Gait Trainer (Community Playthings, Port Was Defined As (A) No Outside Assistance Or 1999) Was Used During Intervention

E ects o Functional Mobility Skills Training or Young Students With Physical Disabilities

STACIE B. BARNES KEITH W. WHINNERY University o/West Florida

AB.STRACT: The Mobility Opportunities Via Education (MOVE®) Curriculum is a functional mo bility curriculum for individuals with severe disabilities. This study investigated the effects of the MOVE Curriculum on the functional walking skills offive elementary-aged students with severe, multiple disabilities. The MOVE Curriculum was implemented using a multiple-baseline across subjects design. Repeated measures were taken during baseline, intervention, and maintenance phases for each participant. All students demonstrated progress in taking reciprocal steps during ei ther intervention or maintenance. Results for each participant are discussed as well as implications andfuture directions for research.

ince the passage of P. L. 94-142, mental model in which therapists attempt to cor students served in special edu rect specific deficits and remediace underlying cation programs have had the processes of movement co promote normalization right to related services (e.g., (Campbell, Mcinerney, & Cooper, 1984; Fetters, occupational therapy and physi 1991). As a result, these treatment programs typi cal therapy) as needed to benefit from their edu cally do nor focus on the development of func cational program (Beirne-Smith, lttenbach, & tional motor skills in natural environments Patton, 2002). Therapists in educational settings because students often are viewed as not ready co who are typically trained under the medical perform such high level skills (Rainforth & York model of disability traditionally have provided Barr). Until recently, this traditional approach to therapy services separate from educational goals therapy was considered acceptable in school set (Craig, Haggart, & Hull, 1999; Dunn, 1989; tings because educational programming for stu Rainforth & York-Barr, 1997). Treatment within dents with disabilities also relied on a this traditional approach is based on the develop- developmental model. It has been only in the past

Exceptional Children 313 15 to 20 years char educational programs for indi away from a developmental approach toward a viduals with disabilities have begun to move away functional n1odel chat emphasizes potential and from instruction based on a developmental model support, the link between. special education and to curriculum approaches emphasizing functional pediatric therapy has been strengthened outcomes (Butterfield & Arthur, 1995). (McEwen & Shelden, 1995). Recent research Current educational practices promote the suggests that when therapy is integrated into che use of a support model that emphasizes an individ student's natural environments, treatn1ent is just ual's future potential rather than an individual's as effective as traditional therapy and chat the in li1nitations (Barnes, 1999). While earlier practices c.egraced approach is 1nore preferred by che school that focused on deficits often lin1iced an individ tea,n (Giangreco, 1986; Harris, 1991). The bene ual's access to environments and activities (Brown fits of providing therapy in integrated settings in et al., 1979), current practices employ a top clude (a) the availability of natural motivators dov,n approach to program planning designed to (Atwater, 1991; Campbell et al., 1984), (b) re teach an individual to function more indepen peated opportunities for practicing motor skills in dently in his or her natural environments. Top meaningful situations (Can1pbell et al.; Fetters, down program planning typically incorporates 1991), and (c) increased generalization of skills the concept of place then train, promoting in across different environmental settings (Campbell struction in the environments in which the skills et al.; Craig et al., 1999; Harris). "Although inter will be used (Beirne-S1nith et al., 2002). Individ vention has historically focused on deficient skills uals served under a support model are not ex with the assumption chat isolated skills must be cluded from activities because they lack learned and then eventually transferred to func prerequisite skills; rather they are supported to tional activities, we now know that for learners participate co their highest potential. A support ,vith severe disabilities, task-specific instruction model approach to programming provides a must take place in the natural environ1nenc for framework for identifying adult outc;:omes, deter retention to occur" (Shelden, 1998, p. 948). mining current levels of functioning, and identi In response to the shortcon1ings of tradi fying supports needed to achieve the targeted tional motor treatment approaches, rhe MOVE outcomes. (Mobility Opportunities Via Education) Curricu As educational practices change, therapy lum was developed to teach functional mobility approaches char stressed remediation of individ skills to students with severe disabilities (Kern ual skills in isolated environments are being re County Superintendent of Schools, 1999). placed by the practice of integrated therapy in MOVE is a top-down, activity-based curriculum which services are provided in natural settings designed co link educational programs and ther where skills \Vil! be functional and performance apy by providing functional mobility practice meaningful for individual students (Rainforth & within typical daily activities in the natural con York-Barr, 1997). Integrated therapy breaks from text. Individuals using the MOVE Curriculum the more traditional, multidisciplinary n1odel follow a top-do\vn approach co progran, plan where team members conduce assessments and set ning, rather than selecting skills from a develop goals in relative isolation (Orelove & Sobsey, mental hierarchy. A transdisciplinary team chat 1996). Parents, teachers, and therapists collabo includes parents, educators, and therapists ,vorks rate as a team co assess the student, write goals, collaboratively co assess the student's skills, design and i1nplement intervention. The tean1 develops . an individualized program, and teach targeted the IEP cogerher by setting priorities and devel skills while the student participates in school and oping child-centered goals through consensus community activities (for additional information (Rainforth & York-Barr). In chis way, all tea1n on the MOVE Curriculum see Bidabe, Barnes, & members are aware of the IEP goals and can work Whinnery, 2001.) cooperatively co embed chem into the child's nat Since the inception of the MOVE Curricu ural activities. lun1 in 1986, chis seemingly successful approach As the fields of physical therapy, occupa has spread co a great number of classrooms, reha tional therapy, and education have begun to move bilitation facilities, and hon1es for students with

314 Spring 2002 disabilities across the United States as well as stationary object and could move her feet recipro throughout Europe and Asia. Although testimony cally while being supported for weight shifting from practitioners and families as well as informal and balance. Although she deJ1'lonstrated these studies have praised the effectiveness of MOVE, skills on rare occasions in physical therapy, she there has been no systematic research related to typically refused to use then1. the effectiveness of this approach to teaching Participant 2, Melissa, ,vas a 4-year-old fe functional mobility skills. While the great num male diagnosed with a developmental delay and ber of anecdotal reports of student successes in cerebral palsy with hypotonia. Melissa was able to the MOVE Curriculum should not be disre bear \I\Teight in standing \I\Thile holding a station garded, there is a critical need for demonstrable ary object and move her legs reciprocally while data co support che efficacy of the program. being supported for balance and weight shifting Therefore, chis study asked the following ques in physical therapy, but she also refused to use tion: Do functional 1nobility skills in students these skills. with physical disabilities improve as a result of di Participant 3, Kevin, was a 3-year-old male rect training using the MOVE Curriculum and diagnosed with cerebral palsy \I\Tith hypotonia, will these skills be maintained over time? right hemiparesis, cortical blindness, and a seizure disorder for which he took medication. Kevin \Vas METHOD unable to bear weight in standing unless his knees, hips, and trunk \.\'ere held in alignment by PARTICIPANTS a standing device. Participant 4, David, \I\TaS a 9-year-old male Five children ,vich severe, multiple disabilities be diagnosed with spastic quadriplegic cerebral palsy C\I\Teen the ages of 3 and 9 were selected to partici and asthma for which he took medication. David pate in chis study. All of the children attended a had the ability to maintain hip and knee exten public elementary school located in an urban, sion when supported by an adult and to tolerate southeastern school district, were served in special fully pron1pted reciprocal steps when supported education classes, and received occupational and in a walker. physical therapy as related services. Four of the Participant 5, Caleb, was a 4-year-old male participants were served in a preschool classroom diagnosed with global developmental delays, spas for students with severe, multiple disabilities. The tic quadriplegic cerebral palsy, chronic lung disor remaining participant was served in a varying ex der, and a seizure disorder for which he cook ceptionalities classroom for students with moder medication. Additionally, Caleb had a tra ate to severe disabilities. cheostomy that required frequent suctioning, a The following criteria ,vere used to select gastrostomy tube, and occasionally had breaching participants for the study: (a) diagnosis of a se distress. He required a one-on-one nurse in atten vere, multiple disability including a physical im dance at all times, and his n1edical co1nplicacions pairment, (b) parent al consent, (c) medical sometimes resulted in extended absences. Caleb eligibility, (d) willingness of the school team to had the ability to maintain hip and knee exten participate and co be trained in MOVE, and (e) sion when supported by an adult and to tolerate no prior implementation of the MOVE Curricu fully prompted reciprocal seeps when supported lum. Five of the 17 students served in the C\I\TO in a walker. classes met all the selection criteria. RESEARCH METHODOLOGY The pri1nary means of n1obility for all par ticipants was either being pushed in a wheelchair A single-subject, multiple-baseline across subjects or being carried. Participant l, Ki1n, was a 7-year study was employed. The independent variable old female diagnosed \Vith Do\vn syndrome, se was the MOVE Curriculum that consists of six vere mental retardation, general hypotonia in all steps: (1) Testing, (2) Setting Goals, (3) Task extremities, and a seizure disorder for which she Analysis, (4) Measuring Prompts, (5) Reducing took anticonvulsant medication. Kim was able to Prompts, and (6) Teaching the Skills. The depen bear her own ,veight in standing while holding a dent variable was the number of reciprocal steps.

£,:ceptional Children 315 A reciprocal step was defined as a step within a week until a pattern of stable performance was es time interval of not more than 10 seconds be tablished. Baseline measures began by the fifth tween initial contact of one foot and initial con vveek of the school year. D.ue co the multiple base tact of the opposite foot in a forward motion. line design, baseline ,vas collected for 1 I /2 weeks for the first participant, Kim, and continued for SETTING 12 weeks for the last participant, Caleb. Each par Mobility practice ,vas conducted in the natural ticipant was given the least amount of adult assis context in accordance with the principles of the tance (i.e., one or two hands held or support at MOVE Curriculurn. Meaningful and relevant ac trunk) necessary for weight bearing in standing tivities that naturally occur during the school day and verbal directions to walk. No assistance was were selected for each participant. These activities provided for caking reciprocal steps. Baseline mea occurred throughout the school campus. sures of reciprocal stepping were taken with adult The study wa~ conducted over the course of support for all participants. Additional measure one school year beginning in the third week of ments without assistance ,vere taken for Kim and the fall term and lasting until the 27th week in Melissa because they had demonstrated the ability spring. Maintenance data was collected over a 2- to bear weight in standing ,vhile holding a sta .•. week period 2 years following the intervention tionary object. Baseline measures occurred within year. the participants' nonnal school environ1nents; however, no measures were tal

316 Spring2002 cervencion and at the next more independent As is advocated in Seep 5 of MOVE, physi level. In addition, measurements were taken for cal support ,vas faded as soon as the students Melissa at all three levels of support. Although demonstrated an increase in skill level as indicated Melissa required the use of the Gait Trainer, mea by the data. The reduction of prompts differed surements were taken for independent walking for participants according co their individual rate because she had previously demonstrated the abil of progress. ity to bear her own weight and occasionally cake During Teaching the Skills, Seep 6 of one or cwo reciprocal steps with both hands held. MOVE, instruction of skills was embedded into Because Kim began to take reciprocal steps inde typical daily activities in order co provide mean pendently during the second trial of intervention, ingful, intensive, and consistent practice of recip data collection with "adult assistance" ,vas discon rocal stepping. An important component of chis tinued. seep is the identification of practice activities chat are relevant and motivating co the individual co· fNTEROBSERVER AGREEMENT encourage active participation. From these prac Alchough the intervention ,vas implemented by tice opportun1t1es, one act1v1cy per participant all cean1 me1nbers, measurements were taken by ,vas selected for data collection. Data ,vere col , ,. the first author to increase reliability. In addition, · lected cwice a ,veek. interobserver agreement checks were made by the MAINTENANCE ])HASE second author to ensure accurate measurement. For each participant, a minimum of t\VO checks After a period of 2 years, maintenance measures ,vas conducted for each targeted behavior. Per were taken on dependent variables for 4 of the 5 centage of agreement was calculated by dividing participants. David had moved from the area and che total number of agreements by the sum of was unavailable. Data were collected during the agreements and disagreements and multiplying participants' natural activities at che time. Some chat number by 100 (White & Haring, 1980). students had moved into new classrooms and Agreement for the number of reciprocal steps many were participating in different activities taken equaled 1OOo/o. than chose used during the initial intervention phase. fNTER\/ENTION PHASE Measure1nencs were taken for participants The intervention consisted of the implementation at their current level of support necessary for of the six steps of the MOVE Curriculum for functional walking (e.g., independent walking for each participant. Using the information obtained Kim and Melissa, ,valking with adult assistance during Seep 1, Testing, the team was able co iden for Caleb, and walking with the use of the Gait tify each participant's consistent use of mobility Trainer for Kevin). skills and to select functional activities during Step 2. These activities were task analyzed in Seep 3 in order to identify the critical mobility skills to RESULTS be addressed in each activity. Once meaningful daily activities were iden DATA ANALYSIS tified for mobility practice, the level and type of physical support needed to accomplish che acci:,, Data were analyzed using visual inspection of the i ty were determined in Seep 4, Measuring graphs including changes in means, levels, and Pron1pts. A critical component of the MOVE trends as well as percentage of overlap across program is co provide che necessary but minimal phases (Kazdin, 1982). Performance data for in . pron1pcs (physical support) needed for functional tervention and maintenance are presented in Fig mobility within an activity. This level was deter ures 1-3. mined for each individual based upon assessment Kim. A stable baseline with a n1ean and data collected in Step 1. The.refore, not all partici range of O seeps was observed for vvalking forward pants required assistance and all three levels of independencly (see Figure 1). The mean for inter support. vention phase was 5.25 seeps ,vith a range from 0

Exceptional Children 317 FIGURE 1 Independent Walking far Kim and Melissa Across Baseline, Intervention, and Maintenance Phases . ,.. . ~ I 8tiD I E i: :s i! . Iii m=·• :31 12 I IU 1 B I ii ,. I I! D I •• I 2 I 'D D G 10 15 20 :16 .. 15 411 4G 00 G5 ID Trlllk

-~· 4!11 • • 31'.D • • ,• ., l 21'Jl 't 'I 11111 • I 611 •· a •ii l:11 I 12 I I JI 10 di • ii ..a B ' . .. r I :II u: 8 ! ' ! 4 • I 2 'I I a 0 G 10 111 20 H 80 811 a ~ 1111 M Ill 1'11111. to 14 steps. T here was only a 90/o overlap of data points (10 of 26 data points) was noted from points (4 of 45 data points) from baseline with a baseline to intervention. 5.25-poinc increase in the mean. There \Vas an During che n1aincenance phase, n1easure upward trend in reciprocal seeps observed in in ments were taken on independent reciprocal seeps tervention phase with one notable decrease coin since Melissa no longer required che use of rhe ciding with an increase in seizure episodes. Gait Trainer or adult support. All ,neasurernencs D uring the 1naincenance phase, there \Vas a during maintenance sho\ved that Melissa ,vas able sizable increase in the number of independent to walk over 500 ft independently. A 500-poinc reciprocal steps recorded. All measurements dur increase in che n1ean with a 0% overlap of data ing maintenance revealed chat Kim was able to points from intervention to maintenance was ob \Valk over 500 ft independently. This resulted in a served. 494.74-point increase in the mean number of Kevin. For walking forward \.Vith adult sup steps taken with a Oo/o overlap of data points from port, Kevin was unable to bear \Veight or co take intervention phase to the maintenance phase. any seeps during baseline or intervention (see Fig Melissa. A stable baseline with a mean and ure 2). Additionally, he would not accept being range of O steps was observed for \valking (see Fig- · placed into the Gait Trainer during intervention ure 1). Intervention included the use of the Gait (see Figure 3). During maintenance, ho,vever, Trainer (see Figure 3) and ad ult support (see Fig Kevin was taking reciprocal steps both with adult ure 2). As Melissa required less support, the Gait support and while using the Gait Trainer. The Trainer ,vas discontinued (after the 37th trial). mean for walking for,vard \Vith adult support For adult support, there was a general increase in during 1naintenance was 3 .33 seeps \.Vith a range the number of steps with a mean of 30.16 with a from 2 to 4 steps. This showed a slight upward range from O to 100 steps. A 38o/o overlap of data trend and a mean of 3.33 seeps. There was also a

318 Spring2002 FIGURE 2 Walking with Adult Support for Melissa (2-Hand Assistance), Kevin (Support From Behind at Trunk), David (2-HandAssistance), and Caleb (Support From Behind at Trunk) Across Baseline, Intervention, and Maintenance Phases.

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Exceptional Children 319 FIGURE 3 Walking with the Use ofthe Gait Trainer for Melissa, Kevin, and David Across Baseline, Intervention, and Maintenance Phases

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Oo/o overlap of data points (O of 3 points). between cervencion phase with a mean of 6.91 seeps and a intervention and maintenance. While using the range from O to 26 steps. A 55% overlap of data Gait Trainer, Kevin consiscencly was able to rake points (12 of 22 data points) from baseline co in independent reciprocal steps for a minimu1n of tervention with a 5.27-point increase in the mean 100 steps. was observed. David. Foe \Valking forward ,vich adult sup Initially, measurements of reciprocal seeps port, there was a stable baseli ne with a n1ean of \vhile walking in the Gait Trainer were taken since 1.64 steps and a range fron1 1 to 3 seeps (see Fig David was unable co walk che 70-ft distance from ure 2). An upward trend was noted during the in- the bathroom to the classroom (see Figure 3) .

320 Spring 2002 However, once David was able to consistently By the end of intervention, however, Kim ,.,,as walk the entire distance, the measurement of dis able co ,valk short distances independently. tance was discontinued and the measurement of Mdissa, David, and Caleb were .able to walk with time was added (after the 30th trial). For the du adult support to participate more fully in their se ration of the study, n1easurements of time indi lected activities. As the students gained functional cated a steady decrease &om 9 min 20 s to 4 min walking skills, they were able to participate in 54 s by the 53rd trial. David was unavailable dur ocher school and community activities without ing che maintenance phase due to a family move. the use of their wheelchairs. Caleb. For walking forward with adult sup Although Kim demonstrated very little in port, a stable baseline with a mean of .60 steps terest in her environment and would not attempt and a range fron1 0 co 1 was observed (see Figure to take any independent steps during baseline, the 2). The mean for the intervention phase was 4.47 addition of a motivating activity appeared to have steps with a range from O to 12 steps. However, a positive impact. Initially, Melissa resisted all at-· after rhe 33rd trial, all \valking was discontinued te1npts at walking and required the use of the for 3 weeks due to medical complications. This Gait Trainer as well as full physical prompting to resulted in a substantial decrease in walking skills . move her legs reciprocally. By the end of the in following this period. A reintroduction of the in tervention phase, however, she no longer required tervention was follo\ved by another upward trend. the use of the Gait Trainer and did not need to There ,vas a 3.87-point increase in the mean from use her wheelchair during the school day. Despite baseline to intervention with a 21 o/o overlap of Kevin's inability co cake reciprocal steps during data points (4 of 19 data points). There ,vas a sig the intervention phase, the cransdisciplinary ceam nificant decrease in skill level in the maintenance continued to practice supported ,veighc bearing in phase demonstrated by a mean of O steps. This standing and transfers fron1 sitting co standing represented a 4.47-point decrease from the inter with the expectation that reciprocal stepping vention phase with a 0% overlap of data points. would develop. This was fow1d co be true when measurements were taken during maintenance. Although David was able to take a fe,.,, DI S CU SS ION steps wich adult support during baseline, he used The current study investigated che effects of the the Gait Trainer co practice walking for longer MOVE Curriculum on functional mobility skills distances during intervention. David's ability to (e.g., walking fonvard) ,vith 5 students with se v.•alk for,vard with adult support also improved vere, multiple disabilities. The results of chis study significantly during intervention. This new skill provide support for the use of the MOVE Cur allowed David co walk short distances without che riculum to increase functional mobility skills for use of his wheelchair, allowing increased parcici students with severe disabilities. A clear functional pation in crowded environments. relationship between the target behaviors and the Caleb showed a fairly steady increase in rec intervention procedures was demonstrated. Four iprocal steps with adult support during interven of the 5 participants sho,ved increases in v.•alking tion. There was a 3-week period ,vhen Caleb's skills from baseline to intervention. Although the nurse restricted all ,valking due to medical con1- fifth participant, Kevin, did not make any gains plications. After chis break, Caleb experienced a during intervention, he did show a dramatic in temporary regression in walking skills follo\ved by crease in walking during the maintenance phase. progress beyond earlier achievements. In general, prior to intervention none of During the maintenance phase, only 4 of the participants was able to demonstrate func the 5 participants were available. Three of the 4 tional walking skills either independently or with participants not only maintained the gains made support. David and Caleb did demonstrate the in walking skills, but they also continued co n1ake ability to take a few steps with support during improvements beyond the intervention year. The baseline, but these minimal levels did not increase remaining participant, Caleb, experienced a sig their functional participation in daily activities. nificant setback in walking skills.

E.xceprwrutl Children 321 Kim was consistently walking over 500 ft lacionships can be inferred when performance on a variety of surfaces (e.g., sand, grass) and no changes at each point chat intervention is intro longer used her wheelchair at school. Melissa ,vas duced (Kazdin, 1982; Tawney & Gase, 1984). In able co walk independently over 500 ft on a vari chis study some participants did nor demonstrate ety of surfaces, and her mother reported that she immediate increases in skill with the introduction had greater access to che community. Kevin was of che intervention. The slow race of change of consistently walking over 100 ft in che Gait some participants also resulted in introduction of Trainer and was bearing his own \veight to take che curriculum for some students prior co signifi son1e steps with adult support. This was in sharp cant increases of the previous participant. Al contrast co his performance during intervention though this violation of 1nultiple-baseline design when he ,vas unable to bear his own weight. Caleb experienced numerous medical complica lessens the degree of experimental control, the de tions during the time period between interven cision was made co expose all participants to the tion and maintenance. Walking skill practice was intervention within the school year. However, a not a regular component of Caleb's education slow rate of behavior change is characteristic for program resulting in regression in reciprocal step the population studied (Beirne-Sn1ith et al., 2002; ping. During 1naintenance data collection, Caleb Shelden, 1998). Additionally, a visual inspection could bear his own weight for shore periods of of the dac.1 indicat.es chat participants 1nade dra ci1ne, but was not strong enough co indepen matic changes in reciprocal stepping skills in ei dendy cake reciprocal seeps. ther intervention or maintenance. Such dran1atic This study has limitations including a small changes in behavior provide more support for a sample size, variability of data, and difficulty in causal relationship beevveen the intervention and establishing a cause and effect relationship. The an increase in behavior (Kazdin; Tawney & Gast). first issue of small sample size is characteristic of A second consideration related to the infer single-subject designs. The limitations of chis de ence of causal relationships is the effect of external sign were reduced by the use of repeated measure- variables in relation co the intervention. In this 1nen ts over time and n1ultiple baselines. Additionally, the dran1acic effects required of sin study stable and staggered baselines helped co re gle-subject designs may be more generalizable duce the influence of competing variables such as across individuals than are larger group designs maturation and historical events. Further, there chat meet relatively weaker statistical standards were no gains in functional mobility skills for any (Gall, Borg, & Gall, 1996; Kazdin, 1982). participant until after the intervention was intro A second limitation of chis study is the vari duced for chat individual. ability of the data chat makes interpretation of The results of this preli1ninary study sug treac1nent effects difficult. The variety of influ gest that sysce1nacic mobility training programs, ences in the natural environ1nenc and the charac such as MOVE, can lead co an increase in func teristics of individuals with severe disabilities (i.e., tional mobility skills. Additional research investi frequent illnesses and absences, medical complexi gating the effects of the MOVE Curriculum is ties, etc.) typically result in variations in the data. warranted. Systematic direct replication should be While traditional research methods consider vari conducted co help establish reliability and gener ability co be a ,veakness, researchers studying the alizability and could be replicated across at lease 1nulciple factors affecting skill development advo- . five din1ensions (e.g., subjects, behaviors, settings, cate for the preservation of variability because it procedures, and processes). In addition to replica provides valuable infor1nacion about behavior changes (Kamm, Thelen, & Jensen, 1990; Kra tion of initial outcomes of this study, future re cochwill & Williams, 1988). search should investigate the criticality of specific A third limitation of chis study is the diffi components of the MOVE Curriculu1n (e.g., lev culty in establishing a causal relationship between els of family involvement, student-selected versus MOVE and increases in reciprocal stepping. In adult-selected activities, and systen1atic prornpt single-subject multiple-baseline designs, causal re- reduction).

322 Spring 2002 IMPLICATIONS FOR PRACTICE opportunities do not always naturally occur. T he This study emphasizes the importance of environ results from chis study support the use of practice mental support in the development of new skills. opportunities that are both n1e~ningful and con The importance of supports was obvious with tinuous. Melissa appeared co have the potential co David who was unable to walk independently, walk, but not the 1nocivacion. The continuous op but could walk short distances with adult support portunities for practice seemed co be related co and even greater distances with the use of the her increased desire co walk. With Caleb and Gait Trainer. This discrepancy would suggest chat Kevin who appeared to lack both the skill and the without assistance, David would not have had che will to walk, increased mobility oppottunicies opportunity to practice walking skills. Kevin not provided the consistent practice necessary for the acquisition of walking skills. When progress is not only required postural support, bur he also immediately apparent, as ,vith Melissa and Kevin, needed to develop weight-bearing skills before he educational teams must be committed co concinu-· experienced gains in walking. As muscle strength ous meaningful practice. In both cases, the partic and proprioceptive awareness developed, he even ipants initially appeared co be unaffected by the tually was able to walk proficiently in the Gair intervention, but eventually n1ade significant Trainer. The implications of chis study are signifi-· gains in functional walking. Regardless of whether cant for individuals with severe disabilities \Vho lack of progress is due co limited skills or low mo may not have opportunities to participate in tivation, continuous opportunities for practice meaningful life activities without environmental should be a critical component of mobility train support. ing. A second in1plication of chis study was re lated to motivation. In addition co a lack of pos tural balance and strength, son1e of the REFERENCES participants appeared to have no interest in walk ing. This see1ned ro be the case with Melissa who Atwater, S. W. (1991). Should che normal motor devel showed no signs of progress for over 2 months be opmental sequence be used as a theoretical model in fore making rather rapid and dramatic gains in pediatric physical therapy? In J. M . Lister (Ed.), Con her walking skills. The use of the Gait Trainer as temporary management of rnotor control problems: Pro well as full physical prompting allowed the school ceedings of the II Step Confe,·ence (pp. 89-93). Alexandria, VA: T he Foundation for Physical Therapy. team ro provide Melissa with the experience of walking to 1nany different environments until she Barnes, S. B. (1999). The MOVE Curriculum: An ap became actively engaged in walking. Thus, ic ap plicarion of contemporary theories of physical therapy and education. (Doctoral dissertation, University of peared chat once Melissa was motivated co walk West Florida, 1999). Dissertation Abstracts \Vithin meaningful activities, she made dramatic International, 9981950. increases in her functional walking abilities. Moti Beirne-Smith, M., lttenbach, R. F., & Patton, J. R. vation was a factor with Kim's program, also. (2002). Mental retardation. (5th ed.). Upper Saddle Once Ki1n developed ,valking skills, she would River, NJ: Prentice-Hall. walk only co the cable co eat or when returning to Bidabe, D. L., Barnes, S. B., & Whinnery, K. W. the "safety" of her classroon1. As she bec.1me more (2001). M.O.V.E.: Raising expectations for individuals excited about che freedom walking gave her, she with severe disabiliries. Physical Disabilities: Education began ro generalize chis skill across many environ and.Related Services, 19(.2), 31 -48. ments and activities. The natural motivation asso Bro,vn, L., Branson, M. B., Han1rc-Nictupski, S., ciated with acciviry-based instruction is a key Pumpian, I., Cereo, N., & Gruenewald, L. (1979). A . component of the MOVE Curriculum, and this strategy for developing chronological age-appropriate study supports the importance of practice during and funcrional curricular content for severely handi . . moc1vac1ng acttv1t1es. capped adolescents and young adults. The journal of A third implication relates to the need for Special Education, 13(1), 81-90. increased opportunities ro practice new skills. For Butterfield, N., & Arthur, M. (1995). Shifting the many individuals with severe disabilities, these focus: Emerging priorities in com,nunicarion progra,n-

Exceptional Children 323 ,ning for students with a severe intellectual disability. Orelove, F. P., & Sobsey, D. (1996). Educating children Education and Training in Mental Retardation and De with multiple disabilities: A transdisciplinary approach. velopmental Disabilities, 30(1), 41-50. Balti,nore: Paul H. Brookes.* Campbell, P. H., Mcinerney, W. F., & Cooper, M. A. Rainforth, B., & York-Barr, J. (1997). C:ollaborative (1984). Therapeutic programming for students with se teams for students with severe disabilities: Integrating ther vere handicaps. The American Journal of· Occupational apy and educeltional services. Balci,norc: Paul H. Therapy, 38(9), 594-602. Brookes.* Comn1l1nity Playthings. (1999). Rifton equipment (Cat Shelden, M. L. (1998). Invited con11nentary. Physical alog). Rifton, NY: Community Products LLC. Therapy, 78, 948-949. Craig, S. E., Haggart, A. G., & Hull, K. M. (1999). In Ta,vney, J. W, & Gast, D. L. (1984). Single subject re tegrating therapies into the educational setting: Strate search in special education. Colu1nbus, 01-:1: Merrill. gies for supporting children wirh severe disabilities. White, 0. R., & Haring, N. G. (1980). Exceptional Physical Disabilities: Education and Related Ser teaching(2nd ed.). (',0lu1nbus, OH: Merrill. vices,17(2), 91-109. Dunn, W. (1989). Integrated related services for preschoolers with neurological impairments: Issues and strategies. Remedial and Special Education, 10(3), 31- A BOUT TH E A UTHOR S

39. STACIE B . B ARNES, Assistant Professor, K EITH Fetters, L. (1991). Cerebral palsy: Contemporary treat- w. WHINNERY, Associate Professor, University 1nent concepts. In J. M. Lister (Ed.), Contemporary of West Florida, Pensacola. management ofmotor control problems: Proceedings ofthe II Step Conference (pp. 219-224). Alexandria, VA: The Foundation for Physical Therapy. Correspondence regarding chis manuscript should Gall, M. D., Borg, W. R., & Gall, J. P. (1996). Educa be addressed co: Dr. Stacie B. Barnes, Division of tional 1·esearch: An introduction (6th ed.). White Plains, Teacher Education, University of West Florida, NY: Longman."' 11000 University Parkway, Pensacola, FL 32514- Giangreco, M. F. (1986). Effecrs of integrated therapy: 5753; E-n1ail: [email protected]. A pilot study. Journal ofThe Association for Persons with Severe Handicaps, 11(3), 205-208. Manuscript received April 200 I ; accepted Sep Harris, S. R. ( 1991). Funcrional abilities in context. In tember 2001. J. M. Lister (Ed.), Contemporary management of motor control problems: Proceedings of the II Step Conference (pp. 253-259). Alexandria, VA: The Foundation for Physical Therapy. Kamm, K., Thelen, E., & Jensen, J. L. (1990). Ady * To order books referenced in this journal, please namical systems approach to motor development. Phys call 24 hrs/365 days: 1-800-BOOKS-NC)W (266- ical Therapy, 70, 763-775. 5766); or 1-732-728-1040; or visit chem on the Kazdin, A. E. (1982). Single-case research designs. New Web at http://www.BooksNow.co1n/Exceprional York: Oxford. Children.hem. Use Visa, MIC, AMEX, Discover, or Kern County Superintendent of Schools. (1999). send check or money order + $4.95 S&H ($2.50 MOVE: Mobility Opportunities Via Education: Bakers each add'! item) to: Clicksmart, 400 Morris Avenue, field, CA: Author. Long Branch, NJ 07740; 1-732-728-1040 or FAX Kratochwill, T. R., & Williams, B. L. (1988). Perspec l-732-728-7080. tives on pitfalls and hassles in single-subject research. Jou1·nal for The Association ofPersons with Severe Handi caps, 13(3), 147-154. McEwen, I. R., & Shelden, M. L. (1995). Pediatric therapy in the l 990's: The demise of the educational versus medical dichotomy. Occupational and Physical Therapy in Educational Environments, 15(2), 33-45.

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