Abstract
This study supports the effects of ride-on car training with conventional therapy to improve mobility, psychosocial function, and play performance of young children with motor disabilities.
A child’s independent mobility and mastery motivation play a prominent role during early development. Mastery motivation is the psychological force that drives children to persist in moderately challenging tasks, solve problems, and master relative skills (Morgan et al., 1990). It includes instrumental and expressive aspects that represent the tendency toward or preference for tasks with a moderate level of difficulty and the emotional expressions during or after the completion of goal-directed tasks (Morgan et al., 1995). Studies have found positive effects of increased motivation on the developmental abilities and exploratory behaviors of children with typical development (TD) and on the maternal behaviors of their caregivers (Adolph & Kretch, 2015; Sparks et al., 2012). Compared with children with TD, young children with motor disabilities often lack curiosity about and interest in practicing skills and challenging tasks, which indicates lower mastery motivation (Hauser-Cram, 1996; Wang et al., 2014). Clinicians consider contextual factors that relate to both caregivers and children to increase mastery motivation among young children with motor disabilities, especially those factors related to developmental skills and maternal behaviors (Huang, Sun, et al., 2017). Using powered mobility devices (PMDs) as a physical environmental modification to improve mobility function and integrating caregivers’ roles into training programs as a social environmental modification may be a practical way to enhance mastery motivation (Huang, 2018).
The combination of the novel PMD of a modified ride-on car (ROC) and social play with caregivers has increasing evidence to support its positive effects on the psychosocial function of children with motor disabilities (James et al., 2019). Family and clinicians can use ROCs in various environments with young children with disabilities such as cerebral palsy, Down syndrome, and complex medical conditions (James et al., 2019). Integrating the coaching model from family-centered service into the ROC training program may help increase children’s motivation and caregivers’ perceptions of their children’s capabilities (Huang, 2018). However, the evidence for the application of ROC training to enhance mastery motivation is very limited (Huang, Chen, & Huang, 2017; Huang et al., 2018). Huang et al. (2018) found that, in comparison with home education, a 9-wk program combining ROC training with a structured, adult-directed social interaction program was beneficial for improving object persistence. Moreover, both groups showed significantly increased mastery pleasure. To further investigate the influence of ROC training as an environmental modification to enhance mastery motivation, and to ascertain its treatment effects, a study with a larger sample size using a randomized method was suggested (Huang et al., 2018).
Recently, Logan, Feldner, et al. (2017) suggested a novel application of ROCs: driving with a standing posture. A standing posture helps to expand children’s reach and visual field, which may benefit their interactions with various objects and people. A longitudinal study (Thurman & Corbetta, 2017) found that different mobility skills were positively associated with travel distance and initiation of movement for exploration. These results imply that driving a ROC with a standing posture may offer more opportunities for children to explore the environment and have more positive effects on mastery motivation than driving with a sitting posture (Logan, Lobo, et al., 2017). However, the current level of evidence regarding the use of a ROC with a standing posture is low.
To examine the effectiveness of using ROCs with different postures, this randomized controlled trial (RCT) included two ROC training groups and a control group that received conventional therapy with similar treatment frequency, dosage, and goal setting. Using a hospital-based environment and a 12-wk intervention and 12-wk follow-up, we examined the effects of ROC training in standing and sitting postures on mastery motivation among young children with disabilities and on parenting stress among caregivers. To verify the influence of ROC training on motivation and parent–child interactions, we also investigated the relationship between mastery motivation and parenting stress after the training programs were administered.
Method
A multiple pretest–posttest design was adopted, including a ROC training group that used a sitting posture (ROC–Sit), a ROC training group that used a standing posture (ROC–Stand), and a conventional therapy group (control). The inclusion criteria and detailed procedure were based on those of previous studies (Huang & Chen, 2017; Huang et al., 2018). Participants were enrolled from November 2015 through October 2019. The study duration for each participant was 24 wk: a 12-wk intervention and a 12-wk follow-up period. A licensed occupational therapist who was familiar with the ecological and motor learning perspectives provided the training. Another independent licensed occupational therapist (Ching-Hao Chang) performed the assessments in an assessment room at the university. The assessments were conducted before and after the 12-wk intervention and at the end of the 12-wk follow-up phase.
Participants
The participants were young children with disabilities ages 1 to 3 yr recruited from local hospitals and communities in Taoyuan and New Taipei, Taiwan. Figure 1 shows the Consolidated Standards of Reporting Trials flowchart for this study. Fifty-three participants were randomly assigned to one of three study groups: ROC–Sit (n = 19), ROC–Stand (n = 17), and control (n = 17; see Figure 1). Fourteen did not receive the allocated intervention as a result of family issues or their health condition (e.g., job relocation, surgery). The final analysis included 39 participants—16 in the ROC–Sit group, 12 in the ROC–Stand group, and 11 in the control group.
CONSORT flow diagram for the study.
Participants did not receive any ROC training or socialization training before the study. The inclusion criteria were as follows: (1) ages 12 mo to 36 mo; (2) a diagnosis of motor delay (SD < −1.5), assessed by a pediatrician using the Chinese Child Developmental Inventory (Wu et al., 2013), resulting in motor impairments that prevented functional independent walking; (3) the ability to stand independently for 2 s or stand with support for 10 min; (4) height ranging from 69 to 103 cm and weight ranging from 7 to 18 kg; (5) the ability to reach for objects with either one or two hands; and (6) caregivers’ approval for the testing procedure and participation in the training. The exclusion criteria included severe sensory impairments, such as blindness and deafness. This study was reviewed and approved by the Chang Gung Medical Foundation Institutional Review Board. The parents provided written informed consent before their children participated in the study.
Procedure
As noted, the participants were randomly assigned to the ROC–Sit, ROC–Stand, and control groups. For the two ROC training groups, the research team modified a ROC so that it could be used with either a standing or a sitting posture during the intervention. The modifications were based on previous studies (Huang & Galloway, 2012; Logan, Feldner, et al., 2017). The car’s control system was modified to be activated with either a switch or a joystick. Caregivers could use the wireless joystick as a shared controller to provide assistance when the car needed to turn (Mitchell et al., 2014). During the entire 24-wk study period, all participants continued their regular therapy, including occupational, physical, and speech therapy, in their own clinical settings.
Intervention
ROC–Sit Group
Each 2-hr training session included 50 min of natural play and 70 min of car play, which was context focused and emphasized physical and social environmental modifications that were based on ecological theory and previous evidence (Huang et al., 2018). The physical environmental modifications involved setting up the physical environment so that children could move freely or explore novel objects or surfaces using the modified ROC. For example, to obtain desired objects or touch an elevator button on the wall, participants could move independently by pressing the switch installed on the ROC and press the button on the wall. The position and size of the switch could be modified on the basis of each participant’s posture and hand function. For the social environmental modification, the therapist provided caregivers with guidelines for appropriate behaviors or reactions based on Waldman-Levi and Erez’s (2015) suggestions, which included supportive attitudes, delayed responses, or reinforcement.
ROC–Stand Group
The training principles and frequency of intervention were the same for the ROC–Stand group as for the ROC–Sit group. The only difference was the posture used to drive the ROC during car play, which provided different physical and social environmental modifications.
Control Group
Participants in the control group received conventional therapy, which was child focused and emphasized skills training from a motor learning perspective. For example, to increase the strength of the lower extremity and improve postural control skills for mobility, the therapist focused on practicing sit-to-stand movements by providing toys at different heights and requiring the participants to reach. Meanwhile, participants received feedback regarding movement outcomes and patterns and encouragement from the therapist, which were also related to the increase in motivation. The training frequency was the same as that for the ROC training groups.
Follow-Up
The three groups continued their regular therapy in their own clinical settings. No additional ROC training or conventional therapy was provided by the research team during the 12-wk follow-up phase.
Measures
The Revised Dimensions of Mastery Questionnaire (DMQ 18)–Chinese version is a caregiver-report questionnaire that uses a 5-point scale ranging from 1 (not at all like this child) to 5 (exactly like this child) to measure both the instrumental and the expressive aspects of mastery motivation (Hwang et al., 2017; MacTurk et al., 1995). The DMQ 18 has seven subscales: Cognitive/Object Persistence, Gross Motor Persistence, Social Persistence/Mastery Motivation With Adults, Social Persistence/Mastery Motivation With Children/Peers, Mastery Pleasure, Negative Reactions to Challenge in Mastery Situations, and General Competence. A higher score indicates higher motivation. For children ages 6 mo to 19 yr, the DMQ 18 has shown good validity and reliability (Hwang et al., 2017; Józsa & Morgan, 2015). Considering the age of participants, we used two versions of the DMQ 18, the Infant version (ages 6–18 mo) and the Preschool version (ages 1.5–5 yr).
The Chinese version of the Parenting Stress Index Short Form (PSI/SF) measures the overall level of parenting stress experienced by parents or caregivers of children ages 1 mo to 12 yr. Scores on its three subscales—Parental Distress, Parent–Child Dysfunctional Interaction, and Difficult Child—add up to a Total Stress score. A higher score indicates higher stress. The PSI/SF is a tool with excellent validity and reliability (Yeh et al., 2001).
Statistical Analysis
Because the data were normally distributed, we used a one-way analysis of variance (ANOVA) to compare the demographic characteristics of the three groups. The effects of the three programs were evaluated using a repeated-measures ANOVA (3 [group] × 3 [time]) with the outcome measures. The overall interaction (Group × Test Session) tested whether there was any interaction effect within and between groups. In the case of a significant interaction, time and group effects were further analyzed using the pairwise post hoc Bonferroni test separately at each time point. A Pearson product–moment correlation coefficient was computed to assess the relationship between mastery motivation and parenting stress. An α level of .05 was used to determine significance. All analyses were performed using IBM SPSS Statistics (Version 22).
Results
Participants
Table 1 presents the demographic data for the 39 participants, which showed no significant between-groups differences for all variables, including age (p = .58), gender (p = .94), diagnosis (p = .63), height (p = .30), weight (p = .29), regular therapy (p = .18), and socioeconomic status (SES; mothers’ education level, p = .60; family annual income, p = .49). Mothers’ education level and family annual income were mostly college level and middle range (NTD550,000–800,000 [USD19,000–28,700]), respectively.
Participants’ Demographic Data
Note. N = 53. ROC = ride-on car.
Ride-On Car Training and Mastery Motivation
At pretest, no significant differences were observed among the three groups on any of the DMQ 18–Chinese version subscales. There were no significant interaction, testing, or group effects for the Cognitive/Object Persistence, Gross Motor Persistence, Social Persistence/Mastery Motivation With Children/Peers, and Negative Reactions to Challenge in Mastery Situations subscales (Table 2). Only the Social Persistence/Mastery Motivation With Adults, Mastery Pleasure, and General Competence subscales showed a significant main effect of testing session. The post hoc test indicated that all groups showed a significant change from pretest to posttest (Social Persistence/Mastery Motivation With Adults, p = .016; Mastery Pleasure, p = .02; General Competence, p = .001) and from pretest to follow-up (Social Persistence/Mastery Motivation With Adults, p = .014; Mastery Pleasure, p = .01; General Competence, p = .004).
Comparison of Mastery Motivation Measured by Revised Dimensions of Mastery 18–Chinese Version
Note. The ns for each group are as follows: ROC–Sit, n = 16; ROC–Stand, n = 12; and control, n = 11. ROC = ride-on car.
Difference is significant at p < .05.
Overall, although there were no significant group differences, only the ROC–Stand group showed a positive trend of changes on all DMQ 18–Chinese version subscales during the 12-wk intervention phase. The ROC–Sit group showed a trend of decreased negative reactions to challenge, frustration, and anger (Negative Reactions to Challenge in Mastery Situations) and no change in social persistence with adults (Social Persistence/Mastery Motivation With Adults). The control group also showed a tendency toward decreased negative reactions to challenge, frustration, and anger and social persistence with children (Social Persistence/Mastery Motivation With Children/Peers).
ROC Training and Parental Stress
At pretest, no significant differences were found among the three groups. There was no significant Time × Group interaction or a main effect of testing session on parenting stress (Table 3). However, a main group effect on Total Stress, Parental Stress, and Parent–Child Dysfunctional Interaction was found, with the ROC–Stand (Total Stress, p = .006; Parent–Child Dysfunctional Interaction, p = .04) and ROC–Sit (Total Stress, p = .03; Parental Stress, p = .003; Parent–Child Dysfunctional Interaction, p = .05) groups having lower scores than the control group. On the Parental Stress scale, the ROC–Stand group had significantly higher scores than the control group after the 12-wk intervention (p = .004). There was no significant difference between the two ROC training groups. In addition, to understand the relationship between mastery motivation and parenting stress during intervention, the correlation coefficient was calculated. No significant correlation was found between mastery motivation and parenting stress in the ROC–Sit group. Only the DMQ 18–Chinese version’s General Competence scale showed a significant negative correlation with the PSI/SF’s Parent–Child Dysfunctional Interaction in the ROC–Stand (r = −.73, p = .007) and control (r = −.65, p = .02) groups. Moreover, for the ROC–Stand group, General Competence also showed a significant negative correlation with Difficult Child (r = −.69, p = .014) and Total Stress (r = −.70, p = .01). Other subscales of the DMQ 18–Chinese version showed no significant correlations with parenting stress in the ROC–Stand and control groups.
Comparison of Parenting Stress Measured by the Chinese Version of the Parenting Stress Index Short Form
Note. The ns for each group are as follows: ROC–Sit, n = 16; ROC–Stand, n = 12; and control, n = 11. ROC = ride-on car.
Difference is significant at p < .05.
Discussion
The findings of this first RCT support the positive effects of ROC training in two different postures and conventional therapy on enhancing social persistence with adults, mastery pleasure, and general competence among children with motor disabilities. These findings are consistent with previous evidence indicating that early powered mobility training may increase children’s social persistence with adults and mastery pleasure (Huang, Chen, & Huang, 2017; Kenyon et al., 2017). A standing posture provides a different locomotor experience, optical flow, and visual–proprioception integration that may cause updated perceptual information, different emergent actions, and psychological changes (Anderson et al., 2013). Moreover, Franchak et al. (2018) found that face looking in infants and caregivers and mutual gaze in dyads decreased when the postural context made looking more difficult, such as between prone infants and upright caregivers. Thus, compared with crawling infants with TD, walking infants make more social bids, look at the body and environment more, and interact more with caregivers. ROC training with a standing posture may have a similar effect on interactive behaviors among young children with motor disabilities; that is, they may show increased social persistence with adults.
Providing environmental modifications and tasks that relate to the just-right challenge of postural requirements and social looking behaviors is critical for enhancing the instrumental and expressive aspects of mastery motivation (Huang, 2018). Huang et al. (2018) found that using a ROC in a sitting posture resulted in significant improvements in instrumental persistence and mastery pleasure in young children with motor disabilities. Compared with previous ROC studies (Huang & Chen, 2017; Huang et al., 2018), the current participants were able to stand for a few seconds and thus may have been at a higher developmental level than participants in previous studies. The standing posture requires more postural adjustment skills than the sitting one, which may have fit the current participants’ abilities and offered the just-right challenge. The decreased scores on mastery motivation in the ROC–Sit group during the intervention phase, particularly on Cognitive/Object Persistence, Gross Motor Persistence, and Social Persistence/Mastery Motivation With Adults, may support the assumption that less difficult tasks result in less psychological change.
Notably, conventional therapy also showed significant effects on increasing children’s social persistence with adults, mastery pleasure, and general competence. Studies have shown that both context-focused and child-focused programs improve functional skills among children with disabilities (Darrah et al., 2011; Law et al., 2011). Our findings support similar effects on psychosocial function, that is, mastery motivation. However, the therapist-directed program did not include cooperation with caregivers during the intervention phase, which may not be beneficial for decreasing parenting stress. Thus, the two ROC training programs resulted in a significantly higher decrease in parenting stress than conventional therapy.
In addition to the use of a modified ROC with different postures, an encouraging and supportive environment that is viewed as a social environmental modification promotes parent–child relationships and has a positive effect on children’s mastery motivation (Logan et al., 2019; Waldman-Levi & Erez, 2015). The current intervention strategies of the ROC training program focused on contexts and applied the coaching model to consult with the caregivers, which resulted in a significant decrease in total parenting stress. To be specific, the interaction of decreased stress and parent–child dysfunction strongly correlated with children’s higher general competence in the ROC– Stand group. For 18-mo-old children with TD, maternal parenting stress was found to be correlated with mastery motivation, and parent–child dysfunctional interaction was consistently associated with all mastery motivation subscales at ages 6 mo and 18 mo, including Cognitive/Object Persistence, Gross Motor Persistence, Social Persistence/Mastery Motivation With Adults, Social Persistence/Mastery Motivation With Children/Peers, Negative Reactions to Challenge in Mastery Situations, and General Competence (Sparks et al., 2012). Lower general competence of infants at an early age is associated with greater maternal parenting stress when infants are older. Interventions such as ROC training with a standing posture are helpful for enhancing the relationship of children with motor disabilities with their parents at an early age.
This study has several limitations. First, the sample size restricted the generalizability of these results to all young children with motor disabilities. Second, the lack of information on the severity levels of motor delay may have affected the interpretation of the observed outcomes. Evidence supports the level of severity of impairments, maternal interactive behavior, and SES as possible factors that affect children’s mastery motivation (Wang et al., 2014). The current findings exclude the influence of SES because we found no group differences between the ROC training and conventional therapy groups at pretest. However, the level of severity of the children’s impairments may account for their effectiveness. Future studies should include a larger sample and investigate the impact of different developmental levels on the related outcomes to provide a complete examination of this topic.
Implications for Occupational Therapy Practice
The results of this study have the following implications for occupational therapy practice: ROC training with a sitting or standing posture and conventional therapy all benefited mastery motivation. Use of a coaching model increases general competence and parent–child interactions.
Conclusion
In recent years, there has been increasing evidence for the effectiveness of using a ROC to improve mobility, psychosocial function, and play performance of young children with motor disabilities. This first RCT supports the effect of ROC training with two different postures and conventional therapy on mastery motivation and parenting stress. ROC training with a standing posture provides moderately challenging physical and social environmental modifications that enhance mastery motivation and lead to more decreased parenting stress than conventional therapy. The critical factors are to provide a large amount of active, exploratory experiences with goal-directed, moderately challenging tasks and to cooperate with the caregivers, which may result in the greatest benefits to young children with motor disabilities.
Footnotes
Acknowledgement
We declare no conflict of interest. This work was supported by the Ministry of Science and Technology, Taiwan (Grant No. 104-2314-B-182-023-MY3), and Chang Gung Memorial Hospital (Grant No. BMRPD28).