Outcome of recommendations for augmentative communication in children

Revised consensus statement on the preventive and symptomatic care of patients with leukodystrophies

Leukodystrophies are a broad class of genetic disorders that result in disruption or destruction of central myelination. Although the mechanisms underlying these disorders are heterogeneous, there are many common symptoms that affect patients irrespective of the genetic diagnosis. The comfort and quality of life of these children is a primary goal that can complement efforts directed at curative therapies. Contained within this report is a systems-based approach to management of complications that result from leukodystrophies. We discuss the initial evaluation, identification of common medical issues, and management options to establish a comprehensive, standardized care approach. We will also address clinical topics relevant to select leukodystrophies, such as gallbladder pathology and adrenal insufficiency. The recommendations within this review rely on existing studies and consensus opinions and underscore the need for future research on evidence-based outcomes to better treat the manifestations of this unique set of genetic disorders.

Enabling Persons with Multiple Disabilities to Choose among Environmental Stimuli and Request Stimulus Repetitions through Microswitch and Computer Technology

This study assessed microswitch and computer technology to enable two participants with multiple disabilities, 32 and 19 years of age, to choose among environmental stimuli and request their repetition whenever they so desired. Within each session, 18 stimuli (12 preferred and 6 nonpreferred) were available. For each stimulus, a computer system provided a sample of 3 sec. duration. During the intervention, participants' vocal responding in relation to a stimulus sample activated a microswitch and a computer system turned on that stimulus for 15–30 sec. When participants did not vocally respond, the computer system paused briefly and then presented the next scheduled stimulus sample. When participants vocally responded at the end of a stimulus presentation, the stimulus was repeated. Intervention data showed that the participants learned to choose preferred stimuli and bypass nonpreferred ones as well as to request repetitions of the preferred stimuli. This performance was maintained at a 1-mo. postintervention check and transferred to sets of stimuli not used in the intervention. The implications of these results were discussed.

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.

Pediatric rehabilitation: 4. Prescribing assistive technology to promote community integration

OBJECTIVE

This self-directed learning module highlights the equipment and assistive technology needs of children and youth with disabilities. This article specifically focuses on preparing families and patients for equipment transitions that occur over the course of childhood and adolescence including progressing from stroller to wheelchair to powerchair, as well as job training and use of augmentative communication. It is part of the study guide on pediatric rehabilitation in the Self-Directed Physiatric Education Program for practitioners and trainees in physical medicine and rehabilitation and pediatric medicine. The goal of this article is to modify the learner's current practice techniques to ensure that assistive technology is used to promote community integration from early childhood through transition and into adulthood.

Evaluating a computer system used as a microswitch for word utterances of persons with multiple disabilities

PURPOSE

To assess the effectiveness of a computer system used as a microswitch for word utterances of two adults with multiple disabilities. The system combined a new control software programme with a commercially available speech recognition programme.

METHOD

Nine word utterances were targeted for each participant. The participant's emission of those utterances triggered the occurrence of related (favourite) stimuli during the intervention and the post-intervention check.

RESULTS

Intervention data showed that (1) the participants increased the frequencies of the target utterances and (2) the computer system recognized about 80% of those utterances correctly, providing the participants with high levels of favourite stimulation. The post-intervention check showed comparable data with both participants.

CONCLUSIONS

The computer system proved an adequate microswitch for word utterances. Based on this evidence, microswitch programmes could be extended beyond the use of conventional motor responses.

Students with multiple disabilities using technology-based programs to choose and access stimulus events alone or with caregiver participation

The first of these two studies extended preliminary evidence on the use of technology-based programs for enabling students with severe and profound multiple disabilities to choose and access environmental stimuli on their own. Each of the three participants had two microswitches linked to specific sets of stimuli through a computer system. The activation of one of the microswitches triggered the computer system to present a sample of one of the stimuli. If the student chose it, the computer system turned it on for a specific time interval. The second study tested a new technology that allowed the students to choose and access the chosen stimuli with the involvement of the caregiver. The two participants had three microswitches linked to a computer system. The participants' choice of a stimulus alerted the caregiver who then got involved in the stimulation process. The results of both studies showed that the participants learned to activate the basic microswitches consistently, had high percentages of choice for the stimulus samples presented by the computer but with wide differences across stimuli, and largely maintained this performance at a 2-month post-intervention check. These findings were analyzed in terms of the usability of the two types of programs, the role they may play within educational and living contexts, and their innovative technical dimensions.

Microswitch-Based Programs for Persons with Multiple Disabilities: An Overview of Some Recent Developments

Persons with multiple disabilities are often unable to interact with their environment due to their limited response repertoire. Microswitch programs are designed to help them control environmental events, generally preferred stimulation, through simple (feasible) responses. To make microswitch programs a more widely usable and relevant resource for intervention with these persons, a number of new developments were pursued in recent years. This paper examines three of those developments as specifically addressed in our research activity, namely, (a) assessment of new, nontypical responses and matching microswitches, (b) fostering of multiple responses and exercise of choice, and (c) targeting of habilitative and clinical (therapeutic) objectives. The encouraging outcomes of these developments are reviewed in relation to their potentially wide implications for daily practice and the need of additional developments in the area.

Elation or frustration? Outcomes following the provision of equipment during the Communication Aids Project: data from one CAP partner centre

BACKGROUND

The Communication Aids Project (CAP) was a 4-year initiative by the UK Department for Education and Skills to provide communication equipment for students who were unable to speak in order to facilitate their access to education. Each child was given three goals or targets which were then evaluated after 6 months of provision of the communication aid.

METHODS

We evaluated the targets of 60 children, between the ages of 3 and 18 years. Six months after receipt of equipment, the targets were mailed to the initial referrer who was requested to record whether the child had achieved, partially achieved or not achieved each target. Evidence and explanations of these outcomes were also requested. Data were analysed using descriptive statistics, and the explanations were grouped into common themes using a keyword analysis.

RESULTS

Sixty-three per cent of targets were not achieved and 36% were achieved. We investigated any possible associations to attempt to explain some of the possible reasons for the children's non-achievement of targets. Targets were grouped into operational, linguistic, social and academic, but there were no differences between the successes because of target type. Age may be an influence on success, but neither school placement or type of communication aid influenced success. The explanations for non-achievement highlighted the misunderstanding or interpreting of the underlying skills of the communication aid user as a potential cause.

CONCLUSION

The CAP raised the profile of children with Augmentative and Alternative Communication needs within education. However, only one-third of the targets of children using the equipment were achieved. The reasons for this include inappropriate provision of equipment, demands of the equipment, lack of appropriate support and targets. The major consequence, however, is the need for detailed assessment and provision appropriate to the individual needs of each child. There is a need for research into the best methods of providing communication aids and the support needed for successful communication.

Assistive devices for children with functional impairments: impact on child and caregiver function

Functional impairments can limit a child's ability to participate in the experiences of childhood. This'deprivation'can, in turn, have a negative effect on such children's development, academic performance, and quality of life, as well as on the lives of their caregivers and families. Many adults use assistive devices to overcome functional impairments and enable them to participate in daily activities; however, such devices may be underutilized by children. Each of the 54 studies reviewed in this report identified one or more functional impairments towards which an assistive device was targeted: accessing a computer (n=3 [studies]), activity assistance (n=2), behaviour changes (n=3), communication (n=30), independent feeding (n=1), living skills (n=1), mobility (n=9), modifying the environment (n=1), nutrition (n=4), and postural stability (n=2). The aim of this review was to determine the impact of assistive devices on the components of functioning defined by the World Health Organization's International Classification of Functioning, Disability and Health. The impact of these devices was found to be overwhelmingly positive. Study outcomes reported were mainly child-focused and could be classified as influencing activity, participation, and personal contextual factors, with relatively little attention paid to caregiver-focused outcomes. Few studies provided either qualitative evidence or experimentally-based quantitative research evidence using controls.

Enabling students with multiple disabilities to request and choose among environmental stimuli through microswitch and computer technology

This study assessed the possibility of enabling two students with multiple disabilities to request and choose among environmental stimuli through microswitch and computer technology. Each student was provided with two basic microswitches the activation of which made a computer system present a sample of a preferred or non-preferred stimulus. The student could select or reject such a stimulus by vocal utterances discriminated by the computer system as 'yes' or 'no'. If the student selected the stimulus, the computer system presented it for a preset time. If the student rejected the stimulus, the computer system waited for the next input of one of the basic microswitches. Data showed that both students learned to activate the basic microswitches consistently, selected the preferred stimuli about 90% of the times, and largely rejected the non-preferred stimuli. The students also showed some preferences between the two basic microswitches/responses. The performance was maintained at the post-intervention checks carried out 3 and 6 weeks after the end of the intervention. Implications of the findings are discussed technically, practically, and in terms of quality of life.

Extending the evaluation of a computer system used as a microswitch for word utterances of persons with multiple disabilities

BACKGROUND

Micro-switches can be vital tools to help individuals with extensive multiple disabilities acquire control of environmental stimulation. This study was aimed at extending the evaluation of a computer system used as a microswitch for word utterances with three participants with multiple disabilities.

METHOD

Sets of 7 or 12 word utterances were used for the participants. The utterances were divided into three groups, which were exposed to intervention successively. During the intervention and a 2-month post-intervention check, the participants' emission of the target utterances led the system to present favourite, matching stimuli (i.e. provided that it recognized the utterances).

RESULTS

Intervention data showed that (1) the participants increased the frequencies of the target utterances and (2) the computer system recognized approximately 80% of those utterances. These findings were maintained at the post-intervention check. An analysis of the levels of occurrence of individual utterances showed statistically significant differences among them, in line with the notions of preference and choice.

CONCLUSIONS

The computer system was useful as a microswitch to enable access to favourite stimuli. There is a need to improve the accuracy of the system with respect to its recognition of the participants' utterances.

Microswitch programs for persons with multiple disabilities: an overview of the responses adopted for microswitch activation

BACKGROUND

To introduce a person with multiple disabilities to a microswitch-aided program, one has to select a plausible response(s), that is, a response(s) that can be performed reliably and without excessive effort by the person and can successfully activate the microswitch(es) available (producing preferred stimuli). This paper provides an overview of the responses adopted for microswitch activation in research studies during the last 20 years.

METHOD

Computerized and manual searches were carried out to identify the studies published between 1986 and 2005. Forty-eight research studies were identified. They concerned the use of (1) a single (typical) response, (2) a single (non-typical) response, (3) multiple (typical and non-typical) responses, and (4) multiple (vocal) responses.

RESULTS AND DISCUSSION

The results showed that 151 of the 190 participants involved in the studies had a positive outcome (i.e., clear increases in their responding, which suggested that they had learned the association between responding and consequent preferred stimuli). Failures were largely concentrated in the first group of studies. The discussion focused on (a) the importance of selecting plausible responses for increasing the chances of success, (b) the need of non-typical responses for persons with minimal motor behavior, (c) implications of programs with multiple responses on engagement and choice, and (d) relevance of using vocal utterances. Some suggestions for future research concerning these points were also examined.

A microswitch program including words and choice opportunities for students with multiple disabilities

Two students with multiple disabilities were provided with two or three request microswitches and one choice microswitch. Activation of a request microswitch triggered the verbal announcement of one of the stimulus events related to it. The student could choose such an event through the choice microswitch or bypass it. The request microswitches were introduced individually and made available simultaneously by the end of the intervention and the postintervention period. Analysis showed that both students learned to use the microswitches. Transfer of the microswitch program into the students' home was very successful with one student and presented some difficulties with the other. Implications of the findings and new possible developments were discussed.

Using computer systems as microswitches for vocal utterances of persons with multiple disabilities

We assessed the effects of two computer systems used as microswitches for the vocal utterances of an adolescent and a young adult with multiple disabilities. The systems were to respond to three one-syllable utterances of the first participant and nine word-like utterances of the second participant by presenting favorite stimuli linked to those utterances. The computer system used for the first participant relied on a software program developed specifically for this study. The computer system used for the second participant combined a new software program with a commercially available speech recognition program. Results showed that both participants increased the frequencies of their target utterances and obtained high levels of stimulation. Positive performance was maintained at post-intervention checks. Technical and practical implications of the data are discussed.

Using microswitches with persons who have profound multiple disabilities: evaluation of three cases

This study evaluated the effectiveness of microswitch programs in promoting and maintaining responding of persons with profound multiple disabilities. Three participants were provided one or two microswitches. Their responding (microswitch activation) produced favorite stimuli. Analysis showed that all participants increased responding significantly, albeit with clear differences among them, during the intervention period of a few weeks. Two participants continued with the microswitch program in the daily context and had 3-mo. follow-up data similar to the intervention data. One participant did not continue with the program (reportedly because of inconsistent/low responding) and so did not receive a follow-up assessment. Links between responding and vigilance conditions and stereotypy are discussed.

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.

Evaluating the use of multiple microswitches and responses for children with multiple disabilities

BACKGROUND

The present study assessed the feasibility of (1) establishing multiple microswitches and responses (some of which had not been used before) with two children with multiple disabilities, and (2) maintaining such microswitches and responses in the children's daily contexts.

METHODS

The microswitches were introduced individually and then combined. During the last part of treatment and the follow-up, each child had three microswitches.

RESULTS

The data show that both children learned to use all three available microswitches. Moreover, they retained fairly high levels of responding with the microswitches in their daily contexts during follow-up periods of 4 and 6 months.

CONCLUSIONS

The personal and practical implications of these findings are discussed.

Impact of stimulation versus microswitch-based programs on indices of happiness of people with profound multiple disabilities

This study was designed to assess whether the impact of a microswitch-based program on indices of happiness would be comparable with that of a stimulation program. Three persons with profound multiple disabilities participated. The microswitch-based program produced increases in indices of happiness which were fairly clear for the first two participants and quite modest for the third participant. These data were largely comparable with those obtained with the stimulation program. Implications of the findings in terms of program practicality, participants' independence and environmental control are discussed.

A microswitch for vocalization responses to foster environmental control in children with multiple disabilities

The present study assessed whether two children with multiple disabilities could learn to successfully operate a special microswitch through vocalization responses so as to obtain environmental stimulation. The study was carried out using a non-concurrent multiple baseline design across individuals. The treatment phase of the second child started after he had received twice the number of baseline sessions used for the first child. The results were positive, with both children increasing the frequencies of their vocalization responses during the treatment. The importance of using such responses (which do not require excessive efforts and are highly valued) for operating a microswitch with children with multiple disabilities is discussed.

Use of microswitches and speech output systems with people with severe/profound intellectual or multiple disabilities: a literature review

Microswitches and speech output systems are two forms of technology which have been used with people with severe/profound intellectual or multiple disabilities to help them reduce their isolation and interact with the surrounding world (i.e., thus obtaining environmental stimulation independently or requesting it efficiently). This paper reviews the studies which used microswitches and speech output systems with the aforementioned people during the 1986-1999 period, and discusses the research findings and the practicality of these two forms of technology. Some relevant issues for future research are also pointed out.