Assessing a Microswitch-Based Stimulation Procedure for Eye-Blinking Responses in a Young Woman with Profound Multiple Disabilities

Initiation of activities and alertness in individuals with profound intellectual and multiple disabilities

BACKGROUND

When providing activities to individuals with profound intellectual and multiple disabilities (PIMD), direct support persons (DSPs) often face questions that are, among other things, related to the alertness of the person with PIMD. While previous studies have revealed that stimulation might have a greater impact on levels of alertness than the internal conditions of the individual, they have also emphasized the importance of interaction in order to influence the level of alertness. Because the initiation of this interaction has been described as one of its core components, the present study has focused on the relationship between the stimuli presented, the initiation of the activity (by the person with PIMD or the DSP), and the level of alertness of the person with PIMD.

METHOD

Videotapes of the one-to-one interactions of 24 individuals with PIMD and their DSPs in multisensory environments have been scored using the Alertness Observation List. In a sequential analysis, the percentages of stimuli presented were related to the percentages of initiation. Furthermore, two other analyses focused on the relationship between the level of alertness and the preceding and subsequent percentages of initiation respectively.

RESULTS

The results show that high percentages of the activities are initiated by the DSPs. In addition, activities that were initiated by the individual with PIMD were preceded and followed by higher percentages of alert behaviour than those initiated by the DSP. Outcomes differed for the different types of stimuli.

CONCLUSIONS

These results have striking implications for the lives of individuals with PIMD. It is quite possible that DSPs often act too quickly, whereas they would be better off waiting for a reaction on the part of their client. In general, DSPs need to find a balance between being passive themselves and promoting in the individual with PIMD a state of being as active and alert as possible.

Speech and language therapists' approaches to communication intervention with children and adults with profound and multiple learning disability

BACKGROUND

People with profound intellectual and multiple disabilities (PMLD) have communication impairments as one defining characteristic.

AIMS

To explore speech and language therapists' (SLTs) decision making in communication interventions for people with PMLD, in terms of the intervention approaches used, the factors informing the decisions to use specific interventions and the extent to which the rationales underpinning these decisions related to the components of evidence based practice (EBP), namely empirical evidence, clinical experience and client/carer views and values.

METHODS & PROCEDURES

A questionnaire on communication assessment and intervention for people with PMLD was sent to SLTs in the UK to elicit information on: the communication intervention approaches they used; their rationales for their intervention choices; their use of published evidence to inform decision making.

OUTCOMES & RESULTS

Intensive interaction and objects of reference were the communication interventions most often used with people with PMLD, with some differences between children and adults evident. Rationales provided conformed somewhat to the EBP framework though extension of the existing framework and addition of practical and organizational considerations led to a revised typology of rationale for decision making. Rationales most frequently related to the empowerment, development and behavioural preferences of the person with PMLD.

CONCLUSIONS & IMPLICATIONS

Empirical research evidence was seldom mentioned by SLTs as informing intervention decision making leading to very diverse practice. There is a need for further research on the effectiveness of commonly used but under-evaluated interventions. There is also a need to alert SLTs to the evidence base supporting other approaches, particularly switch-based, cause and effect approaches.

Catch the wave! Time-window sequential analysis of alertness stimulation in individuals with profound intellectual and multiple disabilities

BACKGROUND

While optimally activities are provided at those moments when the individual with profound intellectual and multiple disabilities (PIMD) is 'focused on the environment' or 'alert', detailed information about the impact that the design and timing of the activity has on alertness is lacking. Therefore, the aim of the present study is to shed light on the sequential relationship between different stimuli and alertness levels in individuals with PIMD.

METHOD

Video observations were conducted for 24 participants during one-on-one interactions with a direct support person in multisensory environments. Time-window sequential analyses were conducted for the 120 s following four different stimuli.

RESULTS

For the different stimuli, different patterns in terms of alertness became apparent. Following visual stimuli, the alertness levels of the individuals with PIMD changed in waves of about 20 s from 'active alert' to 'passive alert'. While auditory and tactile stimuli led to 'alert' reactions shortly after the stimulation, alertness levels decreased between seconds 20 and 120. Reactions to vestibular stimuli were only visible after 60 s; these were 'active alert' or 'withdrawn'.

CONCLUSIONS

The results of the present study show that individuals with PIMD show their reactions to stimuli only slightly, so that 'waves' might reflect the optimal alertness pattern for learning and development. Consequently, it is especially important that direct support persons follow and stimulate these individual 'waves' in the activities they provide to their clients.

The role of attention in the affective life of people with severe or profound intellectual disabilities

Although it is shown that attention plays an important role both in the onset and in the regulation of emotions in people without disabilities there is no information about how attention is related to emotions in people with severe or profound intellectual disability (ID). Therefore, in our study, we investigated the role of attention in the onset and regulation of the emotions of persons with severe or profound ID. We presented 27 participants with 4 staff-selected negative and 4 staff-selected positive stimuli. The situations were videotaped and their heart rate and attention was measured. Contrary to the expected higher attention to negative stimuli during the onset of negative emotions, we did not find differences in attention in the fourth to sixth second of stimulus presentation. However, in support of the emotion regulation theory of Gross (2008) we did find less attention to the negative stimuli than to the positive stimuli after these first 6s of stimuli presentation. As expected from research in people without disabilities, there was also a negative relationship between the heart rate and the probability of being attentive. Our results suggest that people with severe and profound ID use attentional deployment to regulate their emotions and that, as in people without disabilities, a low heart rate is associated with attention.

Observing and Influencing Alertness in Individuals With Profound Intellectual and Multiple Disabilities in Multisensory Environments

While alertness is widely acknowledged as one of the most important preconditions for learning and development, individuals with profound intellectual and multiple disabilities (PIMD) experience a wide range of difficulties in the contact with their environment. The aim of the present study was to identify aspects of stimulation situations that influence the alertness levels of individuals in the target population.

Based on video recordings of 24 participants, alertness levels and environmental conditions were scored. Descriptive analyses and multilevel logistic regression analysis were used to identify the aspects of the stimulation situation that were related to occurrence of alertness.

The results show that visual stimuli (optimally in combination with auditory stimuli) produced the highest alertness levels. Furthermore, the effects of stimuli outweighed the effect of time. The role of direct support persons is thus especially important in alertness stimulation of individuals with PIMD.

Alertness in individuals with profound intellectual and multiple disabilities: a literature review

Direct support persons (DSPs) often face problems in observing and determining alertness in individuals with profound intellectual and multiple disabilities (PIMD). A literature study was carried out to gather information about the problems just described. A search of two electronic databases and the references found in relevant hits revealed 42 relevant publications. The results show that two types of descriptions of alertness can be distinguished: (1) those with a focus on the individual only or (2) those with a focus on the interaction of individual and environment. Several observation categories were used in the studies that were found. The reliability of the observations turned out to be a core problem in most of the studies. Only a limited number of environmental conditions that were expected to have an impact on alertness in individuals with PIMD were investigated. While modifications of the environment, interaction strategies, stimulation strategies and staff training were found to have a positive impact on alertness, studies about treatment activities led to conflicting results. Finally, we will formulate the resulting implications for future studies and for the development of an instrument for DSPs in order to observe alertness in individuals with PIMD in clinical practice.

A learning setup for a post-coma adolescent with profound multiple disabilities involving small forehead movements and new microswitch technology

PURPOSE

A learning setup was arranged for an adolescent with profound multiple disabilities and a diagnosis of vegetative state. Signs of learning by the adolescent would underline an improvement in his immediate situation with potential implications for his general prospect, and could help revise his diagnosis.

METHOD

The response adopted in the learning setup was forehead skin movement. The microswitch technology used for detecting such a response consisted of (a) an optic sensor (i.e., barcode reader), (b) a small tag with horizontal bars attached to the participant's forehead, and (c) an electronic control system that activated stimuli in relation to the participant's forehead responses. The study followed an ABABACAB sequence, in which A represented baseline periods, B intervention periods with stimuli contingent on the response, and C a control condition with stimuli presented non-contingently.

RESULTS

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, indicating clear signs of learning.

CONCLUSIONS

Intervention strategies based on a learning format and suitable technology might be useful to improve the situation and prospect of persons with profound multiple disabilities and a diagnosis of vegetative state.

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.