Low-Cost Technology-Aided Programs for Supporting People With Motor, Visual, and Intellectual Disabilities in Functional Forms of Occupation and Communication: Proof-of-Concept Study.

BACKGROUND: People with motor, visual, and intellectual disabilities may have serious problems in independently accessing various forms of functional daily occupation and communication. OBJECTIVE: The study was aimed at developing and assessing new, low-cost technology-aided programs to help people with motor or visual-motor and intellectual disabilities independently engage in functional forms of occupation and communication with distant partners. METHODS: Two programs were set up using a smartphone interfaced with a 2-switch device and a tablet interfaced with 2 pressure sensors, respectively. Single-subject research designs were used to assess (1) the first program with 2 participants who were blind, had moderate hand control, and were interested in communicating with distant partners through voice messages; and (2) the second program with 2 participants who possessed functional vision, had no or poor hand control, and were interested in communicating with their partners through video calls. Both programs also supported 2 forms of occupational engagement, that is, choosing and accessing preferred leisure events consisting of songs and music videos, and listening to brief stories about relevant daily topics and answering questions related to those stories. RESULTS: During the baseline phase (when only a conventional smartphone or tablet was available), 2 participants managed sporadic access to leisure or leisure and communication events. The other 2 participants did not show any independent leisure or communication engagement. During the intervention (when the technology-aided programs were used), all participants managed to independently engage in multiple leisure and communication events throughout the sessions and to listen to stories and answer story-related questions. CONCLUSIONS: The findings, which need to be interpreted with caution given the nature of the study and the small number of participants, seem to suggest that the new programs may be viable tools for helping people with motor or visual-motor and intellectual disabilities independently access leisure, communication, and other forms of functional engagement.

A Behavioral Approach to Treatment and Assessment of People with Disorders of Consciousness: The Response-contingent Stimulation Strategy.

Response-contingent stimulation is a behavioral strategy used to improve the situation of patients with disorders of consciousness. Such strategy involves the presentation of brief periods (e.g., 10 to 15 s) of stimulation considered preferred by the patients, contingent on (immediately after) the emission of specific patients' responses. The aim is to help the patients learn the link between their responding and the preferred stimulation and thus learn to use their responding to access the stimulation in a self-determined/independent manner. Achieving these goals is considered important for the patients' recovery process and thus the response-contingent stimulation strategy that promotes such an achievement can be considered a valuable treatment approach. The same strategy combined with the use of periods of non-contingent stimulation (i.e., stimulation delivered independent of responding) may also serve as an assessment supplement with patients with apparent unresponsive wakefulness. The patients' increase in responding during the response-contingent stimulation and decline in responding during the non-contingent stimulation could be taken as a sign of discrimination between conditions, and possibly a sign of awareness of the immediate environmental situation, compatible with a diagnosis of minimally conscious state. This paper analyzes a number of studies aimed at using the response-contingent stimulation as a treatment strategy and a number of studies aimed at combining response-contingent stimulation with non-contingent stimulation for treatment and assessment purposes. The results of the studies are discussed in terms of the effectiveness, accessibility and affordability of the strategy. The need for new research (i.e., replication studies) is also pointed out.

Promoting physical activity in people with intellectual and multiple disabilities through a basic technology-aided program.

This study assessed a technology-aided program (monitoring responding, and ensuring preferred stimulation and encouragements) for promoting physical activity with 11 participants with severe/profound intellectual and multiple disabilities. Each participant was provided with an exercise device (e.g. a static bicycle and a stepper) and exposed to the program according to an ABAB design, in which A and B represented baseline and intervention phases, respectively. Data recording concerned (a) the participants' responses with the exercise device (e.g. pedaling) during baseline and intervention phases and (b) their heart rates during the last intervention phase. The results showed that all participants had significant increases in responding with the exercise devices during the intervention phases. Heart-rate values during the intervention sessions indicated that the participants' responding during those sessions mostly amounted to moderate-intensity physical activity, with potential benefits for their overall physical condition. Implications of the findings and questions for future research in the area were discussed.

Assistive technology to help persons in a minimally conscious state develop responding and stimulation control: Performance assessment and social rating.

BACKGROUND: Post-coma persons in a minimally conscious state (MCS) and with extensive motor impairment and lack of speech tend to be passive and isolated. OBJECTIVE: This study aimed to (a) further assess a technology-aided approach for fostering MCS participants' responding and stimulation control and (b) carry out a social validation check about the approach. METHODS: Eight MCS participants were exposed to the aforementioned approach according to an ABAB design. The technology included optic, pressure or touch microswitches to monitor eyelid, hand or finger responses and a computer system that allowed those responses to produce brief periods of positive stimulation during the B (intervention) phases of the study. Eighty-four university psychology students and 42 care and health professionals were involved in the social validation check. RESULTS: The MCS participants showed clear increases in their response frequencies, thus producing increases in their levels of environmental stimulation input, during the B phases of the study. The students and care and health professionals involved in the social validation check rated the technology-aided approach more positively than a control condition in which stimulation was automatically presented to the participants. CONCLUSIONS: A technology-aided approach to foster responding and stimulation control in MCS persons may be effective and socially desirable.

EXTENDING THE ASSESSMENT OF TECHNOLOGY-AIDED PROGRAMS TO SUPPORT LEISURE AND COMMUNICATION IN PEOPLE WITH ACQUIRED BRAIN INJURY AND EXTENSIVE MULTIPLE DISABILITIES.

Intervention programs for people with acquired brain injury and extensive motor and communication impairment need to be diversified according to their characteristics and environment. These two studies assessed two technology-aided programs for supporting leisure (i.e., access to songs and videos) and communication (i.e., expressing needs and feelings and making requests) in six of those people. The three people participating in Study 1 did not possess speech but were able to understand spoken and written sentences. Their program presented leisure and communication options through written phrases appearing on the computer screen. The three people participating in Study 2 did not possess any speech and were unable to understand spoken or written language. Their program presented leisure and communication options through pictorial images. All participants relied on a simple microswitch response to enter the options and activate songs, videos, and communication messages. The data showed that the participants of both studies learned to use the program available to them and to engage in leisure and communication independently. The importance of using programs adapted to the participants and their environment was discussed.

Assisting persons with advanced amyotrophic lateral sclerosis in their leisure engagement and communication needs with a basic technology-aided program.

BACKGROUND: Eye-tracking communication devices and brain-computer interfaces are the two resources available to help people with advanced amyotrophic lateral sclerosis (ALS) avoid isolation and passivity. OBJECTIVE: This study was aimed at assessing a technology-aided program (i.e., a third possible resource) for five patients with advanced ALS who needed support for communication and leisure activities. METHODS: The participants were exposed to baseline and intervention conditions. The technology-aided program, which was used during the intervention, (a) included the communication and leisure options that each participant considered important for him or her (e.g., music, videos, statements/requests, and text messaging) and (b) allowed the participant to access those options with minimal responses (e.g., finger movement or eyelid closure) monitored via microswitches. RESULTS: The participants started leisure and communication engagement independently only during the intervention (i.e., when the program was used). The mean percentages of session time spent in those forms of engagement were between about 60 and 80. Preference checks and brief interviews indicated that participants and families liked the program. CONCLUSIONS: The program might be viewed as an additional approach/resource for patients with advanced ALS.

Technology-based orientation programs to support indoor travel by persons with moderate Alzheimer's disease: impact assessment and social validation.

The present study (a) extended the assessment of an orientation program involving auditory cues (i.e., verbal messages automatically presented from the destinations) with five patients with Alzheimer's disease, (b) compared the effects of this program with those of a program with light cues (i.e., a program in which strobe lights were used instead of the verbal messages) with the same five patients, and (c) conducted a social validation assessment of the two programs with 70 university psychology students employed as social raters. Results confirmed the effectiveness of the program with auditory cues and showed an equally strong impact of the program with light cues with all five patients. The psychology students involved in the social validation assessment provided significantly higher scores for the program involving light cues on a six-item questionnaire. Those scores suggested that this program was perceived as a practically and socially preferable choice. The implications of the findings for daily contexts dealing with patients with Alzheimer's disease are discussed.

Self-regulated music stimulation for persons with Alzheimer's disease: impact assessment and social validation.

OBJECTIVE: To assess the impact and the social rating of an active music condition (in which 10 patients with Alzheimer's disease regulated their music input) vs. a passive music condition. METHOD: In the active condition, the patients used a simple hand response and a microswitch to activate music stimulation periods. In the passive condition, music stimulation was prearranged and continued through the sessions. The active and passive stimulation sessions were preceded and followed by control (non-stimulation) sessions. RESULTS: The active condition sessions showed an increase in the patients' indices of positive participation (e.g., singing or music-related movements, and smiles) similar to that observed in the passive condition sessions. Social raters (140 psychology students) favored the active condition on a six-item questionnaire dealing, among others, with conditions' suitability, respect of patients' dignity and independence, and practicality. CONCLUSION: An active music stimulation condition can be viable, effective, and socially preferable.

Promoting adaptive behavior in persons with acquired brain injury, extensive motor and communication disabilities, and consciousness disorders.

These two studies extended the evidence on the use of technology-based intervention packages to promote adaptive behavior in persons with acquired brain injury and multiple disabilities. Study I involved five participants in a minimally conscious state who were provided with intervention packages based on specific arrangements of optic, tilt, or pressure microswitches (linked to preferred environmental stimuli) and eyelid, toe and finger responses. Study II involved three participants who were emerging from a minimally conscious state and were provided with intervention packages based on computer presentations of stimulus options (i.e., preferred stimuli, functional caregiver's procedures, and non-preferred stimuli) and pressure microswitches to choose among them. Intervention data of Study I showed that the participants acquired relatively high levels of microswitch responding (thus engaging widely with preferred environmental stimuli) and kept that responding consistent except for one case. Intervention data of Study II showed that the participants were active in choosing among preferred stimuli and positive caregivers' procedures, but generally abstained from non-preferred stimuli. The results were discussed in terms of the successful use of fairly new/infrequent microswitch-response arrangements (Study I) and the profitable inclusion of functional caregiver's procedures among the options available to choice (Study II).

A technology-assisted learning setup as assessment supplement for three persons with a diagnosis of post-coma vegetative state and pervasive motor impairment.

Post-coma persons in an apparent condition of vegetative state and pervasive motor impairment pose serious problems in terms of assessment and intervention options. A technology-based learning assessment procedure might serve for them as a diagnostic supplement with possible implications for rehabilitation intervention. The learning assessment procedure adopted in this study relied on hand-closure and eye-blinking responses and on microswitch technology to detect such responses and to present stimuli. Three participants were involved in the study. The technology consisted of a touch/pressure sensor fixed on the hand or an optic sensor mounted on an eyeglasses' frame, which were combined with a control system linked to stimulus sources. The study adopted an ABABCB sequence, in which A represented baseline periods, B intervention periods with stimuli contingent on the responses, and C a control condition with stimuli presented non-contingently. Data showed that the level of responding during the B phases was significantly higher than the levels observed during the A phases as well as the C phase for two of the three participants (i.e., indicating clear signs of learning by them). Learning might be deemed to represent basic levels of knowledge/consciousness. Thus, detecting signs of learning might help one revise a previous diagnosis of vegetative state with wide implications for rehabilitation perspectives.

A learning assessment procedure to re-evaluate three persons with a diagnosis of post-coma vegetative state and pervasive motor impairment.

PRIMARY OBJECTIVE: Detecting signs of learning in persons with a diagnosis of post-coma vegetative state and profound motor disabilities could modify their diagnostic label and provide new hopes. In this study, three adults with such a diagnosis were exposed to learning assessment to search for those signs. PROCEDURE AND DESIGN: The assessment procedure relied on participants' eye-blinking responses and microswitch-based technology. The technology consisted of an electronically regulated optic microswitch mounted on an eyeglasses' frame that the participants wore during the study and an electronic control system connected to stimulus sources. Each participant followed an ABABCB design, in which A represented baseline periods, B intervention periods with stimuli contingent on the responses and C a control condition with stimuli presented non-contingently. MAIN OUTCOMES AND RESULTS: The level of responding during the B phases was significantly higher than the levels observed during the A phases as well as the C phase for all participants (i.e. indicating clear signs of learning by them). CONCLUSIONS: These findings may have important implications for (a) changing the participants' diagnostic label and offering them new programme opportunities and (b) including learning assessment within the evaluation package used for persons with post-coma profound multiple disabilities.

A microswitch-cluster program to foster adaptive responses and head control in students with multiple disabilities: replication and validation assessment.

A program relying on microswitch clusters (i.e., combinations of microswitches) and preferred stimuli was recently developed to foster adaptive responses and head control in persons with multiple disabilities. In the last version of this program, preferred stimuli (a) are scheduled for adaptive responses occurring in combination with head control (i.e., head upright) and (b) last through the scheduled time only if head control is maintained for that time. The first of the present two studies was aimed at replicating this program with three new participants with multiple disabilities adding to the three reported by Lancioni et al. [Lancioni, G. E., Singh, N. N., O'Reilly, M. F., Sigafoos, J., Didden, R., Oliva, D., et al. (2007). Fostering adaptive responses and head control in students with multiple disabilities through a microswitch-based program: Follow-up assessment and program revision. Research in Developmental Disabilities, 28, 187-196]. The second of the two studies served to carry out an expert validation of the program's effects on head control and general physical condition with the three participants of Study I as well as the three participants involved in the Lancioni et al. study mentioned above. The expert raters were 72 new physiotherapists and 72 experienced physiotherapists. The results of Study I supported previous data and indicated that the program was effective in helping the participants increase the frequency of adaptive responses in combination with head control and the length of such control. The results of Study II showed that the raters found the effects of the new program more positive than those of other intervention conditions and also considered such program a useful complement to formal motor rehabilitation programs.

Fostering adaptive responses and head control in students with multiple disabilities through a microswitch-based program: follow-up assessment and program revision.

A program was recently developed to promote adaptive responses and upright head position in students with multiple disabilities through the use of microswitch clusters (i.e., combinations of two microswitches). The five students exposed to the program showed a significant increase in adaptive responses performed with head upright. The first purpose of this study was to carry out a long-term follow-up assessment of the five students' frequencies of adaptive responses and percentages of those responses combined with head upright. Recordings were also made of the length of time the head position was kept during each stimulation period following a successful response event and through the sessions. The second purpose of this study was to arrange a program revision for the students with less favorable data on head upright. The revision consisted of making the stimulation following successful response events synchronous with head upright with a maximum duration of 9s per event. The results of the follow-up assessment showed that two of the students kept the upright head position for nearly the entire stimulation periods that followed successful response events as well as much of the session time. The other three students kept such position for small or intermediate portions of the stimulation periods and of the session time. For these three students, the revised program was applied with substantial benefits. Implications of the findings were discussed.

Choice and preference assessment research with people with severe to profound developmental disabilities: a review of the literature.

Since the last major empirical review on choice interventions and preference assessments among people with severe to profound developmental disabilities (Lancioni, O'Reilly, & Emerson, 1996) the body of research in this area has grown extensively. This paper reviews thirty studies carried out between 1996 and 2002 that have been sorted into four categories. These categories are (a) building choice opportunities into daily contexts; (b) assessing the effects of choice making on various parameters of behavior; (c) assessing preferences; and (d) assessing the effectiveness of various preference assessment formats. The main findings in these studies were that choice interventions led to decreases in inappropriate behavior and increases in appropriate behavior, and that various preference assessments could be used to identify reinforcing stimuli. The findings are discussed in relation to technical and practical rehabilitation questions. Potential issues for future research are also examined.

Using paired-choice assessment to identify variables maintaining sleep problems in a child with severe disabilities.

In this study, we used a paired-choice assessment protocol to identify the relative reinforcing value of stimuli and activities for a child with severe disabilities when she failed to settle to sleep at night. The results of this assessment indicated that the child preferred the mother's attention relative to other activities presented. Assessment results were incorporated into an intervention, that produced a reduction in sleep disturbance that was maintained at a 12-month follow up.

A social validation assessment of the use of microswitches with persons with multiple disabilities.

The purpose of this two-part study was to conduct a social validation assessment of microswitches versus interaction/stimulation conditions used with persons with multiple disabilities. In Part I, 32 teacher-assistant trainees were shown video-tapes reporting the use of microswitches versus interaction conditions for six children. In Part II, 40 teacher-assistant trainees or classroom aides and 44 rehabilitation staff were presented with video-tapes showing the use of microswitches versus systematic stimulation strategies for four adults. Raters scored the microswitch and the interaction or stimulation conditions on a 7-item questionnaire covering social/emotional and practical aspects. The microswitch condition was viewed as generally more positive than or comparable to the interaction or stimulation conditions. Main features of the findings and their implications are discussed.