Infants & Young ChildrenVol. 21, No. 2, pp. 94–106Copyright c© 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins

Adaptation Interventionsto Promote Participationin Natural Settings

Philippa H. Campbell, PhD; Suzanne Milbourne, PhD;M. Jeanne Wilcox, PhD

Children’s participation in everyday activities and routines in home and community settings isan important focus of services for infants and young children with disabilities. Data indicate thatassistive technology (AT) is not widely used nor do early intervention service providers reportfrequent use of AT devices with infant-toddlers. Adaptation interventions combine environmentalaccommodations and AT in ways that promote children’s participation in activities and routines andprovide functional skill-building learning opportunities. A decision-making process for planningand implementing adaptation interventions is outlined with examples of strategies and formats thatservice providers can use to create successful interventions for infants and young children. Keywords: activities and routines, adaptation, assistive technology, intervention, participation

THE use of assistive technology (AT) ser-vices and devices with infants and tod-

dlers in early intervention (EI) programs ap-peared to be increasing from 1992 to 1996(Technical Assistance Project, 2000); how-ever, more recent reports indicate a stable pat-tern of underutilization (Campbell & Wilcox,2004; Dugan, Campbell, & Wilcox, 2006).National reports of the percentage of infant-toddlers with AT listed as a service/device ontheir Individual Family Service Plans (IFSPs)have averaged about 4% in each year since1999 (U.S. Department of Education, 2006).Furthermore, an analysis of the 2820 servicerecords for infants and toddlers participatingin the National Early Intervention Longitudi-nal Study (Hebbeler & Zercher, 2003) revealedthat AT was listed on 4% of these servicerecords.

Author Affiliations: Thomas Jefferson University,Philadelphia, Pennsylvania (Drs Campbell andMilbourne); and Department of Speech and HearingScience, Arizona State University, Tempe (Dr Wilcox).

Corresponding Author: Philippa H. Campbell, PhD,Thomas Jefferson University, 130 South 9th St, Suite526, Philadelphia, PA 19107 (philippa.campbell@jefferson.edu).

A number of explanations for low rates ofutilization have been suggested including par-ent unwillingness to accept device use withtheir children, provider biases to work ontypical skill development, inability to financedevices, lack of consensus about what com-prises AT, and limited emphasis on or train-ing about AT in state EI programs (Kemp& Parette, 2000; Lahm & Sizemore, 2002;Sullivan & Lewis, 2000). Furthermore, it hasbeen suggested that state policies such as uni-form Individual Family Service Plans (IFSPs)that do not require documentation of AT de-vices may under-represent actual AT utiliza-tion by not providing mechanisms for report-ing actual use (Lesar, 1998). In a nationalsurvey of 967 EI providers, 44% reported thateither none or few of the children they servedwho needed AT were in fact receiving AT ser-vices or devices (Wilcox, Guimond, Camp-bell, & Weintraub-Moore, 2006).

The Tots-n-Tech (T-n-T) Research Insti-tute on Assistive Technology for Infants andToddlers has conducted a number of stud-ies to explore utilization of AT with infants(Campbell & Wilcox, 2004). In an analysisof data from 2 national surveys, more than90% of 424 EI providers reported positive

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Adaptation and Assistive Technology Interventions 95

perspectives about providing AT for infantsand toddlers (Dugan et al., 2006). These sameproviders were interviewed to explore deci-sion making about what types of interven-tions would be considered in which devel-opmental situations and at what time pointswithin the infant-toddler age range. The ques-tions focused on decisions about mobility,communication, self-care, and play situations.Each question was structured so that respon-dents selected an option from a series thatwas representative of several interventioncategories (eg, low tech, high tech, skill build-ing, not a concern at this time). These op-tions were repeated within each of 3 age-level categories of less than 12 months, 12to 24 months, and more than 24 months.To contrast the perspectives of EI serviceproviders with those of providers serving chil-dren with the most severe disabilities, 37 co-ordinators of State Deaf-Blind Programs com-pleted a written questionnaire using the sameseries of questions. For the most part, DeafBlind coordinators reported use of both low-or high-technology interventions at youngerages than did the EI providers. AlthoughEI providers reported beliefs that supportedearly use of AT, they did not report actualuse until children were over 2 years old. Asa whole, a majority of EI providers selectedskill-building interventions as a primary inter-vention across all functional areas for childrenyounger than 2 years and almost a third of theproviders continued to select skill-buildingoptions even when children were older than2 years.

ACCOMMODATION, ADAPTATION,

UNIVERSAL DESIGN, AND AT

To gain an understanding of perspectivesabout definitions of AT, T-n-T surveyed 967EI providers and asked them to provide ex-amples of devices they considered to below and high technology (Wilcox, Dugan,Campbell, & Guimond, 2006). Providers weremore likely to mention low- than high-technology devices. However, the same de-vices (eg, communication devices) were fre-

quently mentioned as examples in boththe low-technology and high-technology cat-egory. These data as well as other reports(eg, Lahm & Sizemore, 2002; Parette & Broth-erson, 2004) seem to indicate that serviceproviders may not have a clear definition ofeither what AT services and devices includeor when to use them with children.

Part of the apparent confusion for providersmay relate to the different terminology anddefinitions about AT that are incorporatedinto federal programs that support individu-als with disabilities. For example, each stateincludes definitions of Durable Medical Equip-ment (DME) that are eligible for payment un-der state Medicaid programs. Our T-n-T datasuggested that providers seemed to link theirown state definitions of DME, a source offunding for AT, with their personal defini-tions of high-technology AT. The Americanswith Disabilities Act (1990) protects rights ofindividuals with disabilities in a variety ofsituations and settings including child careprograms. Legislation specifies that discrim-ination cannot take place without reason-able accommodation for an individual’s dis-ability. Reasonable accommodations includechanging facilities so that they are accessi-ble (eg, installing a ramp into a child careprogram for a child in a wheelchair) andacquiring or modifying materials (eg, pro-viding adapted positioning equipment for achild with physical disabilities or special ma-terials for a child who is blind or visuallyimpaired).

Regulations for both the Assistive Technol-ogy Act of 1998 (as amended, 2004) andthe Individuals with Disabilities Education Im-provement Act (2004) include identical defi-nitions for both AT services and AT devices.The definition of devices is expansive and in-cludes any item, equipment, or product sys-tem that is used to “increase, maintain, or im-prove functional capabilities of an individualwith a disability” (CFR 300.5). These defini-tions are broad, linked specifically to func-tional capabilities, and incorporate some, butnot all, items that would be likely to beincluded under Medicaid DME categories

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or under the reasonable accommodation re-quirement of the Americans with DisabilitiesAct (ADA).

AT is beginning to be viewed within a con-text of universal design, a new concept beingincorporated into federal programs. The pro-posed regulations for IDEA [Federal Register:June 21, 2005 (Vol 70, No. 118)] referencethis concept by adding the same definition forthis term that is included in the Assistive Tech-nology Act. Universal design means “a con-cept or philosophy for designing and deliver-ing products and services that are usable bypeople with the widest possible range of func-tional capabilities, which include productsand services that are directly accessible (with-out requiring assistive technologies) and prod-ucts and services that are inter-operable withassistive technologies” (CFR 300.43). Whendevices and other materials are designed insuch a way as to be useable by people withdisabilities, the modifications, adaptations, orspecial devices that are defined as AT arenot needed. For example, universal design in-cludes many modifications that may have orig-inally been designed for individuals with dis-abilities but are useable by children and adultswithout disabilities such as curb cuts, high toi-lets, positioning devices for infants such asstroller or car seat head protectors, cardboard-paged books, or built-up handled spoons. Un-der IDEA, the concept of universal design isstrongly linked to assessment and curriculumand is viewed as a way to provide childrenwith access to the general education curricu-lum. When child care or preschool curric-ula, for example, are designed for childrenwith a range of abilities, then fewer modifica-tions, adaptations, or AT devices are neededfor a child with a disability to participatesuccessfully in a program’s curricular activi-ties. For example, when playgrounds are de-signed to accommodate all children’s abilities,then the modification and adaptations neces-sary to provide access and promote partici-pation of children with disabilities are min-imized or eliminated. Or, when items suchas knob crayons are used in programs forall young children, a child with difficulty

grasping is more likely to be able to partici-pate in a coloring activity.

The often-subtle differences in definitionsand terms for accommodation, AT, or univer-sal design may make little difference to fam-ilies who want their children to be able toparticipate in typical activities and routines orto child care providers or preschool teacherswho also have expectations for children’s par-ticipation (Milbourne & Campbell, 2007). Wehave taken an approach in our work of com-bining the reasonable accommodation defini-tions from the ADA and the AT definitionsused in IDEA and the Assistive TechnologyAct to propose a category of intervention thatwe have labeled “adaptation”and which bothencompasses features labeled as accommoda-tion or AT devices and acknowledges con-cepts of universal design.

TYPES OF INTERVENTIONS

Adaptation interventions are a type of in-tervention where therapists and teachers as-sist in the identification, design, fabrication,and monitoring of interventions that are pro-vided by families and other caregivers withinthe context of typical activities and routines.These interventions function as a “bridge” ora mediator between the skills that a child cancurrently perform and the requirements orexpectations of the activity. When there is amismatch between a child’s current abilitiesand the requirements of an activity, adapta-tion interventions may allow a child to par-ticipate fully even without being able to per-form the required skills (Campbell, 2004). Allchildren may be able to participate more eas-ily or successfully in various activities whenadaptations are used. For example, a typicalinfant rides more easily and safely in a carwhen positioned in a car seat. However, whena preschooler is unable to sit because of aphysical disability, a car seat may be essentialto successfully ride in a car.

Use of typical activities and routines thatoccur in natural settings as a context for in-tervention has been emphasized in EI (Dunstet al., 2001; Dunst, Hamby, Trivette, & Bruder,

Adaptation and Assistive Technology Interventions 97

2000). Adaptation interventions, includingaccommodation and AT, are used to helpchildren participate in typical activities androutines within the everyday settings wherethey spend time (Campbell, 2004; Lane &Mistrett, 2002; Milbourne & Campbell, 2007;Mistrett, 2004). AT can be used with childrenwith a wide range of developmental concernsranging from mild delays in development tochildren with severe or multiple disabilities.Its use may both promote participation andhelp children with functional skill limitationsachieve mobility, communication, play, orself-care skills (Blackhurst & Lahm, 2003;Mistrett, 2001). Specialized teaching ortherapy strategies are another type of inter-vention used to teach children to performthese same skills naturally or without exten-sive use of adaptations or devices (Campbell,2005). These skill-building interventions aretraditionally provided via one-on-one interac-tions between children and EI personnel andtake place during home visits (Campbell &Sawyer, 2007). In preschool and child care,children may receive one-on-one interactionswith therapists or teachers via a “pullout”model. Services provided through one-on-oneinteraction between a child and an adult aregenerally described as a direct interventionbecause of their dependence on contrivedactivities and intense adult intervention.

When promoting participation, the focusof intervention shifts from skill building toinclude strategies that ensure maximal par-ticipation as quickly as possible. Adaptationinterventions include use of both low- andhigh-technology AT devices that allow chil-dren to participate in the absence of beingable to perform skills required in the activityor routine. For example, a child may be un-able to participate in art activities at the childcare center because she is unable to grasp ob-jects such as art materials, brushes, or crayonswithout adult assistance. The requirement ofan adult to help the child hold and manip-ulate objects may alter the child’s participa-tion by isolating the child from other chil-dren, thereby limiting natural opportunitiesfor peer interaction, communication, or other

group expectations. Providing the child withadapted brushes, crayons, or other materialsand having the child care program choose artactivities that do not require high levels of ma-nipulation of objects may allow the child toparticipate without adult assistance, therebyproviding natural opportunities for communi-cation and social interaction.

DECISION MAKING USING AN

ADAPTATION HIERARCHY FRAMEWORK

A 4-step process for making decisions aboutpossible adaptations to promote children’sparticipation in activities and routines is illus-trated in Figure 1. It may be helpful to reframeskill-building goals (eg, “use a pincher grasp”;“write 4 capital letters when provided witha model”; “express wants and needs whenasked”) as participation-based outcome state-ments such as “participate in family mealtimesby feeding himself finger and spoon foods,drinking from a cup, and socializing with fam-ily members.” Participation-based outcomesestablish the child’s goal as one of participa-tion in a specified activity (or routine) ratherthan as skill building although an activity or aroutine provides a context in which to prac-tice particular skills. For example, mealtimesthat specifically include finger foods may pro-vide a child with opportunities to practice us-ing a pincher grasp.

GATHERING INFORMATION

As an initial step in designing adaptationinterventions, providers first work withfamilies or other child caregivers (eg, childcare providers; preschool teachers) to learnabout the typical activities and routines inwhich the child participates or is unable toparticipate. Family activities include a widerange of situations, some of which are typicalacross families (eg, grocery shopping; watch-ing TV), but many of which may be uniqueand based on family preferences (eg, playingat the beach). Child care and other groupactivities (eg, library story book hour; toddlermusic or gymnasium programs) also include

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Figure 1. A 4-step process for making adaptation decisions to promote children’s participation in activities

and routines.

participation opportunities such as storybookreading, learning centers, gross motor activi-ties, or snack. Family routines occur regularlyand often involve caregiving (eg, bathtime)or family organization (eg, getting up in themorning; bedtime; mealtimes). In child care,most routines are those that involve caregiv-ing (eg, diaper changing, toileting, naptime)

or provide structure for managing groups ofchildren (eg, making a transition from oneactivity to another; leaving at the end of theprogram). Service providers can learn aboutactivities and routines in a variety of waysranging from simply having a conversationwith the family or caregiver-teacher to usingmore structured assessment techniques.

Adaptation and Assistive Technology Interventions 99

Figure 2. A hierarchy for designing adaptation interventions including assistive technology devices and

ranging from environmental accommodations (least restrictive) to adult assistance (most restrictive).

The important thing is to find out about theactivities and routines that are not going wellas judged from the perspective of the familyor caregiver-teacher. The end goal of theprocess is to promote children’s participationin all identified activities and routines butparticularly in those that are judged by fam-ilies or others (eg, child care staff; librarian)as not going well (Campbell, 2004, 2005).

The second step is to learn about adults’satisfaction with the child’s performance in4 functional skill areas including communica-tion, social interaction with adults and chil-dren, use of hands and arms, and mobil-ity. Children with disabilities may have manydevelopmental performance limitations butthese limitations may or may not impact neg-atively on participation in specified activitiesand routines. When functional skill abilitiesnegatively influence participation in a partic-ular activity or routine, these limitations mayoften be reduced or eliminated through use ofadaptations. For example, if a child needs toask for more food or drink during snack timeat a child care center, holding the 2 objects upso that the child can indicate a choice, a pic-ture board that allows a child to point to items,a picture exchange system, or using a simplevoice output device can allow the child to par-

ticipate in snack time and meet adult expecta-tions without being able to talk.

ADAPTATION HIERARCHY FRAMEWORK

The third step is to use the adaptation hi-erarchy framework (Fig 2) for making deci-sions about possible adaptation strategies tohelp a child successfully participate in typi-cal activities and routines (Campbell, 2004,2005; Milbourne & Campbell, 2007). The hi-erarchy lists categories of intervention strate-gies from those that are least (at the top) tomost (at the bottom) restrictive. Modifyingthe environment in some way that allows achild to participate or providing a child withspecific types of equipment is the least intru-sive type of adaptation strategies. Removinga child from the typical environment so thatthe child is doing something different withan adult, generally in a one-on-one situation,is the most restrictive. The framework is notmeant to suggest that more restrictive optionsare never needed in particular situations orwith certain children but rather that restric-tive interventions should not be tried as a firstsolution and should be used only when othercategories of adaptation have been tried withno success.

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Assistive technology devices, as definedin IDEA and other legislation, fit into theadaptation hierarchy primarily within cate-gories of environmental adaptations of posi-tioning and selection or adaptation of mate-rials. Other non-AT types of adaptation maybe used to promote child participation. Inter-vention strategy categories that are at the topof the chart typically involve accommodationsor adaptations to the environment in which anactivity or a routine occurs. For example, ar-ranging the furniture at home or in a child careprogram so that the child can get around isan example of an environmental accommoda-tion. Placing heavy sandbags into plastic fur-niture (eg, a play kitchen) so that a child canuse the furniture safely to pull up to standingis an example of an environmental modifica-tion. Purchasing puzzles with big knobs onthe pieces or adapting existing puzzles withbig knobs allows a child without good ma-nipulation skills to play with other children.When adaptations do not occur, children mustbe assisted by other children or by adults toparticipate successfully. Requiring assistancefrom an adult to participate in an activity or aroutine is a restrictive intervention.

Examples of strategies for each of the adap-tation intervention categories on the hierar-chy are listed on Table 1. Further examplescan be found in Milbourne and Campbell(2007). Typically developing infants and tod-dlers share many of the same functional skilllimitations as children with disabilities andthese limitations are likely to impact their par-ticipation in activities and routines. As a re-sult, equipment, toys, and other items usedwith typically developing children can beused with children with disabilities if carefullyselected and matched to the child’s interestsand abilities. In a sense, items used with ba-bies have universal design characteristics andmay require little to no adaptation to promoteparticipation with children with disabilities.These items include baby equipment such ashighchairs, strollers, toilet chairs, floor sitters,or child chairs that are readily available butneed to be carefully selected to provide thetypes of support that may be needed by a child

with a disability. Purchasing carefully selectedtoys that match a child’s interests and manip-ulation abilities or can be easily adapted to ac-commodate for any functional ability limita-tion also is effective for a majority of infantsand young children. Inexpensive adaptationsto off-the-shelf items also work well. For exam-ple, a preschooler who can physically fit into amotorized off-the-shelf car (eg, Corvette; Bar-bie jeep) may be able to use the car for outsidemobility with simple adaptations for position-ing and switch operation of the car.

Similarly, many of the activities and routinesin which infants and young children partici-pate can be easily adapted to allow childrenwith disabilities to participate without anygreater amount of adult assistance than wouldbe provided for a child of the same chronolog-ical age. Items used within an activity such asspecific materials (eg, materials in the kitchenarea of a child care room; books) or toys oftenrequire no adaptation if well selected or mini-mal adaptation to accommodate a child’s func-tional abilities. A preschooler with disabilitiesmay be able to learn to “write” the letters inhis name by moving magnetic letters aroundon a board or play at the woodworking areaif tools are adapted with built-up handles. Infamilies, and children’s programs where chil-dren of a variety of ages are included, older ormore competent children may be able to helpchildren with disabilities. Early learning pro-gram curricula that use multiage groupings(eg, Montessori or Reggio-Emila) offer manyopportunities for bringing children togetherin cooperative working relationships so thatchildren with disabilities have natural formsof assistance.

All of these adaptation strategies can allow achild with a disability to be successful withoutrequiring above-average adult assistance. Ob-viously, young children require considerableassistance from adults when they are infant ortoddler-aged and the amounts and types of as-sistance decrease as children get older. Chil-dren with disabilities are viewed frequently asneeding a lot of adult assistance to participatein settings that are designed for typical chil-dren. A goal in using adaptation interventions

Adaptation and Assistive Technology Interventions 101

Table 1. Examples of adaptation interventions

Adaptation hierarchy level Examples

Adapt setup of environment Moving furniture within the home to allow a child to walk with a

walker; placing all unsafe materials (such as cleaning solutions)

in a locked cupboard

Adapt/select “equipment” Using boppies and bean bag chairs in a child care program so that

children can sit with support; purchasing a particular brand

off-the-shelf stroller or off-the-shelf toilet chair in which a child

can sit comfortably and safely

Equipment/adaptations for

positioning

Using a stander so that the child can work with others at the sand

table; obtaining a customized chair that positions the child

Adapt schedule Allow longer times for mealtime so that a child who needs more

time to self-feed will have enough time to complete the meal;

plan an art activity in which children complete 2 projects to

provide enough time for a child with a disability to complete

one project

Select or adapt activity Reading a story using props so that children may participate

actively while listening; incorporating a variety of riding toys

into outside play so that all children can ride; making sure that

one riding toy can be used by the child with a disability either

through selection or adapting existing toys; singing songs during

opening circle/morning meeting time so that all children have

an opportunity to vocalize

Adapt/select materials & toys Purchasing an off-the-shelf puzzle with knobs so that the child can

complete the puzzle independently; attaching a switch to a toy

so that the child can play with the toy without assistance

Adapt requirements or

instructions

Allowing a child to self-feed for the beginning of the meal and then

feeding the child for the remainder; use picture boards that

relate to a story so that a child can successfully “talk” about the

story or answer story questions.; read 2 very short stories and

require a child who has difficulty attending to attend for one

story only; construct or select situations for children to request

assistance; allow the use of picture boards, voice output devices,

or other means (eg, sign, gestures) for children who are unable

to speak

IS for children is to be as independent as otherchildren of the same chronological ages.

IMPLEMENTING ADAPTATION

INTERVENTIONS

The fourth step is to make decisions abouthow potential adaptation interventions willbe implemented. Implementation may be assimple as selecting or designing an adapta-tion that both “fits” a child’s abilities and thecharacteristics of the activities and routines in

which the adaptation promotes participationand, then, providing the adaptation. How-ever, more often than not, family membersand caregivers who will use the adaptationintervention with the child will need someexplanation and may require actual training.When more complex AT devices have been se-lected, training and monitoring are built intothe implementation plan to ensure that theadults can support the child in using the de-vice and that device operation is monitored toensure that the device is working as expected.

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Figure 3. The “Here’s the Situation: Try This Adaptation” form was completed for a 20-month-old whose

family used storybook reading as part of their bedtime routine.

Abandonment of AT devices (ie, rejectingtheir use) has been reported as a frequentoccurrence when parents, other caregivers,or teachers cannot adequately support thechild’s device use or maintain its use withindesired activities and routines (eg, Mistrett,2001; Parette & McMahon, 2002).

One example of an implementation tool isthe “Here’s the Situation: Try This Adaptation”(Fig 3) matrix that may be used to summa-rize and represent information that has beengathered about a child’s participation in aspecified activity or routine. Planning formsprovide structure for brainstorming and iden-tifying potential adaptation interventions.Figure 3 illustrates this process using the ma-trix. Functional skills are listed and matchedwith steps of the adaptation hierarchy. Thisparticular format has been used to guide pro-fessionals and families in identifying poten-tial adaptation strategies and structuring deci-sion making about which strategies to try. The

child whose plan is represented on Figure 3 isa 20-month-old who enjoys books. In his fam-ily, book reading is part of the children’s bed-time routine in which this activity providesa transition between bathing and bedtime aswell as an activity for other times during theday. Implementation forms such as this arecompleted through discussion with the familyby an interventionist or EI team. They serve afunction of focusing on promoting participa-tion in a specified activity or routine and struc-turing opportunities for communication, mo-bility, hand and arm use, and socialization.

The second tool (Fig 4) is a web that canbe used in 2 ways. One way is to representhow a particular activity provides opportu-nities for a child to practice various func-tional skills. With the use of successful adapta-tions, children are not only able to participatein the activity but also provided natural op-portunities for learning and practicing skills.Skills may be those that are developmentally

Adaptation and Assistive Technology Interventions 103

Figure 4. Webs can be used to represent a child’s skill learning opportunities within a particular activity

or routine as is illustrated in this web of a bedtime routine of storybook reading.

appropriate for all children of a particularchronological age or have been identified forlearning on the child’s IFSP or IEP. Figure 4illustrates the web for the same child whose“Here’s the Situation” plan is illustrated onFigure 3. Webs provide a context for in-tegrating the perspectives and expertise ofvarious disciplines and help families under-stand how family activities and routines areimportant to children’s learning of devel-opmental skills such as communication, so-cial interaction, mobility, and arm and handuse. Representing opportunities for learningwithin the context of a particular family ac-tivity or routine may help families under-stand how they are effective teachers for theirchildren.

It is not unusual for children’s abilities in aparticular functional skill area to limit partici-pation in more than 1 activity or routine. Forexample, when children have difficulty com-municating, their inability in this area is likelyto impact successful participation in morethan 1 activity or routine. A second way thatwebs may be used is to represent the waysin which a particular adaptation intervention

can be used across activities and routines. Theweb in Figure 5 illustrates how adaptations forcommunication can be integrated into variousactivities and routines. This web was designedfor a 40-month-old girl who attends a childcare center while her mother is at work. Mollyis the only child with a disability in her childcare classroom and her difficulties with com-munication influenced her abilities to partic-ipate successfully in most child care activi-ties. When she was unable to communicatesuccessfully, she often became frustrated andresorted to inappropriate behavior (such ascrying, throwing objects, hitting) to gain theattention of the other children or teachers.A series of communication options was de-signed to be used across the activities inher child care program and represented forthe teacher and family on a web so that theuse of these strategies was illustrated acrossactivities.

PUTTING IDEAS INTO PRACTICE

The potential of adaptation interventionsis substantial. However, service providers

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Figure 5. Children’s functional skill abilities may negatively influence participation in more than 1 activity

or routine. Webs can be used to represent the ways in which particular adaptation interventions may be

incorporated into more than 1 activity or routine.

may not readily use adaptation interventionsbecause they are more focused on traditionalskill building than on children’s participa-tion in activities and routines (Bruder, 2000;Dugan et al., 2006), are unaware of decision-making strategies or of potentially helpfulresources (Romski & Sevcik, 2005), or lackknowledge and training about adaptations(Long, Huang, Woodbridge, Woolverton, &Minkel, 2003). All providers should be awareof AT resources provided through their PartC lead agency, special education in their stateDepartments of Education, or the agency thatadministers the state’s Assistive TechnologyAct grant. By using these resources, manystates have been able to offer training aboutAT services and devices, devices within a par-ticular skill category (eg, Augmentative andAlternative Communication), or on specificdevice products. Some states provide annualExpos where devices can be seen and triedand manufacturers or distributors can answerquestions. These opportunities are generally

directed to AT applications with individuals ofall ages and may not be specific to AT with in-fants and young children.

Trying out devices is often helpful, par-ticularly with high-technology or specializeddevices that may be both costly and com-plicated. Sometimes a device that seemsplausible may not work well in given situ-ations. Lending libraries are a helpful andeffective resource for learning about devicesand obtaining them for trial before pur-chase. Some states have established lendinglibraries within community facilities suchas public libraries and others provide theseprograms on a regional or statewide basis.Lending libraries are also operated by privateorganizations such as Easter Seal or UnitedCerebral Palsy Associations and by Lekotek.Most lending libraries have both low- andhigh-technology items available to borrowbut, in general, available items are morelikely to be considered as high-technology.Providers should explore public and private

Adaptation and Assistive Technology Interventions 105

resources in their own states and familiarizethemselves with what items are availableto borrow, any eligibility requirements, andprocedures for obtaining and trying devices.

With infants and young children, high-technology devices are seldom needed. Apreschooler with a disability may be able toparticipate at the classroom computer learn-ing station by accessing the computer with atouch screen and this adaptation may be usedby the other children in the classroom. Whenkeyboarding skills are needed, a more compli-cated adaptation may be necessary for effec-tive computer use. Infants or toddlers may beable to augment limited speech and improvecommunication through use of pictures or asimple voice output device but may requiremore complicated communication aids to ex-press themselves as they get older. While en-vironmental adaptations and low-technologyaids are less costly and permanent than high-technology devices, information is neededto be knowledgeable about the range of op-tions that are available to both promote par-ticipation and improve functional skill use.Early intervention providers and families mayrequire training and resources to identifypotential aids that can be used. In addition,often the most effective adaptation interven-tions are those that are designed through cre-ative problem solving and trial-and-error use.Providers should be willing to experiment toidentify ways that children’s participation andskill use can be improved.

A reality is that few EI providers re-ceive training about adaptations or devicesor about how to provide AT services (Lahm& Sizemore, 2002; Wilcox et al., 2006).Studies of professional training programs forEI personnel (eg, teachers, therapists) indi-cate that few programs include informationabout designing or using adaptation interven-tions (Stayton & Bruder, 1999) but emphasizestrategies for teaching targeted skills.

Adaptation interventions have the potentialto be powerful interventions with infants andyoung children. However, in telephone inter-views with families whose children were us-ing AT devices, a majority of families reportedthat they learned about adaptations and de-vices from friends and other families—notfrom professionals (Wilcox et al., 2006). Thisfinding is probably not too surprising, giventhe limited training that providers receive andtheir reliance on intervention decision mak-ing that delays the use of adaptation inter-ventions until children are older. Optimally,adaptation interventions would be introducedto providers during their preservice training,supported by state and local policy, and main-tained through ongoing inservice training andavailability of local resources such as devicelending libraries. When providers are knowl-edgeable about and view adaptation interven-tions as effective ways of intervening with in-fants and toddlers, children’s performance offunctional skills and participation in everydayactivities and routines can be enhanced.

REFERENCES

Americans with Disabilities Act of 1990, P.L. 101-336.

Assistive Technology Act of 1998 as Amended (2004), P.L.

108-364.

Blackhurst, E., & Lahm, L. (2000). Functional deci-

sion making model for assistive technology. In

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