bound, being restricted to indoor
only use, he had lost friends as he was no longer able to play outdoors, and
furthermore, he showed a marked decrease in confidence.
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The third child (child #3) was female, aged seven years and nine months. She had a
diagnosis of cerebral palsy with spastic quadriplegia and her parents reported that she
had not achieved functional mobility prior to wheelchair use. She was issued with a
NHS powered wheelchair when she was four years of age and had been using her
powered wheelchair for independent indoor mobility for three years. She used her
powered wheelchair for all indoor mobility at home and at school. She was issued with
a manual powered wheelchair for outdoor mobility, however, this child, similar to the first
did not have sufficient strength or upper limb function to self-propel her wheelchair and
so was dependent on others for outdoor mobility.
Child #3 accrued a total of 70 points out of 500 in her EPIOC training, gaining points
when travelling on the left hand side of the road to the pedestrian crossing when she
was veering too close to the kerb. She had to be prompted twice to move slightly out
from the kerb to avoid any concealed potholes/manhole covers. She also gained points
when travelling to the opposite end of the footpath, being prompted on three occasions
to increase her speed to cross the road safely. Additionally, she accrued points when
she followed a driver’s instructions waving her to cross the road. She did stop
immediately when verbally prompted and returned to a safe position. Throughout the
training she required verbal prompts to drive at an increased speed when crossing the
road. Alike the other children, she displayed a working knowledge of the Green Cross
Code and used this when deciding to cross the road.
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In her EPIOC testing child #3 accrued 100 points. She had not retained all of the
instructions or advice provided during the EPIOC training. She, like the other two
children, required verbal prompting during the test when crossing the road and on one
occasion attempted to cross the road without looking, a potential fatal error. However,
when prompted to complete it again she performed this task successfully. This serves to
highlight the importance of having adult supervision for outdoor child powered mobility.
Towards the end of her test the participant was fatigued and her concentration was
lapsing. She completed the route safely with verbal prompting from her mother, and
despite accruing 100 points she did pass the EPIOC test.
DISCUSSION
This study sought to evaluate if children between the ages of four and nine can safely
complete EPIOC training/testing with adult supervision; if exposure (time in years) to
having an EPIC correlates with performance on EPIOC performance; and if the current
Guideline with age restriction should be amended so that each child can be evaluated
on an individual basis with regards to EPIOC training/testing.
The findings of this study suggest that with appropriate training children aged seven to
nine can become competent EPIOC drivers, however, as illustrated, this does not
remove the need for adult supervision. This adult supervision was important for the
children, as each child required verbal prompting on at least one occasion to maintain
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their safety whilst driving their powered wheelchair outdoors. Interestingly in the Jones
et al. (2012) study parents were also required to provide supervision to assist with
safety when using powered mobility, which was appropriate to the child’s age. All three
participants in this study demonstrated a readiness, willingness and intrinsic motivation
to drive outdoors. Their parents also demonstrated the enthusiasm to supervise their
children and ensure their safety throughout the EPIOC training and testing.
All the children passed the EPIOC test and demonstrated an ability to drive their
powered wheelchair outdoors. Interestingly the error that all three children made was
that of crossing the road after being waved across by a waiting car driver. This is
deemed to be a high risk as the wheelchair user has no indication or awareness as to
other oncoming traffic. Once this error was pointed out the children were all able to
return safely to the starting footpath. Subsequently, they required adult supervision
when using the EPIOC to fully ensure their safety. This is no different from that typically
expected for any other child of commensurate age and development who are equally
acquiring road safety awareness skills.
It was hypothesised that time in years using an EPIC would have a positive correlation
with EPIOC performance with the possibility of transferable skills for outdoor driving.
However, in our small study this factor had variable impact. Child #1 had the most
experience of driving an EPIC with four years of experience and did perform better
overall. Child #2 had the least experience with two years driving, and child #3 had three
years but the latter more experienced indoor driver scored more poorly than child #2,
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who had also been the only child to have previously walked independently. Therefore,
this suggests that there may not be an immediate transfer or acquisition of skills
between indoor and outdoor training, and that young children should be afforded both
the opportunity of exposure and practise using powered mobility with adult supervision
(Ragonesi and Cole, 2012).
The recently published international Best Practice Guidelines: Early Powered Mobility
with Children (Livingstone and Paleg, 2014) explains that children who have already
experienced independent mobility at a young age should use powered mobility in order
to maintain participation in family, school, and community life. Current NI Regional
Wheelchair Guidelines that impose an age restriction on outdoor powered mobility for
children is in contrast with these best practice guidelines. Evans et al. (2007) confirmed
the positive impact that outdoor powered wheelchair provision had on the independence
and participation for children aged 10 to 18 years. In their study many of the eighteen
children interviewed reported positive functioning following EPIOC use, including
increased independence and participation in social activities such as wheelchair
football.
Further, Scherer (1998a) in her study assessing parents’ perceptions of social
interactions with family and friends found a significant increase from pre-test to post-test
in parents’ satisfaction with their child’s ability to go where desired (p < .05) as a result
of using their powered mobility. Additionally, when using the MATCH survey to assess
the degree to which parents experience negative emotional states such as being
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discouraged, frustrated, or angry (Scherer, 1998b) significant increases were found
between the pre-tests and post-tests. Specifically, Scherer (1998b) found the parents’
satisfaction with the child’s social and play skills (p<0.05) and the parents’ belief that the
general public accepts their child (p<0.04). Additionally, parents believed the wheelchair
had a strong positive impact, rating the wheelchair an average of 4.6 (with 5 indicating a
“very positive impact”) in terms of improving the child’s quality of life. Therefore, these
findings illustrate the importance of enabling these children with mobility limitations the
opportunity to access powered mobility for outdoor use.
In our study, there was not a strong correlation between age and EPIOC performance.
All the children passed both the practice and the test for EPIOC use. Child #2, the
oldest child, scored 0 in the practice and 40 in the test, with child #1 obtaining the
reverse of these scores. The youngest child, child # 3, accrued the most points in her
EPIOC training and test. Throughout the intervention she required verbal prompting to
concentrate on the task and this served to illustrate the importance of having adult
supervision. This is further supported by the Best Practice Guidelines (Livingstone and
Paleg, 2014) whereby it is highlighted that children’s use of powered mobility should be
commensurate with age-appropriate and developmental expectations. For example,
children with cognitive or sensory limitations may need adult supervision or assistance
in the community (as they would if able to walk) but may learn to use a powered
wheelchair to meet their independent mobility needs (Durkin et al., 2014). This perhaps
raises the issue that those who are providing supervision to their children on the use of
powered wheelchairs should also be adequately trained on the supervision of the use of
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powered wheelchairs for outdoor use. This training should include developing traffic
awareness, where and when to cross the road (Congiu et al. 2008), avoiding potholes,
and how best to prompt the child so that the child is learning rather than merely
following instructions.
Limitations
The small sample size of this study means the results should be interpreted cautiously.
As all of the intervention was completed in the Belfast Trust area it may have inhibited
recruitment of a larger sample, as some wheelchair users and their parents may not
have been willing to drive long distances to participate. However, the findings of this
study will still be relevant to both a Northern Ireland agenda for children under ten years
who use powered mobility, and as encouragement elsewhere in the World for clinicians
and parents to afford young children opportunities to experience powered mobility. An
aim of this study was to evaluate EPIOC performance for children aged between four
and nine, however, the youngest participant was aged seven. Therefore, further
research evaluating the performance of younger children using multi-site trials to
increase participant numbers is recommended. Also, exploration of how powered
mobility can be used to enable young children to fully participate in daily activities
should be considered (Casey et al. in press) to contribute to the limited evidence base
on the effectiveness of powered mobility as an intervention.
CONCLUSIONS
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The recruitment process highlighted that out of potentially twenty-one paediatric
powered wheelchair users (EPIC) in NI fourteen, i.e. 66% were interested in completing
a study to evaluate EPIOC performance in school aged children. This would suggest
that children and their parents view outdoor mobility as an important issue. It is vital
therefore that all children are given the chance to practise and experience driving
outdoors in order to acquire the skills to safely and competently drive a powered
wheelchair. This opportunity to participate can not and should not be based solely upon
an age criterion, which can only serve to restrict their occupational rights. Ultimately
children deserve to have their needs and occupations assessed like any other individual
and to have access to appropriate powered mobility.
[4,672 wds]
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KEY FINDINGS
EPIC users aged seven to nine years can become competent EPIOC users with adequate
training and adult supervision.
Length of time (in years) driving an EPIC may not correlate with improved EPIOC
performance.
Criteria relating to EPIOC provision based upon age only should be reviewed.
WHAT THE STUDY HAS ADDED
Provision of children’s powered mobility for outdoor use should be considered on an
individual basis, and not be age-restricted.
ACKNOWLEDGEMENTS
The authors acknowledge the assistance given by XX who acted as a blind assessor in
this study; YY who acted as the local collaborator for the Belfast Health & Social Care
Trust; ZZ for her reviewing support; and importantly the children and their caregivers
who participated in this study.
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