1 Introduction

Cerebral palsy is characterized by non-progressive neuropathological disorders that occur in children up to two years old, encompassing a series of different clinical syndromes, which may or may not be associated with cognitive impairment (^{Brandão, Oliveira, & Mancini, 2014}; ^{Monteiro, Vasconcelos, Silva, & Calvacante, 2012}; ^{Silva & Pontes, 2016}).

Depending on the area of the affected nervous system, the individual is affected in different ways, presenting disorders marked by the lack of control over movements that can impair functional performance (^{Brandão, Oliveira, & Mancini, 2014}; ^{Mancini et al., 2004}; ^{Pfeifer et al., 2014}; ^{Silva & Araujo, 2019}; ^{Sposito & Riberto, 2010}). Studies indicate that most children with cerebral palsy have some kind of motor disorder that directly impacts their daily lives, influencing their way of controlling their environment, independence and autonomy (^{Guerzoni et al., 2008}; Martins, Müller, & Heidrich, 2008; ^{Ostensjo, Carlberg, & Vollestad, 2005}). Thus, most of these children require an extensive assistance to perform day-to-day activities such as self-care (^{Ostensjo, Carlberg, & Vollestad, 2005}).

Literature indicates that Assistive Technology (AT) can help them to gain independence and control of the environment, favoring its exploration, control of space and experience in their multiple life contexts (^{Copley & Ziviani, 2004}; ^{Cowan & Khan, 2005}; ^{Earde, Praipruk, Rodprait, & Seanjumla, 2018}; ^{Ostensjo, Carlberg, & Vollestad, 2005}; ^{Watson, Ito, Smith, & Anderson, 2010}).

AT is an area of knowledge that consists of assisting persons with disabilities in the performance of their duties, not being limited only to the resources offered, but also covering the direct assistance available, selection, acquisition and/or training of a device. Its concept is broad, and resource development has allowed the appreciation, integration and inclusion of many people, promoting their human rights and their participation (^{Cook & Polgar, 2015}; ^{Cowan & Khan, 2005}).

The resources of AT are organized in modalities and their classification may vary according to the different authors or institutions that work with it, such as equipment for self-care activities, mobility and communication, among others. The characteristics of AT recommendations are driven by the needs, objectives, capabilities, skills and desired roles of the consumer and should be considered in assessing his/her purposes, interests and desire, as well as those of his/her family, caregivers, and the context in which this individual is inserted (^{Cook & Polgar, 2015}; ^{Trombly & Radomski, 2005}).

The AT implementation process is integrated and should involve the performance of a multidisciplinary rehabilitation team, with different stages, namely: the assessment of the patient and of the existing and used devices; the assessment of the demands of the patient, his/ her family and caregiver; the prescription of an AT resource and its preparation; training to use it with a patient, teachers, caregivers and/or family members; monitoring the use and periodic reevaluations that may cause adaptations, modifications or replacement of resources; and possible locations for the use of the resource (^{Cook & Polgar, 2015}; ^{Cowan & Khan, 2005}; ^{Fachinetti, Gonçalves, & Lourenço, 2017}; ^{Sposito & Riberto, 2010}; ^{Trombly & Radomski, 2005}).

Studies by ^{Ostensjo, Carlberg and Vollestad (2005}) and ^{Cowan and Khan (2005}) describe the impact of AT devices on daily life activities and the care of children with cerebral palsy as beneficial, pointing out the effectiveness of their use when inserted in the early life of these children and demonstrating the importance of prescription and use of AT in childhood. However, it lacks studies that describe the step-by-step implementation of AT resources, such as decision making and operationalization of resource-making steps for children with cerebral palsy in the context of daily living activities, which would assist in the reasoning of the professionals involved at the time of prescription. Reliable scientific evidence would favor the appropriate indication of resources that enable the social participation and autonomy of people with disabilities, but little is found in the literature on the impacts of their use on daily life and on the promotion of functionality in daily activities through substantiated evidence (^{Copley & Ziviani, 2004}; ^{Cury & Brandão, 2011}).

Thus, the hypotheses posed in the study were: it is possible to prescribe AT resources that favor feeding activity with a child with cerebral palsy through a home intervention focused on the demands of family routine; the decision-making process for the most appropriate equipment can be made through the child’s functional performance during the activity, with the systematization of continuous data throughout the intervention. In this sense, the aim of the study was to investigate and evaluate the process of implementing AT resources for feeding activity with a child with cerebral palsy.

2 Methodology

This paper is characterized as experimental research on a single subject design. In this study model applied to the participant’s reality, it is sought to control the dependent, independent and intervening variables (^{Gast & Ledford, 2014}). There is the independent variable, characterized by the assistive technology resources, which is programmatically inserted at different times and its effect is observed in the dependent variable, behaviors performed in the selected feeding activities. The intervening variables were observed and reported in order to enable better intervention schedules for future studies. The use of this design allows the researcher to plan when interventions will be implemented and to observe their effects. The multiple baseline design between behaviors, being a single subject derivative (^{Gast & Ledford, 2014}), was chosen for this research in order to allow the inference of program effects.

3 Results

The results were obtained by applying the event protocol on the participant’s independence level and the level of assistance offered for teaching during all experimental phases of the study and in all proposed activities. The proposition of changes in seat heights in activity 1; in the types of glasses and straws, in activity 2; and cutlery, in activity 3, could occur based on the performance that the child obtained in the session.

In Figure 1, the abscissa axis shows the participant’s independence percentage, ranging from 0 to 100%; the ordinate axis marks the day of the session in which the participant reached the represented percentage. In gray columns are the assistance levels obtained per session. The dotted line divides the sessions into the phases in which they were made.

Source: Elaborated by the authors.

Figure 1 Percentage of participant independence to perform the activity (black line) and levels of assistance provided by the researcher (gray columns).Legend: Act. - Activities taught. 

When verifying the data obtained during the baseline, in activity 1, which consisted of sitting at the table, the child presented a percentage of independence for the activity performance of 14 to 31%, presenting an average of 26,75% independence to accomplish it. With the beginning of the intervention, the change in the percentage of independence was observed, with an abrupt increase. It can be seen that the percentage of independence begins to increase, reaching a 69% independence at the end of the seven practice sessions. After the intervention was completed, this activity began to be maintained and, from the 22nd session, the child began to show an increase in independence, reaching 77% of independence. In the follow up phase, the child had 77% independence during three sessions. In this activity, no behavior was performed independently in the baseline phase, with most of the task being considered as dependent. In the intervention sessions, it was possible to gradually observe the decrease in the dependency level and the increase of partial assistance. Assistance levels varied during sessions, for example, in session 9, 10 and 11 it is possible to verify the presence of verbal hint. In the maintenance phase, total physical assistance stabilized at 30%, obtaining variations in partial assistance, verbal hint and demonstrative hint. In the follow-up phase, assistance levels stabilized, with a score of 30% total assistance and 70% independence.

In activity 2, in which the child learned to use the glass, the data obtained during the baseline presented a constant independence percentage of 13%. When the interventions started, after activity 1, he had reached the 60% independence criterion, it was clearly observed the participant’s increased independence in performing the activity, which reached 63% in the last two sessions prior to the maintenance phase. During the maintenance phase, the child maintained his level of independence in this activity, in the 24th session, in which he zeroed, not because of inability to perform the activity, but because the child did not have the opportunity to do this activity that day. During follow up, the child maintained 53% independence.

As for the levels of assistance, at baseline, the child depended on help 95% of the time, and had only 5% independence in carrying out the activity. In the intervention phase, assistance levels varied as the various AT strategies and resources were implemented and the level of independence increased. In the maintenance phase, the level of dependence stabilized at 40%, achieving 60% independence in this activity. Except for session 26, in which the child presented 100% dependence, being the session in which the child had no opportunity to perform the task, since he did not use the glass that day. At the follow-up, the child maintained the dependence level at 40%, with 10% total physical assistance and 50% independence. According to the mother’s report, the speech therapist who accompanied the child observed changes and improvements in his swallowing due to the use of the drinking glass offered to the child. The child became increasingly independent, adjusting the limitations for his use.

In activity 3, the use of cutlery during the baseline phase, the child showed total dependence to perform the activity, scoring 0% independence. After activity 2 reached the 60% independence criterion, the implementation of AT resources for the third activity was started. At the beginning of the intervention phase, he presented a performance percentage of 17 to 26% independence, reaching an average of 20.75% independence. During the maintenance phase reached 26% independence, achieving the same score in the three consecutive sessions. At the follow up, the performance was 20 to 26% independence. Thus, at baseline, almost 100% dependence was identified in the activity, except for sessions 1, 4 and 5, which presented 30% of total physical assistance and 70% of dependence, as he actively sought to use the cutlery.

In the intervention phase, the level of total physical assistance increased, varying with dependence and partial physical assistance. In this activity of using the cutlery, the child was very resistant to follow the researcher’s guidelines and to accept her assistance, even when the amount of food was negotiated. In some encounters, the child refused to eat and cried too much. Due to physical limitations and difficulties in dealing with the child who refused to eat, the mother took part in the activity, which helped the child to use the resources. She was instructed on how to stand behind the child, where to hold and how to perform the movement with the child. In the maintenance phase, the total assistance level remained at 60% and 40% partial assistance. During follow up, the child increased the level of total physical assistance.

Regarding the reapplication of the PEDI instrument after 6 months in the self-care functional skills, the gross score obtained was 32, with a normative score below 10, without standard error, with a continuous score of 50.80 and a standard error of 2.09. Regarding caregiver assistance in the self-care area, the gross score obtained was 12, with a normative score below 10 without standard error. The continuous score was 53.38 and its standard error 4.26.

Changes in gross and continuous scores could be observed, which may indicate a gain in ability, but in relation to the normative score, the child still scores below 10. Despite the increase, the change does not reach the predicted results that would be considered as a clinically significant difference for the instrument (^{Iyer, Haley, Watkins, & Dumas, 2003}). However, in Part III of the instrument, which identifies the number of functional activities for which modifications are required, it was possible to visualize changes with the proposed intervention. The first time the test was applied, it was pointed out that the eight items presented by the instrument needed changes, and in the reevaluation, there were seven, since in the food item, the presence of child-centered modification was identified as the resources that were implemented in the research.

Finally, regarding the results related to social validity, the mother reported, in general, that the child presented improvements and evolution, increasing the level of autonomy and independence in feeding. From 0 to 5, she gave the research a score of 3 because, according to her, she had expectations that her child would obtain total autonomy in the feeding activity. The mother also pointed out how much the research helped her to allow her child’s development and to be more patient with the learning process, respecting his time and limitations. She considered that the research had impacted on her family routine, by changing the family dynamics, now sitting at the table to eat along with the child and by arousing the child’s interest in eating more independently, expanding his attempts in other spaces, such as school and restaurants.

4 Discussion

The data obtained by the study indicate that the use of the proposed AT resources impacted the child’s feeding activities, allowing an enhancement towards his autonomy, even occurring in a short time frame for such an intervention. This reinforces the relevance of the use of AT in the interventions of children with cerebral palsy mentioned by ^{Cowan and Khan (2005}) and ^{Ostensjo, Carlberg and Vollestad (2005}), with beneficial impacts and effectiveness of these resources in their daily lives, in order to offset the functional demands for their independence and directly impacting the performance of ADLs, by reducing the amount of aid required for performance of the activity.

^{Cury and Brandão (2011}) and ^{Novak, Smithers-Sheedy and Morgan (2012}) argue that the goal of intervention with a child with Cerebral Palsy is to increase his/her functional independence, promoting his/her abilities, mobility, cognitive development and social interaction. Due to his/her limitations, the child cannot complete the daily activities; thus, the authors point out that the use of AT resources is to increase, maintain and promote function and independence.

For the implementation process, after evaluating the child’s functional skills and observing the research entry repertoire, it was possible to identify the stages of the activities that needed modifications to enable an autonomy and independence gain, in order to think about which resources and strategies would be taken to achieve the proposed goals. Each step represents the implementation process, addressing the procedure for inserting resource use, training, reevaluation, readjustment or replacement of the resource until the proposed objectives are achieved.

We chose to teach each activity gradually, inserting the resources progressively and their use through the child’s response, obtaining the presence of participant-centered modifications. Thus, each decision was taken along the process of prescription and use of resources based on the behavioral responses issued by the participating child, supporting the promoted intervention.

The differential of the proposed methodology using the Multiple Baseline Design (^{Gast & Ledford, 2014}) for collecting and measuring the effects of the intervention is precisely to allow the identification of advances and redirecting paths in favor of the child’s autonomy in order to accomplish the target activity. As evidenced in the study, the intervention performed did not reach the clinically significant rates of change in the PEDI evaluation, but the results indicated that the intervention produced positive effects on the child’s functional capacity. In this study, it was possible to see a gradual reduction in the level of assistance as interventions, training, and resource use were implemented, until the child reached an expected level to switch among activities to be learned, producing evidence on the intervention performed.

The implementation of devices for postural support (seat and footrest) were essential for functional independence, favoring new opportunities for the child, which, prior to the use of the resource, was not able to perform. In this sense, it is important to use resources and small improvements to assist in the execution of the activity, thus allowing the participation of the child, and consequently reducing the amount of help and assistance requested by the child. Thus, the beneficial effects of the use of an adjustable seat as well as eating and drinking utensils have been reported, supporting previous studies that show that adapted seating, as well as other AT devices, can promote eating skills and reduce the support offered for a child with functional limitations (^{Ostensjo, Carlberg, & Vollestad, 2005}; ^{Scherer, Craddock, & Mackeogh, 2010}).

Due to the neuromotor alterations of the child, adaptations were proposed in which he did not need to hold and/or raise the glass to the mouth to drink, and different cup models were tested until finding one that was suitable for the child’s posture. After implementing the use of the glass, the child himself was finding ways to use the resource, adapting it to perform the action in an increasingly independent and comfortable way. Similarly, it was necessary to think of solutions for greater independence in the use of cutlery, since different resources were part of the test and agreements were necessary for the child to accept using some of them. It was often necessary to accept his refusal, such as the Neoprene abductor thumb brace that the child had and did not like to wear, despite pointing to better functional gain from grasping objects. In this sense, it is important to respect the user’s choices, thus allowing the use of the resource to be used on a daily basis and reducing the chances of its abandonment (^{Cruz, Emmel, Manzini, & Mendes, 2016}; ^{Van Niekerk, Dada, Tönsing, & Boshoff, 2017}).

During the resource use intervention process, the child needed to be stimulated and motivated to perform the activity, since oral-motor dysfunction is associated with the length of feeding time for children with cerebral palsy, and thus its implementation intensifies even more the activity duration, which can generate fatigue and frustration. To minimize the negative effects, it is important to respect the process experienced by the child and promote his/her satisfaction in order to reduce the learning pressure, ensuring a pleasant, warm and stimulating environment, resulting in his/her participation and consequent reduction of care intensity for the action (^{Ostensjo, Carlberg, & Vollestad, 2005}; ^{Cook & Polgar, 2015}).

In addition to the child’s adherence to the implementation, it is important to include the family that will reinforce its use and encourage him/her. It was possible to identify the change in the mother’s perception of the child during the intervention regarding her child’s occupational performance. She began to respect and wait for the child’s own process, favoring the activity, reducing the pressure and, consequently, reducing the intensity of care and her interference. Through the social validation questionnaire, it was possible to see the mother’s adherence throughout the resource implementation process, which reinforced its use at different times of the research collection and played an important supporting role in assisting in this learning stage, giving support and motivation, without putting pressure on the child and making the activity stressful (^{Ostensjo, Carlberg, & Vollestad, 2005}). Still, the data obtained directly from the mother, at the end of the intervention, positively highlighted the results achieved, reiterating the importance of taking into account the demands brought by families and caregivers about the priority demands which need to be addressed (^{Brandão, Oliveira, & Mancini, 2014}; Eard et al., 2018).

In this sense, it is emphasized that the intervention in the home context allowed more involvement of the child and his mother in the activity, meeting the considerations put by ^{Cook and Polgar (2015}), ^{Cowan and Khan (2005}) and the findings of ^{Van Niekerk et al. (2017}), who reiterate that the implementation of AT resources should always involve the child and the family, always thinking about the context, willingness, personal functional needs, understanding and respecting the individuality and particularity of the family.

5 Conclusions

It is considered that the results of the study reach the objective that was set, since it proposed and evaluated the process of implementing Assistive Technology resources for feeding activity with a child with cerebral palsy. The findings confirm the hypothesis raised by describing that home intervention allows professionals to organize the intervention with equipment that shows how the feeding activity is actually performed in the daily life of the child and his/her family, which may favor the resources remaining in use and contribute to the child’s autonomy. In addition, it is assumed that the systematic monitoring of the child’s performance during the task and each resource change constitutes an important way to support decision making about the most appropriate resources for the case.

Due to the gap identified in the literature about the lack of more specific studies on how the professional can perform the step-by-step process of implementing these resources in the context of activities of daily living and the low number of productions that support decision-making practice regarding the prescription itself of Assistive Technology resources, this study may contribute to the production of knowledge in the area, more specifically regarding the implementation of different resources for children with cerebral palsy, indicating ways and decisions taken through the child’s response. The procedures adopted to collect and systematize the child’s performance with each resource change brings evidence about the effectiveness in the intended activity, which contributes as an example for professionals dedicated to this type of intervention.

Continuity studies with a larger number of children with cerebral palsy are suggested in order to experiment with new resources and new life contexts, as well as longitudinal studies to verify whether the implemented resources are still in use by the children and their families. It is considered that the study may contribute to the knowledge that has been produced in the area, but it is important to highlight its limitations due to the small number of research participants and the short implementation period of the resource considering the participant’s difficulties.