Two children with multiple disabilities increase adaptive object manipulation and reduce inappropriate behavior via a technology-assisted program.
Disabled children (Technology application)
Self-help devices for the disabled (Usage)
Motor ability (Management)
Lancioni, Giulio E.
O'Reilly, Mark F.
Singh, Nirbhay N.
|Publication:||Name: Journal of Visual Impairment & Blindness Publisher: American Foundation for the Blind Audience: Academic Format: Magazine/Journal Subject: Health Copyright: COPYRIGHT 2010 American Foundation for the Blind ISSN: 0145-482X|
|Issue:||Date: Nov, 2010 Source Volume: 104 Source Issue: 11|
|Topic:||Event Code: 200 Management dynamics Canadian Subject Form: Child behaviour Computer Subject: Handicapped access device; Technology application; Company business management|
|Geographic:||Geographic Scope: United States Geographic Code: 1USA United States|
Persons with severe to profound multiple disabilities, such as
intellectual, visual, and motor disabilities, may be characterized by
low levels of adaptive engagement with the environment (Holburn, Nguyen,
& Vietze, 2004; Mechling, 2006). They may also display forms of
inappropriate, stereotypical behavior (like hand mouthing, that is,
putting their fingers into or over their mouths) or inappropriate
postures and dystonic or spastic behavior (for example, tilting their
heads forward or stretching their legs) (Lancioni, Singh, O'Reilly,
Sigafoos, Didden et al. 2008; Luiselli, 1998; Matson & LoVullo,
Educational efforts that are directed at these persons need to encompass the dual goal of promoting adaptive responses and reducing inappropriate behavior to improve the persons' overall situation. A form of educational intervention that has recently been put forward to pursue such a dual goal relies on programs involving microswitch clusters. One such cluster could be used, for example, to monitor adaptive object manipulation and eye poking and to ensure that the manipulation responses lead to positive stimulation only if performed in the absence of eye poking.
Intervention programs that are based on microswitch clusters have been fairly successfully applied by Lancioni and his colleagues with 15 participants with multiple disabilities (see, for example, Lancioni, O'Reilly et al., 2008; Lancioni, Singh, O'Reilly, Sigafoos, Didden et al., 2008; Lancioni, Singh, O'Reilly, Sigafoos, Oliva et al., 2008; Lancioni et al., 2009). The aim of the study reported here was to extend the evidence available by involving two new participants (children), one of whom exhibited an inappropriate behavior that had not been targeted before (dystonic-spastic stretching of one or both arms) and new cluster technology. This technology allowed small manipulations of objects to serve as adaptive responses and to produce positive stimulation and it interrupted any ongoing stimulation if one or both of the participant's hands were withdrawn from the objects for two seconds or more. Basically, the technology did not monitor the inappropriate behavior per se--dystonicspastic stretching of one or both arms or hand mouthing--but a precursor of it (hand withdrawal) via relatively noninvasive devices.
The participants, Glen and Hugh, were 5.6 and 9.9 years old, respectively, and were rated in the severe to profound range of intellectual disability, although no IQ scores were available. They were diagnosed with encephalopathy that was due to premature birth and perinatal hypoxia, presented with spastic tetraparesis combined with dystonic movements for Glen, and spent most of their time in wheelchairs. They had no speech or any other specific means of communication (Glen) or showed some echolalic expressions but with no obvious communication goals (Hugh). On the basis of previous systematic behavioral observations, Hugh was reported to see only light displays in front of him, while Glen was reported to see relatively large objects within about 1 meter (about 39 inches) and at the center of the visual field (see Morse, Teresi, Rosenthal, Holmes, & Yatzkan, 2004; Sakai et al., 2002). Also, Glen had some previous experience with microswitches. Both participants lived at home with their parents and attended daily educational programs that focused on physiotherapy and general stimulation. The study presented here was approved by the scientific and ethics committee of the Lega F. D'Oro, Osimo, Italy. Parents and teachers provided informed consent for the study.
Position, adaptive responses, inappropriate behavior, and technology
Glen and Hugh were seated at a desk in front of a box that had a base that was 37 centimeters by 27 centimeters (about 15 inches by 11 inches) and was l0 centimeters (about 4 inches) high and open at the top, and contained five to seven objects. The objects, which were loosely tied to the bottom of the box and could be changed over sessions, were elements of the participants' daily context, such as plastic toys. Adaptive responses consisted of pushing, pulling, or turning any of the objects with both hands in the box area. The inappropriate behavior was dystonicspastic stretching of one or both arms forward or sideward for Glen and hand mouthing for Hugh. The first component of the microswitch cluster used for each participant consisted of optic and tilt devices that were placed under and on the objects in the box. These devices were designed to detect the manipulation of objects. The second component of the cluster consisted of watchlike magnetic sensors that were placed on the wrists of the participants to detect the withdrawal of one or both hands from the box area, that is, a withdrawal of about 10 centimeters (about 4 inches) from the magnetic field created in that area through battery-powered circuitry. Such a withdrawal was seen as the precursor of the inappropriate behavior.
The microswitch cluster was connected to a battery-powered electronic control system. This system recorded each new object-manipulation response, which activated the optic or tilt devices related to the objects in the box and occurred with both hands in the box area; turned on preferred stimuli for 8 or 9 seconds contingent on each response recorded during the intervention phases; interrupted the aforementioned stimuli prematurely if one or both hands were withdrawn from the box area for 2 seconds or more; and displayed the number of responses recorded and the stimulation time that occurred during the session.
Data collection and stimuli
[FIGURE 1 OMITTED]
Preferred stimuli were selected through a stimulus-preference screening (Crawford & Schuster, 1993). The screening covered multiple stimuli, each of which was presented 15-40 nonconsecutive times. Only the stimuli that were followed by positive reactions from the participants, such as alerting, orienting, or smiling, in two-thirds or more of the presentations were selected for the study. Those stimuli included music, familiar voices, vibratory inputs, and light displays for Hugh and the same stimuli plus children's songs and noises for Glen.
The study was conducted according to an ABAB design in which A represented the baseline phases and B represented the intervention phases (Barlow, Nock, & Hersen, 2009). A postintervention check occurred 2 months after the second B phase. The participants received three to eight 10-minute sessions a day, depending on their availability.
Baseline (A phases). The two baseline phases included 8 sessions for Glen and 10 and 18 sessions for Hugh. The microswitch cluster and control system were available, but no stimuli were scheduled for the participants' responses. At the start of the sessions, each participant was guided to perform an object-manipulation response without a stimulus consequence. The same guidance was repeated at intervals of about 1 minute during the sessions if no independent responses occurred.
[FIGURE 2 OMITTED]
Intervention (B phases). The two B phases included 37 and 62 sessions for Glen and 81 and 56 sessions for Hugh. During these sessions, general conditions were the same as at the baseline except that the object-manipulation responses were followed by preferred stimulation according to the conditions described earlier. Also, the withdrawal of one or both hands from the box area for 2 seconds or more interrupted any ongoing stimulation.
Postintervention check. The participants continued to receive sessions as in the intervention phases. Fourteen of the sessions, recorded two months after the second B phase, served as the postintervention check.
Figures 1 and 2 summarize the data for Glen and Hugh. The sessions are grouped into two blocks for each baseline and the postintervention check and four blocks for each intervention phase to portray general performance trends. During the first baseline, the participants' mean frequencies of object-manipulation responses were about 10 and 6 per session, respectively (see the top graphs of Figures 1 and 2). Their mean session times with inappropriate behavior, that is, dystonic-spastic arm stretching or hand mouthing, were about 4 and 5 minutes (see the center graphs of Figures 1 and 2). During the first intervention phase, their mean frequencies of manipulation responses rose to about 45 and 28 per session, and their mean session times with inappropriate behavior decreased to about or less than 2.5 minutes. During the second baseline, manipulation responses declined, while inappropriate behavior increased. During the second intervention phase, manipulation responses increased to more than 45 per session, and inappropriate behavior declined to less than 1.5 minutes. The mean session times with stimulation were higher than 4.5 and 2.5 minutes during the first intervention phase and more than 5.5 and 4.5 minutes during the second intervention phase (see the bottom graphs of Figures 1 and 2). The data for the postintervention check matched those of the second intervention phase. The differences between the baseline and the intervention and postintervention data for the first two measures were statistically significant (p < .01) on the Kolmogorov-Smirnov test (Siegel & Castellan, 1988).
The intervention was effective in increasing the two participants' object-manipulation responses and in reducing inappropriate behavior. These data add to the available evidence on the usefulness of microswitch clusters, given the novel or specific aspects of the study, that is, the inclusion of an inappropriate behavior, such as that shown by Glen, which had not been targeted before, and of a new technology.
The technology allowed various forms of object manipulation to serve as adaptive responses and monitored a precursor of the inappropriate behavior to reduce the complexity or invasiveness of the devices on the participants (Baker & Moon, 2008). Targeting object-manipulation responses may be considered particularly important with children with visual impairments. In fact, this impairment may reduce the possibly positive effects of those responses and thus limit their spontaneous occurrences with negative practical consequences (Lancioni, O'Reilly et al., 2008).
A program pursuing an increase in object manipulation and a reduction in inappropriate behavior, like the one tested in this study, may be seen as a relevant resource in any educational or home context. An approach in which a child learns to control his or her own behavior through constructive engagement emphasizes the child's active (central) role and the notion of self-directed therapy (Begnoche & Pitetti, 2007; Ketelaar, Vermeer, Hart, Van Petegem-van Beek, & Helders, 2001). Obviously, the real impact and clinical relevance of such an approach would depend largely on the overall acceptance and usability of the technology within a child's school and home contexts; its level of application during the day, that is, the number of daily sessions that are available; and the possibility of implementing a second microswitch cluster for an alternative form of constructive responding that would avoid high-engagement repetition.
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Giulio E. Lancioni, Ph.D., professor, Department of Psychology, University of Bari, Via Quintino Sella 268, 70100 Bari, Italy; e-mail:
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