Effectiveness of Caregiver Training in Mindfulness-Based Positive Behavior Support (MBPBS) vs. Training-as-Usual (TAU): A Randomized Controlled Trial

Caregivers of individuals with intellectual and developmental disabilities (IDD) often end up having their medical and psychological well-being compromised due to the stressful nature of caregiving, especially when those in their care engage in aggressive behavior. In this study, we provided caregivers with mindfulness-based training to enable them to better manage their psychological well-being and, through this, to also enhance specific indices of quality of life of the individuals in their care. Thus, the aim of the present study was to evaluate in a randomized controlled trial (RCT) the comparative effectiveness of Mindfulness-Based Positive Behavior Support (MBPBS) and Training-as-Usual (TAU) for caregivers in a congregate care facility for individuals with severe and profound IDD. The comparative effects of the two training conditions were assessed in terms of caregiver variables care recipient variable (number of aggressive events), and agency variables Results showed that MBPBS was significantly more effective than TAU in enabling the caregivers to manage their perceived psychological stress, and to reduce the use of physical restraints and stat medications for aggressive behavior of the individuals in their care. In addition, there were significant reductions in aggressive events by the individuals in their care, 1:1 staffing of individuals with aggressive behavior, and staff turnover. Furthermore, the MBPBS training was significantly more cost-effective than the TAU training. If replicated in future RCT studies, MBPBS may provide an effective means of enhancing socially acceptable bidirectional engagement of caregivers and care recipients within a person-centered context.

Comparison of two Orientation Systems for Indoor Travel of Blind Persons with Mental Retardation

Two blind women affected by severe mental retardation were exposed to two previously developed orientation systems. One of the systems was based on acoustic cues, the other on vibratory feedback. The aim was to assess the relative effectiveness of the two systems. Data indicated that the acoustic system ensured a higher frequency of correct moves for one of the subjects and a more rapid performance of the moves for both subjects. The findings are reviewed in relation to the characteristics and applicability of the systems.

Helping people in a minimally conscious state develop responding and stimulation control through a microswitch-aided program

BACKGROUND

Postcoma persons in a minimally conscious state (MCS) and with extensive motor impairment cannot independently access and control environmental stimulation.

AIM

Assessing the effects of a microswitch-aided program aimed at helping MCS persons develop responding and stimulation control and conducting a social validation/evaluation of the program.

DESIGN

A single-subject ABAB design was used for each participant to determine the impact of the program on his or her responding. Staff interviews were used for the social validation/evaluation of the program.

SETTING

Rehabilitation and care facilities that the participants attended.

POPULATION

Eleven MCS persons with extensive motor impairment and lack of speech or any other functional communication.

METHODS

For each participant, baseline (A) phases were alternated with intervention (B) phases during which the program was used. The program relied on microswitches to monitor participants' specific responses (e.g., prolonged eyelid closures) and on a computer system to enable those responses to control stimulation. In practice, the participants could use a simple response such as prolonged eyelid closure to generate a new stimulation input. Sixty-six staff people took part in the social validation of the program. They were to compare the program to basic and elaborate forms of externally controlled stimulation, scoring each of them on a six-item questionnaire.

RESULTS

All participants showed increased response frequencies (and thus higher levels of independent stimulation input/control) during the B phases of the study. Their frequencies for each intervention phase more than doubled their frequencies for the preceding baseline phase with the difference between the two being clearly significant (P<0.01). Staff involved in the social validation procedure provided significantly higher scoring (P<0.01) for the program on five of the six questionnaire items.

CONCLUSIONS

A microswitch-aided program can be an effective and socially acceptable tool in the work with MCS persons.

CLINICAL REHABILITATION IMPACT

The participants and staff's data can be taken as an encouragement for the use of a microswitch-aided program within care and rehabilitation settings for MCS persons.

Adapting a Grid into a Microswitch to Suit Simple Hand Movements of a Child with Profound Multiple Disabilities

We adapted a grid into a microswitch for the hand movements of a girl with profound multiple disabilities who lay on her back. The grid, suspended above the girl's face, was equipped with two mercury devices, i.e., small sealed ampoules containing a mercury drop and ending with conductive leads. A lateral or forward movement of the grid would make the mercury drop of at least one device slide to the conductive leads and activate the device. During the intervention, activations of the devices, i.e., microswitch activations, produced the occurrence of favorite stimuli. Analysis showed that the girl increased the frequency of hand movements and microswitch activations during the intervention phases compared to the baseline phases (when the favorite stimuli were not available). The increase was retained at a 1-mo. postintervention check.

Effects of Automatically Delivered Stimulation on Persons with Multiple Disabilities during Their Use of a Stationary Bicycle

We assessed the effects of automatically delivered favorite stimulation on engagement and indices of happiness of two adults with multiple disabilities during their use of a stationary bicycle. The participants typically received four 5-min. sessions per day over a period of about 3.5 mo. Analysis showed that one participant had a significant increase in both those measures while the other participant had a significant increase in engagement during the intervention phases of the study (when the stimulation was present) as opposed to the baseline periods (when the stimulation did not occur). Implications of the findings are discussed.

Assessing a New Response-Microswitch Combination with a Boy with Minimal Motor Behavior

This study assessed whether a boy with profound multiple disabilities and minimal motor behavior could learn to use a new response-microswitch combination to control environmental stimulation. The response selected was a chin movement; a mechanical microswitch was set up for this response. The boy learned to use the microswitch, increasing the frequency of the chin response and the level of pleasant stimulation following such response. The performance was retained at a 2-mo. postintervention check.

Assessing Influence of Stimulation on Mood and Aberrant Behavior of Persons with Multiple Disabilities during Brief Treadmill Sessions

This study assessed the influence of favorite stimuli on indices of happiness, e.g., smiling or excited vocalizations, and aberrant behavior, e.g., cantilena-like vocalizations or hand waving, of two young adults with multiple disabilities during 5-min. treadmill sessions. Several favorite stimuli, e.g., music and vibratory events, were available for the participants. The stimuli were presented in a rotation fashion during the sessions. To control for the effects of the stimuli, treadmill sessions without stimuli were also conducted. Analysis showed that the treadmill sessions with stimuli led to higher indices of happiness and lower aberrant behavior for both participants, compared to the treadmill sessions without stimuli.

Persons With Advanced Alzheimer’s Disease Engage in Mild Leg Exercise Supported by Technology-Aided Stimulation and Prompts

This study assessed whether nine persons with advanced Alzheimer’s disease would learn to engage in leg responses (exercise) with the support of a technology-aided program, which provided (a) preferred stimulation contingent on the leg responses and (b) verbal reminders/prompts in case of no responding. The study was conducted according to a non-concurrent multiple baseline design across participants and involved sessions of 5 min. During the baseline, the participants’ mean frequencies of leg responses ranged from zero to slightly above two per session. During the intervention, those frequencies ranged from nearly 10 to nearly 17 per session. The mean frequencies of prompts varied across participants from about two to more than seven per session. In addition to the increase in leg responses, participants showed an increase in signs of positive personal involvement (e.g., smiles and positive verbalizations) during the intervention sessions as compared with the baseline sessions. The applicability and potential benefits of the program in daily contexts are discussed.

Individuals with Mental Illness Can Control their Aggressive Behavior Through Mindfulness Training

Verbal and physical aggression are risk factors for community placement of individuals with serious and persistent mental illness. Depending on the motivations involved, treatment typically consists of psychotropic medications and psychosocial interventions, including contingency management procedures and anger management training. Effects of a mindfulness procedure, Meditation on the Soles of the Feet , were tested as a cognitive behavioral intervention for verbal and physical aggression in 3 individuals who had frequently been readmitted to an inpatient psychiatric hospital owing to their anger management problems. In a multiple baseline across subjects design, they were taught a simple meditation technique, requiring them to shift their attention and awareness from the anger-producing situation to the soles of their feet, a neutral point on their body. Their verbal and physical aggression decreased with mindfulness training; no physical aggression and very low rates of verbal aggression occurred during 4 years of follow-up in the community.

Questions About Behavioral Function in Mental Illness (QABF-MI)

The Questions About Behavioral Function (QABF), a 25-item rating scale, was developed to identify the function(s) of maladaptive behavior in individuals with developmental disabilities. The authors adapted it for use with individuals with serious mental illness who engage in maladaptive behavior and assessed the psychometric characteristics of the new scale (Questions About Behavioral Function in Mental Illness; QABF-MI) in a sample of 135 adults with serious mental illness from three inpatient psychiatric hospitals. Staff most familiar with each person rated each item on a 5-point Likert-type rating scale, and the ratings were subjected to a number of psychometric analyses. The results of factor analyses provided a conceptually meaningful five-factor solution: physical discomfort, social attention, tangible reinforcement, escape, and nonsocial reinforcement. Congruence between the five factors derived with the QABF-MI and the corresponding factors in the original QABF was perfect. The results indicated that the QABF-MI has robust psychometric properties and may be useful as a screening tool for determining the nature of the variables that maintain maladaptive behavior exhibited by individuals with serious mental illness.

Mindfulness Training Assists Individuals With Moderate Mental Retardation to Maintain Their Community Placements

The mindfulness procedure Meditation on the Soles of the Feet can help individuals with mild mental retardation control aggressive behavior. In this study, our aim was to teach this mindfulness technique, using a multiple baseline design, to 3 individuals with moderate mental retardation who were at risk of losing their community placements because of their aggressive behavior. These individuals initially found the procedure difficult to comprehend because they could not easily visualize past anger-producing situations, but mastery was achieved when we incorporated recreating-the-scene as a prompt and added a discriminative stimulus on the soles of the participants' feet. Aggressive behavior decreased with mindfulness training, and follow-up data showed that they managed their aggressive behavior in the community for at least 2 years and thus were able to retain their community placements.

Microswitch Clusters Promote Adaptive Responses and Reduce Finger Mouthing in a Boy With Multiple Disabilities

The authors assessed new microswitch clusters (i.e., combinations of two microswitches) and contingent stimulation to increase adaptive responses (i.e., foot and head movements) and reduce aberrant behavior (i.e., finger mouthing)in a boy with multiple disabilities. Initially, intervention was directed at increasing the frequency of each adaptive response, individually, through contingent use of preferred stimuli. Subsequently, adaptive responses led to preferred stimuli only if they occurred in the absence of finger mouthing. Postintervention checks occurred 1, 2, and 3 months after the end of the intervention. Data showed that the boy (a) increased the frequency of the adaptive responses extensively, (b) learned to perform these responses largely free from finger mouthing, and (c) maintained these changes over time. The importance of microswitch clusters to simultaneously pursue the dual objective of promoting adaptive responses and reducing aberrant ones is underlined.

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.

Case Studies of Technology-aided Interventions to Promote Hand Reaching and Standing or Basic Ambulation in Persons with Multiple Disabilities

Motor impairments such as lack of standing and/or independent ambulation are common among persons with multiple disabilities. These two studies assessed technology-aided programs for persons with those impairments. Specifically, Study I assessed a program to teach two non-ambulatory adults to hand reach a stimulation-linked object by standing up. Study II assessed a program to teach a child and a man to ambulate while holding a rail or following a corridor wall. Standing increased from below 15% to about or over 80% of the session duration in Study I. The participants of Study II managed to complete brief ambulation trials independent of guidance. These performance achievements were discussed in relation to the technology-aided programs employed in the studies and the programs' applicability in daily contexts.

Technology-Aided Programs to Support Positive Verbal and Physical Engagement in Persons with Moderate or Severe Alzheimer's Disease

Pilot studies using technology-aided programs to promote verbal reminiscence and mild physical activity (i.e., positive forms of engagement) in persons with moderate or severe Alzheimer's disease have provided promising results (Lancioni et al., 2015a,b). The present two studies were aimed at upgrading and/or extending the assessment of those programs. Specifically, Study 1 upgraded the program for verbal reminiscence and assessed it with eight new participants. The upgraded version automatically monitored the participants' verbal behavior during the sessions, in which photos and brief videos were used to foster verbal reminiscence. Monitoring allowed computer approval and reminders to be consistent with the participants' behavior. Study 2 extended the assessment of the program for promoting mild physical activity with 10 new participants for whom arm-raising responses were targeted. The results of Study 1 showed that the participants' mean percentages of intervals with verbal engagement/reminiscence were below 10 during baseline and control sessions and between above 50 and nearly 80 during the intervention. The results of Study 2 showed that the mean frequencies of arm-raising responses were about or below four and between about 10 and 19 per session during the baseline and the intervention, respectively. The general implications of the aforementioned results and the need for new research in the area were discussed.

Caregiver Training in Mindfulness-Based Positive Behavior Supports (MBPBS): Effects on Caregivers and Adults with Intellectual and Developmental Disabilities

Caregivers often manage the aggressive behavior of individuals with intellectual and developmental disabilities that reside in community group homes. Sometimes this results in adverse outcomes for both the caregivers and the care recipients. We provided a 7-day intensive Mindfulness-Based Positive Behavior Support (MBPBS) training to caregivers from community group homes and assessed the outcomes in terms of caregiver variables, individuals' behaviors, and an administrative outcome. When compared to pre-MBPBS training, the MBPBS training resulted in the caregivers using significantly less physical restraints, and staff stress and staff turnover were considerably reduced. The frequency of injury to caregivers and peers caused by the individuals was significantly reduced. A benefit-cost analysis showed substantial financial savings due to staff participation in the MBPBS program. This study provides further proof-of-concept for the effectiveness of MBPBS training for caregivers, and strengthens the call for training staff in mindfulness meditation.

Technology to support positive occupational engagement and communication in persons with multiple disabilities

Persons with multiple (intellectual and sensory-motor) disabilities can have serious difficulties managing their independent engagement in leisure activities and communication, particularly with partners not present in their immediate environment.

This study assessed two versions of a technology-aided program (involving a computer system to present leisure and communication options and a microswitch to choose among them) with four participants with multiple disabilities. Two participants used the first version of the program, which allowed them to choose among leisure (music) options. The other two participants used the second version of the program, which allowed them to choose among leisure (music and videos) and communication (telephone calls) options. Each program version was implemented according to a non-concurrent multiple baseline design across participants.

Data showed that both program versions were successful in helping the participants achieve the objectives pursued, that is, choose and access leisure or leisure and communication options independently.

Technology-aided programs can enable persons with multiple disabilities to manage positive occupational engagement and communication.

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.