Occupation and communication programs for post-coma persons with or without consciousness disorders who show extensive motor impairment and lack of speech

These two studies were aimed at extending the assessment of technology-aided programs for post-coma persons with extensive motor impairment and lack of speech. Specifically, Study I assessed a new program arrangement, in which stimulation access and caregiver attention could be obtained with variations of the same response (i.e., single- versus double-hand closure) by three participants who were diagnosed at the upper level of the minimally conscious state at the start of the study. Study II was aimed at enabling two persons who had emerged from a minimally conscious state to engage in leisure activities, listen to audio-recordings of family members, and send and receive messages. The responses selected for these participants were hand pressure and eyelid closure, respectively. The results of both studies were positive. The participants of Study I increased their responding to increase their stimulation input and caregiver interaction. The participants of Study II managed to successfully select all the options the program included (i.e., the leisure options, as well as the family and communication options). General implications of the programs and the related technology packages for intervention with post-coma persons with multiple disabilities are discussed.

Comparing acquisition of and preference for manual signs, picture exchange, and speech-generating devices in nine children with autism spectrum disorder

OBJECTIVE

To compare how quickly children with autism spectrum disorder (ASD) acquired manual signs, picture exchange, and an iPad/iPod-based speech-generating device (SGD) and to compare if children showed a preference for one of these options.

METHOD

Nine children with ASD and limited communication skills received intervention to teach requesting preferred stimuli using manual signs, picture exchange, and a SGD. Intervention was evaluated in a non-concurrent multiple-baseline across participants and alternating treatments design.

RESULTS

Five children learned all three systems to criterion. Four children required fewer sessions to learn the SGD compared to manual signs and picture exchange. Eight children demonstrated a preference for the SGD.

CONCLUSION

The results support previous studies that demonstrate children with ASD can learn manual signs, picture exchange, and an iPad/iPod-based SGD to request preferred stimuli. Most children showed a preference for the SGD. For some children, acquisition may be quicker when learning a preferred option.

Technology to help persons with extensive neuro-motor impairment and lack of speech with their leisure occupation and communication

These two studies were aimed at extending the assessment of technology-aided programs to enhance leisure occupation or communication with persons with extensive neuro-motor impairment and lack of speech. Specifically, Study I implemented the program for leisure occupation with two post-stroke patients. Study II implemented the program for communication with two persons affected by amyotrophic lateral sclerosis (ALS). In Study I, a computer system presented the participants with a variety of stimuli. The participants could select/access those stimuli by microswitch activation or could bypass them by abstaining from microswitch responses. In Study II, the participants used a computer-aided telephone system that allowed them to choose via microswitch activation the persons to call. On the computer screen, they also had words and phrases that they could activate during the calls to influence the conversation with the persons called. Data from both studies were largely positive. The post-stroke patients showed high levels of stimulus selection (access) and extended engagement. The patients with ALS were able to make phone calls and to select the words/phrases to influence the conversations. The relevance of technology-aided programs for leisure occupation and communication of persons with extensive multiple disabilities was discussed.

Technology-based intervention programs to promote stimulation control and communication in post-coma persons with different levels of disability

Post-coma persons in a minimally conscious state and with extensive motor impairment or emerging/emerged from such a state, but affected by lack of speech and motor impairment, tend to be passive and isolated. A way to help them develop functional responding to control environmental events and communication involves the use of intervention programs relying on assistive technology. This paper provides an overview of technology-based intervention programs for enabling the participants to (a) access brief periods of stimulation through one or two microswitches, (b) pursue stimulation and social contact through the combination of a microswitch and a sensor connected to a speech generating device (SGD) or through two SGD-related sensors, (c) control stimulation options through computer or radio systems and a microswitch, (d) communicate through modified messaging or telephone systems operated via microswitch, and (e) control combinations of leisure and communication options through computer systems operated via microswitch. Twenty-six studies, involving a total of 52 participants, were included in this paper. The intervention programs were carried out using single-subject methodology, and their outcomes were generally considered positive from the standpoint of the participants and their context. Practical implications of the programs are discussed.

Assessing learning as a possible sign of consciousness in post-coma persons with minimal responsiveness

A learning test procedure based on operant principles may be useful in the diagnosis (and eventually rehabilitation) of post-coma persons with minimal responsiveness. This study was aimed at extending the evaluation of such a procedure with seven participants who presented with very limited behavior and apparently severe disorders of consciousness. The procedure was evaluated through an ABACB design, in which A represented baseline phases without stimulation, B intervention phases with brief stimulation periods contingent on specific responses of the participants, and C a control phase in which stimulation was available all the time. Increased responding during the B phases, as opposed to the A and C phases, was taken to indicate learning and possibly a non-reflective expression of phenomenal consciousness. All participants were also evaluated with the coma recovery scale-revised (CRS-R) prior to the start of the learning test procedure and at the end of it. The results of the learning test showed that all participants had significantly higher responding levels during the B phases. The CRS-R scores suggested minimally conscious state for four of them prior to the learning test and for five of them after the completion of the learning test. The implications of the findings are discussed in terms of potential and time cost of the learning test.

Comparing communication systems for individuals with developmental disabilities: a review of single-case research studies

Studies that have compared different communication systems for individuals with developmental disabilities were systematically reviewed in an effort to provide information useful for clinical decision making and directions for future research. Specifically, 28 studies that compared (a) non-electronic picture systems to speech generating devices, (b) aided AAC (e.g. picture exchange systems and SGDs) to unaided AAC systems (manual sign), or (c) AAC to speech-language interventions were included in this review. Dependent variables forming the basis for comparison included: (a) effectiveness (e.g. acquisition of systems and/or rate of use), (b) efficiency or rate of skill acquisition (c) participants' preference for systems, (d) occurrence of vocalizations and problem behavior, and (e) generalization across communication partners, settings, and time (i.e. maintenance). Results suggest that clear and consistent differences between communication systems are rare, precluding definitive statements regarding a universal best approach for all people with developmental disabilities. Instead, findings of this review support the consideration of an individual's existing skills, goals and preferences as part of the process of selecting an approach to communication.

Comparisons of intervention components within augmentative and alternative communication systems for individuals with developmental disabilities: a review of the literature

Decisions regarding augmentative and alternative communication (AAC) for individuals with developmental disabilities (e.g. what AAC to use and how to teach a person to use a specific AAC modality) should involve consideration of different intervention component options. In an effort to elucidate such decisions and options, this review synthesized 14 studies, published between 2004 and 2012, comparing different AAC intervention components including different symbol sets, instructional strategies, or speech output within aided AAC systems, and different verbal operants within unaided AAC. Evidence supported the following: (a) different instructional strategies such as building motivation, using errorless learning, or adding video models to picture exchange interventions may improve the acquisition or rate of acquisition of picture exchange mands, (b) limited data supports training mimetic (imitated) or mand signs over tacts and (c) differences in symbol sets and speech output levels appeared to have little effect on AAC-based mand acquisition, but listener-based differences should be considered. These findings have implications for future research and clinical practice.

Further evaluation of a telephone technology for enabling persons with multiple disabilities and lack of speech to make phone contacts with socially relevant partners

This study assessed whether a girl and a woman with multiple disabilities could (a) make phone contacts with relevant partners through a special telephone technology, and (b) enjoy their telephone-mediated communication with them. The technology involved a net-book computer, a global system for mobile communication modem (GSM), an optic microswitch, and specific software. The technology was programmed to present the names of the partners available for contact, and the participants could choose at each presentation sequence the one they wanted to contact with a simple microswitch response. Such response triggered the computer to place a phone call to that partner. Both participants (a) learned to use the technology quite rapidly to contact relevant partners and maintained the successful use of it over the intervention and post-intervention sessions, (b) showed high levels of indices of happiness during the phone calls as opposed to pre-baseline control sessions, and (c) showed preferences among the partners. Implications of the findings are discussed.

Technology-aided programs to enable persons with multiple disabilities to choose among environmental stimuli using a smile or a tongue response

Persons with multiple disabilities, including pervasive motor impairment, may have problems controlling even small responses (e.g., vocal emissions, finger movements, or prolonged eyelid closures) within time-sensitive situations, such as those involved in choice programs. Recent research has indicated that smile expressions can be used as functional choice responses for some of these persons. The present two studies were aimed at assessing the smile response for a child with congenital multiple disabilities and a tongue response for a post-coma man who had recovered his consciousness but presented with pervasive multiple disabilities. The first of the two studies represented a research extension (i.e., a new case with a slightly adapted microswitch technology) concerning the smile response, which had recently been evaluated with few other cases. The second study represented a new effort to assess the tongue response within a choice program and for a post-coma man with multiple disabilities. The results showed that the participants used the smile and the tongue responses successfully while they were apparently unsuccessful in using a slight head/chin movement response. Their choice behavior focused reliably on preferred stimuli and avoided non-preferred stimuli. Implications of the results are discussed.

A man with amyotrophic lateral sclerosis uses a mouth pressure microswitch to operate a text messaging system with a word prediction function

OBJECTIVE

To assess whether a man with amyotrophic lateral sclerosis could benefit from using (a) a mouth pressure microswitch instead of an optic microswitch activated via head movement and (b) a special word prediction function within a text messaging system.

METHOD

Initially, both microswitches were used for operating the text messaging system, and their effectiveness and the man's preference were assessed. Subsequently, only the mouth microswitch was used and the messaging system was provided with a word prediction function.

RESULTS

The man was more efficient/rapid in using the text messaging (i.e., in writing) with the mouth microswitch and preferred such a microswitch. Similarly, he was more rapid in writing when the word prediction function was added (as opposed to the initial phase of the study when such function was not available) and preferred to use it.

CONCLUSION

Technology updates are critical in helping persons with motor degeneration.

Persons with multiple disabilities increase adaptive responding and control inadequate posture or behavior through programs based on microswitch-cluster technology

Study I used typical microswitch-cluster programs to promote adaptive responding (i.e., object manipulation) and reduce inappropriate head or head-trunk forward leaning with a boy and a woman with multiple disabilities. Optic, tilt, and vibration microswitches were used to record their adaptive responses while optic and tilt microswitches monitored their posture. The study included an ABB(1)AB(1) sequence, in which A represented baseline phases, B represented an intervention phase in which adaptive responses were always followed by preferred stimulation, and B(1) represented intervention phases in which the adaptive responses led to preferred stimulation only if the inappropriate posture was absent. Study II assessed a non-typical, new microswitch-cluster program to promote two adaptive responses (i.e., mouth cleaning to reduce drooling effects and object assembling) with a man with multiple disabilities. Initially, the man received preferred stimulation for each cleaning response. Then, he received stimulation only if mouth cleaning was preceded by object assembling. The results of Study I showed that both participants had large increases in adaptive responding and a drastic reduction in inappropriate posture during the B(1) phases and a 2-week post-intervention check. The results of Study II showed that the man learned to control drooling effects through mouth cleaning and used object assembling to extend constructive engagement and interspace cleaning responses functionally. The practical implications of the findings are discussed.

Post-coma persons emerging from a minimally conscious state with multiple disabilities make technology-aided phone contacts with relevant partners

Post-coma individuals emerging from a minimally conscious state with multiple disabilities may enjoy contact with relevant partners (e.g., family members and friends), but may not have easy access to them. These two single-case studies assessed whether those individuals could make contact with partners through computer-aided telephone technology and enjoy such contact. The technology involved a computer system with special software, a global system for mobile communication modem (GSM), and microswitch devices. In Study I, the computer system presented a 23-year-old man the names of the partners that he could contact, one at a time, automatically. Together with each partner's name, the system also presented the voice of the partner asking the man whether he wanted to call him or her. The man could (a) place a call to that partner by activating a camera-based microswitch through mouth movements or (b) bypass that partner and wait for the next one to be presented. In Study II, the system presented a 36-year-old man the partners' names only after he had activated his wobble microswitch with a hand movement. The man could place a call or bypass a partner as in Study I. The results showed that both men (a) were able to contact relevant partners through the technology, (b) seemed to enjoy their telephone-mediated communication contacts with the partners, and (c) showed preferences among the partners. Implications of the findings are discussed.

Two men with multiple disabilities carry out an assembly work activity with the support of a technology system

OBJECTIVE

To assess whether two persons with multiple disabilities could learn a work activity (i.e., assembling trolley wheels) with the support of a technology system.

METHOD

After an initial baseline, the study compared the effects of intervention sessions relying on the technology system (which called the participants to the different workstations and provided feedback and final stimulation) with the effects of intervention sessions carried out without technology. The two types of intervention sessions were conducted according to an alternating treatments design. Eventually, only intervention sessions relying on the technology system were used.

RESULTS

Both participants managed to assemble wheels independently during intervention sessions relying on the technology system while they failed during sessions without the system. Their performance was strengthened during the final part of the study, in which only sessions with the system occurred.

CONCLUSION

Technology may be critical in helping persons with multiple disabilities manage multi-step work activities.

Three non-ambulatory adults with multiple disabilities exercise foot-leg movements through microswitch-aided programs

This study assessed the use of microswitch-aided programs to help three non-ambulatory adults with multiple disabilities exercise foot-leg responses. Those responses served to activate a largely neglected part of the participants' body, with possibly positive physical implications (e.g., for blood circulation, swelling, and muscle strength). Intervention focused on the left and right foot-leg response, separately. Eventually, sessions with one response were alternated with sessions with the other response. Responses were monitored via microswitches and followed by 8s of preferred stimulation (e.g., music and vibrotactile stimulation), which was automatically delivered. The results showed that all three participants had high levels of foot-leg responses during the intervention phases and a 3-week post-intervention check. The participants also displayed expressions of positive involvement during those study periods (i.e., engaged in behaviors, such as music-related head movements, smiles, or touching the vibratory devices) that could be interpreted as forms of interest/pleasure and happiness. These results are in line with previous findings in this area and can be taken as an important confirmation of the strength and dependability of the approach in motivating non-ambulatory persons with multiple disabilities to engage in foot-leg movements. The practical implications of these findings are discussed.

Technology-aided recreation and communication opportunities for post-coma persons affected by lack of speech and extensive motor impairment

This study assessed technology-aided intervention programs for two post-coma men who had re-acquired consciousness, but were unable to engage in personally or socially relevant occupations, given their lack of functional speech and their extensive motor disabilities. The microswitches used for accessing the program contents consisted of (a) a pressure sensor fixed in the palm of the first man's hand that could be activated with a small hand closure movement, and (b) an optic sensor fixed under the chin of the second man that could be activated by mouth opening movements. The programs' content consisted of recreation and communication options, which involved activating music, videos, and basic requests, sending and receiving (listening to) text messages, and placing phone calls. The results showed that the men (a) used the technology-aided programs successfully to manage the recreation and communication options available and (b) showed consistent preference for the sessions with the technology-aided program over other daily events. Family and staff members interviewed about the participants' programs (seven members for each participant) thought that the participants enjoyed the intervention sessions with the programs and that the programs had beneficial effects for them. Implications of the findings are discussed.

Supporting daily activities and indoor travel of persons with moderate Alzheimer's disease through standard technology resources

These two studies were aimed at evaluating standard technology resources for supporting activity and travel among patients with moderate Alzheimer's disease. Specifically, Study I assessed a pictorial instruction program relying on the use of a portable computer and a commercially available and inexpensive video editing software for supporting the performance of daily activities with three patients. Study II assessed the indoor travel performance of four patients (i.e., the three involved in Study I and a fourth patient with no previous research exposure) using a commercially available, basic doorbell system with sound and light cues. The percentages of correct activity steps obtained with the instruction program used in Study I were relatively high and largely similar to the percentages reported in previous studies using more sophisticated technology. During Study II, the percentages of correct travels of two patients matched the data of the most successful patients involved in previous studies with more sophisticated technology. The percentages of the other two patients tended to be lower than those obtained previously, but were still practically relevant. The implications of the results of the two studies and a number of issues for new research are discussed.

Technology-aided programs to support exercise of adaptive head responses or leg-foot and hands responses in children with multiple disabilities

OBJECTIVE

Assessing the effectiveness of technology-aided programs to help three children with multiple disabilities exercise adaptive head or leg-foot and hands responses independently.

METHOD

The response selected for the two children included in Study I was head rotation (i.e. movements of at least 25 degrees to the left that could start from a full right position as well as from other positions). The responses selected for the child included in Study II involved forward movement of the left leg-foot and forward movement of his hand(s) to touch objects. Tilt or optic microswitches were used to monitor the responses and a computer system regulated the stimuli contingent on them.

RESULTS

The responses targeted in the two studies showed large frequency increases during the intervention phases of the studies (i.e. when followed by stimulation).

CONCLUSION

Technology-aided programs can be a useful resource to help children with multiple disabilities exercise relevant responses independently.

Walker devices and microswitch technology to enhance assisted indoor ambulation by persons with multiple disabilities: three single-case studies

These three single-case studies assessed the use of walker devices and microswitch technology for promoting ambulation behavior among persons with multiple disabilities. The walker devices were equipped with support and weight lifting features. The microswitch technology ensured that brief stimulation followed the participants' ambulation responses. The participants were two children (i.e., Study I and Study II) and one man (i.e., Study III) with poor ambulation performance. The ambulation efforts of the child in Study I involved regular steps, while those of the child in Study II involved pushing responses (i.e., he pushed himself forward with both feet while sitting on the walker's saddle). The man involved in Study III combined his poor ambulation performance with problem behavior, such as shouting or slapping his face. The results were positive for all three participants. The first two participants had a large increase in the number of steps/pushes performed during the ambulation events provided and in the percentages of those events that they completed independently. The third participant improved his ambulation performance as well as his general behavior (i.e., had a decline in problem behavior and an increase in indices of happiness). The wide-ranging implications of the results 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.

A computer-aided telephone system to enable five persons with Alzheimer's disease to make phone calls independently

This study extended the assessment of a computer-aided telephone system to enable five patients with a diagnosis of Alzheimer's disease to make phone calls independently. The patients were divided into two groups and exposed to intervention according to a non-concurrent multiple baseline design across groups. All patients started with baseline in which the technology was not available, and continued with intervention in which the technology was used. The technology involved a net-book computer provided with specific software, a global system for mobile communication modem (GSM), a microswitch, and lists of partners to call with related photos. All the patients learned to use the system and made phone calls independently to a variety of partners, such as family members, friends, and caregivers. A social validation assessment, in which care and health professionals working with persons with dementia were asked to rate the patients' performance with the technology and with the help of a caregiver, provided generally more positive scores for the technology-assisted performance. The positive implications of the findings for daily programs of patients with Alzheimer's disease are discussed.

Persons with multiple disabilities use forehead and smile responses to access or choose among technology-aided stimulation events

A variety of technology-aided programs have been developed to help persons with congenital or acquired multiple disabilities access preferred stimuli or choose among stimulus options. The application of those programs may pose problems when the participants have very limited behavior repertoires and are unable to use conventional responses and microswitches. The present two studies assessed non-conventional response-microswitch solutions for three of those participants. Study I included two participants who were exposed to a program in which forehead skin movement was the response required to access preferred stimulation. The microswitch was an optic sensor combined with a small black sticker on the forehead. Study II included one participant who was exposed to a program in which a smile response was required to choose among stimuli. The microswitch for monitoring the smile was a new camera-based technology. The results of the two studies showed that the response-microswitch solutions were suitable for the participants and enabled them to perform successfully. Implications of the studies for people with limited motor behavior and issues for future research were discussed.

A voice-sensitive microswitch for a man with amyotrophic lateral sclerosis and pervasive motor impairment

OBJECTIVE

To assess a voice-sensitive microswitch for a 67-year-old man with amyotrophic lateral sclerosis (ALS) who had difficulties continuing to use an optic microswitch through small chin movements.

METHOD

The man used the microswitches in combination with a computer-aided program to (a) access preferred songs and videos or make requests, and (b) operate a messaging system to communicate with his wife and sons. To assess the man's performance with the two microswitches, we alternated sessions with one microswitch with sessions with the other.

RESULTS

The man's performance with the new microswitch was apparently more efficient (i.e. he could generally activate the new microswitch with a single attempt while he needed a mean of about two attempts for each activation of the optic microswitch). The man also developed a clear preference for the new microswitch.

CONCLUSION

Technology updates are critical within programs for persons with motor degeneration.

IMPLICATIONS FOR REHABILITATION

A microswitch that can be used efficiently and without effort is critically important for a person with ALS. The microswitch can be used with programs that allow the person to manage leisure stimulus events, request opportunities and/or text messaging communication. The microswitch needs to be updated (changed) in relation to the person's physical deterioration.

Technology-aided leisure and communication opportunities for two post-coma persons emerged from a minimally conscious state and affected by multiple disabilities

This study assessed technology-aided programs for helping two post-coma persons, who had emerged from a minimally conscious state and were affected by multiple disabilities, to (a) engage with leisure stimuli and request caregiver's procedures, (b) send out and listen to text messages for communication with distant partners, and (c) combine leisure engagement and procedure requests with text messaging within the same sessions. The program for leisure engagement and procedure requests relied on the use of a portable computer with commercial software, and a microswitch for the participants' response. The program for text messaging communication involved the use of a portable computer, a GSM modem, a microswitch for the participants' response, and specifically developed software. Results indicated that the participants were successful at each of the three stages of the study, thus providing relevant evidence concerning performance achievements only minimally documented. The implications of the findings in terms of technology and practical opportunities for post-coma persons with multiple disabilities are discussed.

Assessing the impact and social perception of self-regulated music stimulation with patients with Alzheimer's disease

We assessed the impact and social rating of an active and a passive music condition implemented with six patients with Alzheimer's disease. In the active condition, the patients used a simple hand response and a microswitch to self-regulate music stimulation inputs. In the passive condition, music stimulation was automatically presented throughout the sessions. Active and passive stimulation sessions were preceded and followed by control (non-stimulation) sessions. The active condition sessions showed an increase in the patients' indices of positive participation (e.g., singing or music-related movements, and smiles) greater than that observed in the passive condition sessions for five of the six patients. Positive intervention effects could also spread to the post-intervention sessions. Social raters (42 care and rehabilitation staff members working with persons with multiple disabilities) favored the active condition on a six-item questionnaire dealing with, among others, conditions' suitability, respect of patients' dignity and independence, and practicality. The implications of the findings as to the plausibility/desirability of an active stimulation condition were discussed.