- Email: [email protected]
A social validation assessment of the use of microswitches with persons with multiple disabilities
Research in Developmental Disabilities 23 (2002) 309±318
A social validation assessment of the use of microswitches with persons with multiple disabilities Giulio E. Lancionia,*, Mark F. O'Reillyb, Nirbhay N. Singhc, Doretta Olivad, Monia Marzianid, Jop Groenewega a
Department of Psychology, University of Leiden, Wassenaarseweg 52, 2333 AK Leiden, The Netherlands b University College Dublin, Dublin, Ireland c Virginia Commonwealth University, Richmond, VA, USA d Lega F. D'Oro Research Center, Osimo (AN), Italy
Received 27 November 2001; received in revised form 17 April 2002; accepted 24 April 2002
Abstract 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 teacherassistant trainees or classroom aides and 44 rehabilitation staff were presented with videotapes 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 ®ndings and their implications are discussed. # 2002 Elsevier Science Ltd. All rights reserved. Keywords: microswitches; multiple disabilities; social validation; stimulation
1. Introduction Persons with severe and profound multiple disabilities often experience highly reduced sensory input, minimal mobility, and very limited social interaction with *
Corresponding author. Tel.: 31-71-527-3681; fax: 31-71-527-3619. E-mail address: [email protected] (G.E. Lancioni).
0891-4222/02/$ ± see front matter # 2002 Elsevier Science Ltd. All rights reserved. PII: S 0 8 9 1 - 4 2 2 2 ( 0 2 ) 0 0 1 3 8 - 5
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G.E. Lancioni et al. / Research in Developmental Disabilities 23 (2002) 309±318
the environment (Gutowski, 1996; Lancioni, O'Reilly, & Basili, 2001a; Reid, Phillips, & Green, 1991). The complexity of their situation makes it impossible for staff to use conventional treatment procedures to help them develop speci®c adaptive skills (Ivancic & Bailey, 1996; Ko, McConachie, & Jolleff, 1998; Lancioni, O'Reilly, Singh, Oliva, & Groeneweg, 2002a; Mount & Cavet, 1995). Staff may (a) resort to interaction/stimulation strategies to enhance the persons' sensory input or (b) establish the use of microswitches (Favell, Realon, & Sutton, 1996; Felce & Perry, 1995; Green & Reid, 1996, 1999a; Lancioni et al., 2002b). Microswitches are tools that persons can use on their own to activate sources of stimulation, thus improving their sense of control and their level of input (Kinsley & Langone, 1995; Lancioni et al., 2001a; Langley, 1990; Sullivan & Lewis, 1993). Data reported in studies adopting systematic stimulation strategies have indicated that this approach can have a positive impact on the participants' general mood (indices of happiness) (Favell et al., 1996; Green, Gardner, & Reid, 1997; Green & Reid, 1996, 1999a, 1999b). Recent research evidence suggests that microswitch-based programs also may have similarly bene®cial effects on the persons' mood (Lancioni et al., 2002a). The use of interaction/stimulation may be seen as an opportunity to promote periods of personal, positive relationship between staff or parents and participants. The use of microswitches may be seen as an opportunity to help participants develop speci®c responses that they can use independently to control their stimulation level and reduce their passivity (Crawford & Schuster, 1993). The high value attributed to participants' independent responding and stimulation control, together with an increasing availability and economical accessibility of technological resources, have recently motivated new research initiatives concerning the use of microswitches (Lancioni & Lems, 2001; Lancioni, O'Reilly, Oliva, & Coppa, 2001b, 2001c; Lancioni et al., 2002b; Saunders et al., 2001). This research has shown successful establishment of multiple microswitches for multiple responses or novel microswitches for special responses such as vocalization. While research data suggest that microswitches can be very important resources within programs for persons with multiple disabilities, no attempts have so far been reported to check the social validity (i.e., relevance and suitability/acceptability) of such resources for individuals who are or will be in charge of these programs (e.g., rehabilitation personnel and teacher-assistant trainees). Yet, determining the view of these essential individuals about the microswitches as opposed to interaction/stimulation strategies would help one draw a more systematic picture of those devices' potential and applicability in daily contexts (cf. Ezell, Kohler, Jarzynka, & Strain, 1992; Kazdin, 1980; McDonnell & Sturmey, 2000; Quinn, Sherman, Sheldon, Quinn, & Harchik, 1992; Storey, 1996). 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 special education, teacher-assistant trainees were shown video-tapes reporting the use of microswitches versus interaction situations for six children. They rated both the microswitch and
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interaction conditions on a 7-item questionnaire covering social/emotional and practical aspects. In Part II, 40 teacher-assistant trainees or classroom aides and 44 rehabilitation staff (teachers and physiotherapists) were presented with video-tapes showing the use of microswitches versus systematic stimulation strategies for four adults. They rated both these situations on the aforementioned questionnaire. 2. Part I 2.1. Method 2.1.1. Raters The 32 teacher-assistant trainees (28 females and 4 males) serving as raters were enrolled in a program on special education issues. They were between 23 and 45 (M 30) years of age. While they were familiar with educational issues concerning people with intellectual and multiple disabilities, they usually had limited work experience. None of them had any direct experience with the use of microswitches or previous contact with the children shown in the video-tapes. 2.1.2. Children, video-tapes, and parents' consent The six children shown in the video-tapes (®ve boys and one girl) were 7.1± 13.5 (M 10:5) years old. All of them suffered from severe cerebropathy with multiple physical disabilities that reduced their body control and prevented any ambulation or self-help skills. They had no speech, presented moderate to profound visual or auditory impairments and were rated in the profound range of intellectual disability (see also Lancioni et al., 2001c, 2002b). Four video-tapes were used. The ®rst video-tape showed three of the children who had been taught to use multiple microswitches for multiple responses (e.g., a throat-microphone device for vocalization, a pressure-bar for hand-pushing, and push-buttons for head movements). For each child, there were two clips of 4 min. One clip concerned the central part of a session with microswitches (in which the child's activation of microswitches produced brief periods of stimulation such as lights and music; cf. Lancioni et al., 2001c). The other clip concerned the central part of an interaction period with a caregiver. During the interaction period, the caregiver tried to have the child alert and responsive by talking and presenting various stimuli, and stroking the child's face and hands. The sessions/interactions were randomly chosen from groups of four recorded during a speci®c treatment or assessment week. The order of the interaction and microswitch clips varied across children. The second video-tape reported clips concerning the other three children (two had been taught to use multiple microswitches, and one a single microswitch). The clips corresponded to those described for the ®rst three children. The third video-tape included the same clips used in the ®rst, but the children's sequence and clips' order varied. The fourth video-tape included the same clips used for the second, but the children's sequence and clips' order varied.
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The parents of the six children reported in the video-tapes were informed about the aim of the study, and asked for their formal consent to show the video-tapes. All parents gave their consent. 2.1.3. Procedure and questionnaire The 32 raters were divided into four groups of 8. Each group watched one of the four video-tapes. Before watching it, they were told that they (a) would see different children in two different educational situations (one involving the interaction with a caregiver and the other involving the use of microswitches the activation of which produced brief periods of stimulation), and (b) would have to rate these situations on a 7-item questionnaire. This covered social/ emotional and practical aspects (see Table 1). After watching the two clips of the ®rst child shown in the video-tape, they were asked to complete the questionnaire. For each item, two scores were provided (one for each of the clips). The scores could vary between 1 and 5 (which indicated least and most positive values, respectively). Subsequently, they watched the clips of the second child included in the video-tape and completed a second copy of the questionnaire. Finally, they watched the clips of the third child and completed a third copy of the questionnaire. Each child had 16 copies of the questionnaire completed by 16 raters (i.e., those watching the ®rst and third video-tapes or those watching the second and fourth video-tapes). 2.2. Results Fig. 1 summarizes the raters' scores for the six children as a group. The bars indicate the raters' median scores for the microswitch and interaction conditions across the seven items. The vertical lines indicate the ranges of the scores falling between the 10 and 90th percentiles. Median scores were higher for the microswitch condition on the ®rst, second, fourth, ®fth and seventh items, while they were equal or lower on the other two items. The ranges were narrower for the microswitch condition on the ®rst ®ve items. A Wilcoxon matched-pairs signedranks test was applied to the raters' microswitch and interaction scores of each item, for the six children as a group. The test showed two-tailed signi®cant differences (p < :01) on the ®rst ®ve items and the seventh item, all favoring the microswitch condition (Siegel & Castellan, 1988). Table 1 Questionnaire items Do you think that Do you think that Do you think that Do you think that Do you think that Do you think that How much would
the child ®nds the interaction and microswitch situations pleasant? the child can bene®t from those situations? caregivers and parents ®nd those situations pleasant? those situations have practical bene®ts for parents and caregivers? those situations represent forms of rehabilitation? those situations could be transferred to a home context? you like to be involved in those situations?
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Fig. 1. Data of the 32 raters of Part I. Gray and dotted bars indicate the raters' median scores for the microswitch and interaction conditions across the seven items of the questionnaire. The vertical lines indicate the ranges of the scores falling between the 10 and 90th percentiles.
3. Part II 3.1. Method 3.1.1. Raters A total of 84 raters participated. Forty of them (29 females and 11 males) were teacher-assistant trainees or classroom aides. They were between 22 and 44 (M 31) years of age, had limited experience with intervention strategies and no previous experience with the use of microswitches. The other 44 raters (all females) were rehabilitation staff working in an educational center for people with profound and multiple disabilities (the same that the adults shown in the videotapes attended). They were between 24 and 50 (M 35) years of age and had experience with a variety of intervention strategies. However, they did not have speci®cally direct involvement with the use of microswitches and systematic stimulation procedures, or the adults that they were to rate. 3.1.2. Adults, video-tapes, and parents' consent The four adults shown in the video-tapes (two men and two women) were 24± 46 (M 32) years old. They were in the profound range of mental retardation, were con®ned to wheelchairs, and used medication for various neurological conditions. Two of them were totally blind with normal hearing and two were totally blind and deaf. Three of them had been taught to use two microswitches, and one used a single microswitch. Microswitch activations were followed by brief periods of favorite stimulation. All four were also familiar with stimulation sessions (i.e., sessions in which favorite stimuli were presented to them in a rotation fashion; cf. Green & Reid, 1996; Lancioni et al., 2002a). Four video-tapes were available, one for each of the adults. Each video-tape included eight clips of microswitch sessions and eight clips of stimulation sessions. The clips represented central (1.5 min) portions of parallel 10 min
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sessions with the two conditions (i.e., the ®nal sessions of a treatment period). The order of the 16 clips available within each video-tape varied with the restriction that no more than two clips of the same (microswitch or stimulation) condition would occur successively. Parents' consent was obtained as in Part I. 3.1.3. Procedure and questionnaire The aforementioned groups of 40 trainees/aides and 44 rehabilitation staff were divided into four subgroups of 10 and 11 members, respectively. Each subgroup watched one of the video-tapes (one adult). Prior to this, they were introduced to their task with statements such as those used for the raters of Part I. After watching the video-tape, they completed the 7-item questionnaire, in which the words ``child'' and ``interaction'' had been appropriately replaced. 3.2. Results Figs. 2 and 3 summarize the trainees/aides' scores and the rehabilitation staff's scores for the four adults as a group. In each ®gure, the bars indicate the raters'
Fig. 2. Data of the 40 trainees/aides of Part II. Data are plotted as in Fig. 1.
Fig. 3. Data of the 44 rehabilitation staff of Part II. Data are plotted as in Fig. 1.
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median scores for the microswitch and stimulation conditions on the single items. The vertical lines indicate the ranges of the scores falling between the 10 and 90th percentiles. Higher median scores for the microswitch condition were reported on the ®rst, second, third and seventh items (trainees/aides) and on all items except the sixth (rehabilitation staff). The ranges tended to be narrower for the microswitch condition (see ®rst ®ve items). A Wilcoxon matched-pairs signed-ranks test was applied to the trainees/aides' scores and the rehabilitation staff's scores. It showed two-tailed signi®cant differences (p < :05) favoring the microswitch condition on six items (the ®rst ®ve and the seventh) and on all seven items, respectively. 4. Discussion The results of Part I of the study showed that the 32 teacher-assistant trainees viewed the microswitch condition as generally more positive than or comparable to the interaction condition for the six children involved in the evaluation. The results of Part II showed that the trainees/aides and the rehabilitation staff tended to score the microswitch condition as better than or as good as the stimulation condition for the four adults involved in the evaluation. The median scores for the microswitch condition tended to be relatively high across items. In general, this could be taken to indicate that the microswitch condition was considered by most raters a fairly positive and relatively acceptable solution for persons with multiple disabilities. The very strong agreement among the three groups of raters on the ®rst two items of the questionnaire indicate that they perceived the persons as being (a) more pleased (happier) with the use of microswitches and also (b) more likely to obtain signi®cant bene®ts from using those devices compared to receiving interaction/stimulation conditions (cf. PelaÂez-Nogueras et al., 1997; Sullivan, Laverick, & Lewis, 1995). How the raters decided about these scores, it is not known. One might argue that forms of independent responding (self-determination) and stimulation control are aspects that can easily be associated to a more pleasant condition (cf. Cosden, Gannon, & Haring, 1995; Kern et al., 1998). Similarly, learning and exercise of independent responding (control) may be deemed developmentally relevant (Kinsley & Langone, 1995; Lancioni et al., 2001a). The ratings of the ®fth and seventh items seemed to suggest that (a) the use of microswitches can be seen as part of a rehabilitation effort more easily than the interaction/stimulation strategies, and (b) raters would prefer to be involved in implementing microswitch-based programs rather than in carrying out interaction/ stimulation strategies. With regard to the latter point, the third group of raters (rehabilitation staff) seemed to be less enthusiastic than the other two groups. It might be that they were more aware of the dif®culties of working with these persons or that they were considering the possible dif®culties one can encounter in establishing microswitches, maintaining their effectiveness over time, and ensuring their good technical functioning (cf. Green & Reid, 1994; Lancioni et al., 2001a).
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The ratings of the sixth item appeared to draw a dividing line between groups of raters (only the last group had a statistically signi®cant difference between the scores given to the two conditions). Predominantly, the ratings seemed to show some caution as to the possibility of transferring the microswitches and the other conditions into the home contexts. Whether this caution was due to the fact that the conditions presented aspects deemed dif®cult for parents to handle (e.g., manipulation of technology and need of time investments) or to other considerations is not known. In view of the ®ndings and the above discussion, one could underline four main points. First, the ®ndings as a whole appear quite supportive of the use of microswitches compared to interaction/stimulation conditions with children and adults with multiple disabilities. The value of these data can be considered quite relevant from a practical standpoint (cf. McDonnell & Sturmey, 2000; Wolf, 1978). Second, variations among raters on the sixth and seventh items might easily re¯ect different perceptions of the dif®culties related to establishing and maintaining the microswitches in the rehabilitation context and at home. Such perceptions may be based on different levels of knowledge (con®dence) about these devices and different expectations with regard to external support and supervision. For example, people would probably ®nd microswitches much more readily acceptable if told that these were established within a carefully supervised program that ensured successful outcome and consistent technical support (Green & Reid, 1994; Lancioni et al., 2001a, 2002b). Third, the reported social validation assessment would be greatly enhanced if it also involved the view of parents and other family members. These people would provide an important, direct contribution on determining whether the microswitch and interaction/stimulation conditions could be considered equally pleasant for the participants, enjoyable for parents and caregivers to watch, and realistically applicable in the home context (cf. Elliott, 1988; Quinn et al., 1992; Storey, 1996; Wolf, 1978). Fourth, future research in this area may need to expand the questionnaire in terms of items included as well as in terms of the reasoning underlining the scoring. Such an expansion would allow one to gather wider and more relevant information about raters' opinions and related motives. References Cosden, M., Gannon, C., & Haring, T. G. (1995). Teacher control versus student control over choice of task and reinforcement for students with severe behavior problems. Journal of Behavioral Education, 5, 11±27. Crawford, M. R., & Schuster, J. W. (1993). Using microswitches to teach toy use. Journal of Developmental and Physical Disabilities, 5, 349±368. Elliott, S. N. (1988). Acceptability of behavioral treatments: Review of variables that influence treatment selection. Professional Psychology: Research and Practice, 19, 68±80. Ezell, H. K., Kohler, F. W., Jarzynka, M., & Strain, P. S. (1992). Use of peer-assisted procedures to teach QAR reading comprehension strategies to third-grade children. Education and Treatment of Children, 15, 204±227.
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Favell, J. A., Realon, R. E., & Sutton, K. A. (1996). Measuring and increasing the happiness of people with profound mental retardation and physical handicaps. Behavioral Interventions, 11, 47±58. Felce, D., & Perry, J. (1995). Quality of life: Its definition and measurement. Research in Developmental Disabilities, 16, 51±74. Green, C. W., Gardner, S. M., & Reid, D. H. (1997). Increasing indices of happiness among people with profound multiple disabilities: A program replication and component analysis. Journal of Applied Behavior Analysis, 30, 217±228. Green, C. W., & Reid, D. H. (1994). A comprehensive evaluation of a train-the-trainers model for training education staff to assemble adaptive switches. Journal of Developmental and Physical Disabilities, 6, 219±238. Green, C. W., & Reid, D. H. (1996). Defining, validating, and increasing indices of happiness among people with profound multiple disabilities. Journal of Applied Behavior Analysis, 29, 67±78. Green, C. W., & Reid, D. H. (1999a). A behavioral approach to identifying sources of happiness and unhappiness among individuals with profound multiple disabilities. Behavior Modification, 23, 280±293. Green, C. W., & Reid, D. H. (1999b). Reducing indices of unhappiness among individuals with profound multiple disabilities during therapeutic exercise routines. Journal of Applied Behavior Analysis, 32, 137±147. Gutowski, S. J. (1996). Response acquisition for music or beverages in adults with profound multiple handicaps. Journal of Developmental and Physical Disabilities, 8, 221±231. Ivancic, M. T., & Bailey, J. S. (1996). Current limits to reinforcer identification for some persons with profound multiple disabilities. Research in Developmental Disabilities, 17, 77±92. Kazdin, A. E. (1980). Acceptability of time out from reinforcement procedures for disruptive child behavior. Behavior Therapy, 11, 329±344. Kern, L., Vorndran, C. M., Hilt, A., Ringdahl, J. E., Adelman, B. E., & Dunlap, G. (1998). Choice as an intervention to improve behavior: A review of the literature. Journal of Behavioral Education, 8, 151±169. Kinsley, T. C., & Langone, J. (1995). Applications of technology for infants, toddlers, and preschoolers with disabilities. Journal of Special Education Technology, 12, 312±324. Ko, M. L. B., McConachie, H., & Jolleff, N. (1998). Outcome of recommendations for augmentative communication in children. Child: Care, Health and Development, 24, 195±205. Lancioni, G. E., & Lems, S. (2001). Using a microswitch for vocalization responses with persons with multiple disabilities. Disability and Rehabilitation, 23, 745±748. Lancioni, G. E., O'Reilly, M. F., & Basili, G. (2001a). Use of microswitches and speech output systems with people with severe/profound intellectual or multiple disabilities: A literature review. Research in Developmental Disabilities, 22, 21±40. Lancioni, G. E., O'Reilly, F. M., Oliva, D., & Coppa, M. M. (2001b). A microswitch for vocalization responses to foster environmental control in children with multiple disabilities. Journal of Intellectual Disability Research, 45, 271±275. Lancioni, G. E., O'Reilly, F. M., Oliva, D., & Coppa, M. M. (2001c). Using multiple microswitches to promote different responses in children with multiple disabilities. Research in Developmental Disabilities, 22, 309±318. Lancioni, G. E., O'Reilly, M. F., Singh, N. N., Oliva, D., & Groeneweg, J. (2002a). Impact of stimulation versus microswitch-based programs on indices of happiness of people with profound multiple disabilities. Research in Developmental Disabilities, 23, 149±160. Lancioni, G. E., O'Reilly, M. F., Singh, N. N., Oliva, D., Piazzolla, G., Pirani, P., & Groeneweg, J. (2002b). Evaluating the use of multiple microswitches and responses for children with multiple disabilities. Journal of Intellectual Disability Research, 46, 346±351. Langley, M. B. (1990). A developmental approach to the use of toys for facilitation of environmental control. Physical and Occupational Therapy in Pediatrics, 10, 69±91. McDonnell, A. A., & Sturmey, P. (2000). The social validation of three physical restraint procedures: A comparison of young people and professional groups. Research in Developmental Disabilities, 21, 85±92.
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Mount, H., & Cavet, J. (1995). Multi-sensory environments: An exploration of their potential for young people with profound and multiple learning difficulties. British Journal of Special Education, 22, 52±55. PelaÂez-Nogueras, M., Field, T., Gewirtz, J. L., Gigales, M., Gonzalez, A., Sanchez, A., & Richardson, S. C. (1997). The effects of systematic stroking versus tickling and poking on infant behavior. Journal of Applied Developmental Psychology, 18, 169±178. Quinn, J. M., Sherman, J. A., Sheldon, J. B., Quinn, L. M., & Harchik, A. E. (1992). Social validation of component behaviors of following instructions, accepting criticism, and negotiating. Journal of Applied Behavior Analysis, 25, 401±413. Reid, D. H., Phillips, J. F., & Green, C. W. (1991). Teaching persons with profound multiple handicaps: A review of the effects of behavioral research. Journal of Applied Behavior Analysis, 24, 319±336. Saunders, M. D., Questad, K. A., Kedziorski, T. L., Boase, B. C., Patterson, E. A., & Cullinan, T. B. (2001). Unprompted mechanical switch use in individuals with severe multiple disabilities: An evaluation of the effects of body position. Journal of Developmental and Physical Disabilities, 13, 27±39. Siegel, S., & Castellan, N. J. (1988). Nonparametric statistics (2nd ed.). New York: McGraw-Hill. Storey, K. (1996). Social validation issues in social skills assessment. International Journal of Disability, Development and Education, 43, 167±174. Sullivan, M. W., Laverick, D. H., & Lewis, M. (1995). Fostering environmental control in a young child with Rett syndrome: A case study. Journal of Autism and Developmental Disorders, 25, 215±221. Sullivan, M. W., & Lewis, M. (1993). Contingency, means-end skills, and the use of technology in infant intervention. Infants and Young Children, 5, 58±77. Wolf, M. M. (1978). Social validity: The case for subjective measurement or how applied behavior analysis is finding its heart. Journal of Applied Behavior Analysis, 11, 203±214.
A social validation assessment of the use of microswitches with persons with multiple disabilities Giulio E. Lancionia,*, Mark F. O'Reillyb, Nirbhay N. Singhc, Doretta Olivad, Monia Marzianid, Jop Groenewega a
Department of Psychology, University of Leiden, Wassenaarseweg 52, 2333 AK Leiden, The Netherlands b University College Dublin, Dublin, Ireland c Virginia Commonwealth University, Richmond, VA, USA d Lega F. D'Oro Research Center, Osimo (AN), Italy
Received 27 November 2001; received in revised form 17 April 2002; accepted 24 April 2002
Abstract 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 teacherassistant trainees or classroom aides and 44 rehabilitation staff were presented with videotapes 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 ®ndings and their implications are discussed. # 2002 Elsevier Science Ltd. All rights reserved. Keywords: microswitches; multiple disabilities; social validation; stimulation
1. Introduction Persons with severe and profound multiple disabilities often experience highly reduced sensory input, minimal mobility, and very limited social interaction with *
Corresponding author. Tel.: 31-71-527-3681; fax: 31-71-527-3619. E-mail address: [email protected] (G.E. Lancioni).
0891-4222/02/$ ± see front matter # 2002 Elsevier Science Ltd. All rights reserved. PII: S 0 8 9 1 - 4 2 2 2 ( 0 2 ) 0 0 1 3 8 - 5
310
G.E. Lancioni et al. / Research in Developmental Disabilities 23 (2002) 309±318
the environment (Gutowski, 1996; Lancioni, O'Reilly, & Basili, 2001a; Reid, Phillips, & Green, 1991). The complexity of their situation makes it impossible for staff to use conventional treatment procedures to help them develop speci®c adaptive skills (Ivancic & Bailey, 1996; Ko, McConachie, & Jolleff, 1998; Lancioni, O'Reilly, Singh, Oliva, & Groeneweg, 2002a; Mount & Cavet, 1995). Staff may (a) resort to interaction/stimulation strategies to enhance the persons' sensory input or (b) establish the use of microswitches (Favell, Realon, & Sutton, 1996; Felce & Perry, 1995; Green & Reid, 1996, 1999a; Lancioni et al., 2002b). Microswitches are tools that persons can use on their own to activate sources of stimulation, thus improving their sense of control and their level of input (Kinsley & Langone, 1995; Lancioni et al., 2001a; Langley, 1990; Sullivan & Lewis, 1993). Data reported in studies adopting systematic stimulation strategies have indicated that this approach can have a positive impact on the participants' general mood (indices of happiness) (Favell et al., 1996; Green, Gardner, & Reid, 1997; Green & Reid, 1996, 1999a, 1999b). Recent research evidence suggests that microswitch-based programs also may have similarly bene®cial effects on the persons' mood (Lancioni et al., 2002a). The use of interaction/stimulation may be seen as an opportunity to promote periods of personal, positive relationship between staff or parents and participants. The use of microswitches may be seen as an opportunity to help participants develop speci®c responses that they can use independently to control their stimulation level and reduce their passivity (Crawford & Schuster, 1993). The high value attributed to participants' independent responding and stimulation control, together with an increasing availability and economical accessibility of technological resources, have recently motivated new research initiatives concerning the use of microswitches (Lancioni & Lems, 2001; Lancioni, O'Reilly, Oliva, & Coppa, 2001b, 2001c; Lancioni et al., 2002b; Saunders et al., 2001). This research has shown successful establishment of multiple microswitches for multiple responses or novel microswitches for special responses such as vocalization. While research data suggest that microswitches can be very important resources within programs for persons with multiple disabilities, no attempts have so far been reported to check the social validity (i.e., relevance and suitability/acceptability) of such resources for individuals who are or will be in charge of these programs (e.g., rehabilitation personnel and teacher-assistant trainees). Yet, determining the view of these essential individuals about the microswitches as opposed to interaction/stimulation strategies would help one draw a more systematic picture of those devices' potential and applicability in daily contexts (cf. Ezell, Kohler, Jarzynka, & Strain, 1992; Kazdin, 1980; McDonnell & Sturmey, 2000; Quinn, Sherman, Sheldon, Quinn, & Harchik, 1992; Storey, 1996). 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 special education, teacher-assistant trainees were shown video-tapes reporting the use of microswitches versus interaction situations for six children. They rated both the microswitch and
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interaction conditions on a 7-item questionnaire covering social/emotional and practical aspects. In Part II, 40 teacher-assistant trainees or classroom aides and 44 rehabilitation staff (teachers and physiotherapists) were presented with video-tapes showing the use of microswitches versus systematic stimulation strategies for four adults. They rated both these situations on the aforementioned questionnaire. 2. Part I 2.1. Method 2.1.1. Raters The 32 teacher-assistant trainees (28 females and 4 males) serving as raters were enrolled in a program on special education issues. They were between 23 and 45 (M 30) years of age. While they were familiar with educational issues concerning people with intellectual and multiple disabilities, they usually had limited work experience. None of them had any direct experience with the use of microswitches or previous contact with the children shown in the video-tapes. 2.1.2. Children, video-tapes, and parents' consent The six children shown in the video-tapes (®ve boys and one girl) were 7.1± 13.5 (M 10:5) years old. All of them suffered from severe cerebropathy with multiple physical disabilities that reduced their body control and prevented any ambulation or self-help skills. They had no speech, presented moderate to profound visual or auditory impairments and were rated in the profound range of intellectual disability (see also Lancioni et al., 2001c, 2002b). Four video-tapes were used. The ®rst video-tape showed three of the children who had been taught to use multiple microswitches for multiple responses (e.g., a throat-microphone device for vocalization, a pressure-bar for hand-pushing, and push-buttons for head movements). For each child, there were two clips of 4 min. One clip concerned the central part of a session with microswitches (in which the child's activation of microswitches produced brief periods of stimulation such as lights and music; cf. Lancioni et al., 2001c). The other clip concerned the central part of an interaction period with a caregiver. During the interaction period, the caregiver tried to have the child alert and responsive by talking and presenting various stimuli, and stroking the child's face and hands. The sessions/interactions were randomly chosen from groups of four recorded during a speci®c treatment or assessment week. The order of the interaction and microswitch clips varied across children. The second video-tape reported clips concerning the other three children (two had been taught to use multiple microswitches, and one a single microswitch). The clips corresponded to those described for the ®rst three children. The third video-tape included the same clips used in the ®rst, but the children's sequence and clips' order varied. The fourth video-tape included the same clips used for the second, but the children's sequence and clips' order varied.
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The parents of the six children reported in the video-tapes were informed about the aim of the study, and asked for their formal consent to show the video-tapes. All parents gave their consent. 2.1.3. Procedure and questionnaire The 32 raters were divided into four groups of 8. Each group watched one of the four video-tapes. Before watching it, they were told that they (a) would see different children in two different educational situations (one involving the interaction with a caregiver and the other involving the use of microswitches the activation of which produced brief periods of stimulation), and (b) would have to rate these situations on a 7-item questionnaire. This covered social/ emotional and practical aspects (see Table 1). After watching the two clips of the ®rst child shown in the video-tape, they were asked to complete the questionnaire. For each item, two scores were provided (one for each of the clips). The scores could vary between 1 and 5 (which indicated least and most positive values, respectively). Subsequently, they watched the clips of the second child included in the video-tape and completed a second copy of the questionnaire. Finally, they watched the clips of the third child and completed a third copy of the questionnaire. Each child had 16 copies of the questionnaire completed by 16 raters (i.e., those watching the ®rst and third video-tapes or those watching the second and fourth video-tapes). 2.2. Results Fig. 1 summarizes the raters' scores for the six children as a group. The bars indicate the raters' median scores for the microswitch and interaction conditions across the seven items. The vertical lines indicate the ranges of the scores falling between the 10 and 90th percentiles. Median scores were higher for the microswitch condition on the ®rst, second, fourth, ®fth and seventh items, while they were equal or lower on the other two items. The ranges were narrower for the microswitch condition on the ®rst ®ve items. A Wilcoxon matched-pairs signedranks test was applied to the raters' microswitch and interaction scores of each item, for the six children as a group. The test showed two-tailed signi®cant differences (p < :01) on the ®rst ®ve items and the seventh item, all favoring the microswitch condition (Siegel & Castellan, 1988). Table 1 Questionnaire items Do you think that Do you think that Do you think that Do you think that Do you think that Do you think that How much would
the child ®nds the interaction and microswitch situations pleasant? the child can bene®t from those situations? caregivers and parents ®nd those situations pleasant? those situations have practical bene®ts for parents and caregivers? those situations represent forms of rehabilitation? those situations could be transferred to a home context? you like to be involved in those situations?
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Fig. 1. Data of the 32 raters of Part I. Gray and dotted bars indicate the raters' median scores for the microswitch and interaction conditions across the seven items of the questionnaire. The vertical lines indicate the ranges of the scores falling between the 10 and 90th percentiles.
3. Part II 3.1. Method 3.1.1. Raters A total of 84 raters participated. Forty of them (29 females and 11 males) were teacher-assistant trainees or classroom aides. They were between 22 and 44 (M 31) years of age, had limited experience with intervention strategies and no previous experience with the use of microswitches. The other 44 raters (all females) were rehabilitation staff working in an educational center for people with profound and multiple disabilities (the same that the adults shown in the videotapes attended). They were between 24 and 50 (M 35) years of age and had experience with a variety of intervention strategies. However, they did not have speci®cally direct involvement with the use of microswitches and systematic stimulation procedures, or the adults that they were to rate. 3.1.2. Adults, video-tapes, and parents' consent The four adults shown in the video-tapes (two men and two women) were 24± 46 (M 32) years old. They were in the profound range of mental retardation, were con®ned to wheelchairs, and used medication for various neurological conditions. Two of them were totally blind with normal hearing and two were totally blind and deaf. Three of them had been taught to use two microswitches, and one used a single microswitch. Microswitch activations were followed by brief periods of favorite stimulation. All four were also familiar with stimulation sessions (i.e., sessions in which favorite stimuli were presented to them in a rotation fashion; cf. Green & Reid, 1996; Lancioni et al., 2002a). Four video-tapes were available, one for each of the adults. Each video-tape included eight clips of microswitch sessions and eight clips of stimulation sessions. The clips represented central (1.5 min) portions of parallel 10 min
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sessions with the two conditions (i.e., the ®nal sessions of a treatment period). The order of the 16 clips available within each video-tape varied with the restriction that no more than two clips of the same (microswitch or stimulation) condition would occur successively. Parents' consent was obtained as in Part I. 3.1.3. Procedure and questionnaire The aforementioned groups of 40 trainees/aides and 44 rehabilitation staff were divided into four subgroups of 10 and 11 members, respectively. Each subgroup watched one of the video-tapes (one adult). Prior to this, they were introduced to their task with statements such as those used for the raters of Part I. After watching the video-tape, they completed the 7-item questionnaire, in which the words ``child'' and ``interaction'' had been appropriately replaced. 3.2. Results Figs. 2 and 3 summarize the trainees/aides' scores and the rehabilitation staff's scores for the four adults as a group. In each ®gure, the bars indicate the raters'
Fig. 2. Data of the 40 trainees/aides of Part II. Data are plotted as in Fig. 1.
Fig. 3. Data of the 44 rehabilitation staff of Part II. Data are plotted as in Fig. 1.
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median scores for the microswitch and stimulation conditions on the single items. The vertical lines indicate the ranges of the scores falling between the 10 and 90th percentiles. Higher median scores for the microswitch condition were reported on the ®rst, second, third and seventh items (trainees/aides) and on all items except the sixth (rehabilitation staff). The ranges tended to be narrower for the microswitch condition (see ®rst ®ve items). A Wilcoxon matched-pairs signed-ranks test was applied to the trainees/aides' scores and the rehabilitation staff's scores. It showed two-tailed signi®cant differences (p < :05) favoring the microswitch condition on six items (the ®rst ®ve and the seventh) and on all seven items, respectively. 4. Discussion The results of Part I of the study showed that the 32 teacher-assistant trainees viewed the microswitch condition as generally more positive than or comparable to the interaction condition for the six children involved in the evaluation. The results of Part II showed that the trainees/aides and the rehabilitation staff tended to score the microswitch condition as better than or as good as the stimulation condition for the four adults involved in the evaluation. The median scores for the microswitch condition tended to be relatively high across items. In general, this could be taken to indicate that the microswitch condition was considered by most raters a fairly positive and relatively acceptable solution for persons with multiple disabilities. The very strong agreement among the three groups of raters on the ®rst two items of the questionnaire indicate that they perceived the persons as being (a) more pleased (happier) with the use of microswitches and also (b) more likely to obtain signi®cant bene®ts from using those devices compared to receiving interaction/stimulation conditions (cf. PelaÂez-Nogueras et al., 1997; Sullivan, Laverick, & Lewis, 1995). How the raters decided about these scores, it is not known. One might argue that forms of independent responding (self-determination) and stimulation control are aspects that can easily be associated to a more pleasant condition (cf. Cosden, Gannon, & Haring, 1995; Kern et al., 1998). Similarly, learning and exercise of independent responding (control) may be deemed developmentally relevant (Kinsley & Langone, 1995; Lancioni et al., 2001a). The ratings of the ®fth and seventh items seemed to suggest that (a) the use of microswitches can be seen as part of a rehabilitation effort more easily than the interaction/stimulation strategies, and (b) raters would prefer to be involved in implementing microswitch-based programs rather than in carrying out interaction/ stimulation strategies. With regard to the latter point, the third group of raters (rehabilitation staff) seemed to be less enthusiastic than the other two groups. It might be that they were more aware of the dif®culties of working with these persons or that they were considering the possible dif®culties one can encounter in establishing microswitches, maintaining their effectiveness over time, and ensuring their good technical functioning (cf. Green & Reid, 1994; Lancioni et al., 2001a).
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The ratings of the sixth item appeared to draw a dividing line between groups of raters (only the last group had a statistically signi®cant difference between the scores given to the two conditions). Predominantly, the ratings seemed to show some caution as to the possibility of transferring the microswitches and the other conditions into the home contexts. Whether this caution was due to the fact that the conditions presented aspects deemed dif®cult for parents to handle (e.g., manipulation of technology and need of time investments) or to other considerations is not known. In view of the ®ndings and the above discussion, one could underline four main points. First, the ®ndings as a whole appear quite supportive of the use of microswitches compared to interaction/stimulation conditions with children and adults with multiple disabilities. The value of these data can be considered quite relevant from a practical standpoint (cf. McDonnell & Sturmey, 2000; Wolf, 1978). Second, variations among raters on the sixth and seventh items might easily re¯ect different perceptions of the dif®culties related to establishing and maintaining the microswitches in the rehabilitation context and at home. Such perceptions may be based on different levels of knowledge (con®dence) about these devices and different expectations with regard to external support and supervision. For example, people would probably ®nd microswitches much more readily acceptable if told that these were established within a carefully supervised program that ensured successful outcome and consistent technical support (Green & Reid, 1994; Lancioni et al., 2001a, 2002b). Third, the reported social validation assessment would be greatly enhanced if it also involved the view of parents and other family members. These people would provide an important, direct contribution on determining whether the microswitch and interaction/stimulation conditions could be considered equally pleasant for the participants, enjoyable for parents and caregivers to watch, and realistically applicable in the home context (cf. Elliott, 1988; Quinn et al., 1992; Storey, 1996; Wolf, 1978). Fourth, future research in this area may need to expand the questionnaire in terms of items included as well as in terms of the reasoning underlining the scoring. Such an expansion would allow one to gather wider and more relevant information about raters' opinions and related motives. References Cosden, M., Gannon, C., & Haring, T. G. (1995). Teacher control versus student control over choice of task and reinforcement for students with severe behavior problems. Journal of Behavioral Education, 5, 11±27. Crawford, M. R., & Schuster, J. W. (1993). Using microswitches to teach toy use. Journal of Developmental and Physical Disabilities, 5, 349±368. Elliott, S. N. (1988). Acceptability of behavioral treatments: Review of variables that influence treatment selection. Professional Psychology: Research and Practice, 19, 68±80. Ezell, H. K., Kohler, F. W., Jarzynka, M., & Strain, P. S. (1992). Use of peer-assisted procedures to teach QAR reading comprehension strategies to third-grade children. Education and Treatment of Children, 15, 204±227.
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