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A microswitch-cluster program to foster adaptive responses and head control in students with multiple disabilities: Replication and validation assessment
Research in Developmental Disabilities 29 (2008) 373–384
A microswitch-cluster program to foster adaptive responses and head control in students with multiple disabilities: Replication and validation assessment Giulio E. Lancioni a,*, Nirbhay N. Singh b, Mark F. O’Reilly c, Jeff Sigafoos d, Doretta Oliva e, Michela Gatti e, Francesco Manfredi a, Gianfranco Megna a, Maria L. La Martire a, Alessia Tota a, Angela Smaldone a, Jop Groeneweg f a University of Bari, Italy ONE Research Institute, United States c University of Texas at Austin, United States d University of Tasmania, Australia e Lega F. D’Oro Research Center, Italy f University of Leiden, The Netherlands b
Received 25 June 2007; accepted 28 June 2007
Abstract A program relying on microswitch clusters (i.e., combinations of microswitches) and preferred stimuli was recently developed to foster adaptive responses and head control in persons with multiple disabilities. In the last version of this program, preferred stimuli (a) are scheduled for adaptive responses occurring in combination with head control (i.e., head upright) and (b) last through the scheduled time only if head control is maintained for that time. The first of the present two studies was aimed at replicating this program with three new participants with multiple disabilities adding to the three reported by Lancioni et al. [Lancioni, G. E., Singh, N. N., O’Reilly, M. F., Sigafoos, J., Didden, R., Oliva, D., et al. (2007). Fostering adaptive responses and head control in students with multiple disabilities through a microswitch-based program: Follow-up assessment and program revision. Research in Developmental Disabilities, 28, 187–196]. The second of the two studies served to carry out an expert validation of the program’s effects on head control and general physical condition with the three participants of Study I as well as the three participants involved in the Lancioni et al. study mentioned above. The expert raters were 72 new physiotherapists and 72 experienced physiotherapists. The results of Study I supported previous data and indicated that the program was effective in helping the
* Corresponding author at: Department of Psychology, University of Bari, Via Quintino Sella 268, 70100 Bari, Italy. E-mail address: [email protected] (G.E. Lancioni). 0891-4222/$ – see front matter # 2007 Elsevier Ltd. All rights reserved. doi:10.1016/j.ridd.2007.06.007
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participants increase the frequency of adaptive responses in combination with head control and the length of such control. The results of Study II showed that the raters found the effects of the new program more positive than those of other intervention conditions and also considered such program a useful complement to formal motor rehabilitation programs. # 2007 Elsevier Ltd. All rights reserved. Keywords: Microswitch clusters; Adaptive responses; Head control; Multiple disabilities; Expert validation
1. Introduction Posture improvement is a clearly relevant objective for students who tend to have inappropriate body positions (e.g., head forward tilting) as well as dystonic/uncontrolled movements (Nwaobi & Smith, 1986; Redstone & West, 2004). Such improvement can have positive implications from a social and adaptive standpoint (facilitating acceptance and care) and also in terms of physical condition and well being (facilitating basic functions such as breathing) (Larnert & Ekberg, 1995; Myhr, von Wendt, Norrlin, & Radell, 1995; Redstone, 2004; Redstone & West, 2004). Recently, studies were directed at improving head position within an active context (i.e., in combination with adaptive/constructive responding) (Lancioni et al., 2004, 2005a, 2005b, 2005c). This integration of adaptive responding and head control is thought to represent substantial progress (developmentally and practically) over the exercise of any of those two skills separately (Fetters & Kluzik, 1996; Lancioni et al., 2005a). The studies were based on the use of microswitch clusters (i.e., combinations of microswitches), which allowed one to monitor concurrently the adaptive response and head position and to regulate preferred stimuli. For example, a microswitch cluster consisting of a sound-detecting device and a tilt microswitch at the participant’s head ensured that adaptive vocalization responses were followed by preferred stimuli only if they were combined with upright (correct) head position (cf. Lancioni et al., 2005c). The stimuli were presented for a preset time irrespective of whether the student kept the head upright for that entire period of time or not. The five students involved in those studies increased their adaptive responding and showed upright head position concomitant with most adaptive responses. A follow-up assessment was then carried out to (a) ascertain whether the students had maintained the combination of adaptive responding and upright head position over time and (b) measure their actual level of head control, that is, the length of time they kept the upright head position during the stimulation following successful responses (i.e., adaptive responses with upright head position) and throughout the sessions (Lancioni et al., 2007). The results of this assessment showed that all five students maintained satisfactory levels of adaptive responding and this mostly occurred together with head upright. Two of them kept the upright head position for nearly the entire stimulation periods that followed successful responses as well as much of the session time. The other three students, however, kept such position for small or intermediate portions of the stimulation periods and of the session time. For these three students, a new program version was applied, in which the stimulation used for each successful response was synchronous with the upright head position. The stimulation would continue for up to 9 s if the position was maintained for all that time and it would be interrupted if the position was not maintained. The results showed that all three students had an increase in head upright following successful responses as well as throughout the sessions
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(Lancioni et al., 2007). These results (a) highlighted the potential contribution of the new program in helping students with multiple disabilities improve their overall condition in a very active manner and (b) underlined the need for replication of such program with additional students and for external validation of the program’s effects on head control and general physical condition (Barlow, Andrasik, & Hersen, 2006; Cunningham, McDonnell, Easton, & Sturmey, 2003; Lancioni et al., 2006; Storey, 1996). The present two studies pursued the aforementioned goals. Specifically, Study I was an effort to replicate the new program with synchronous stimulation with three additional participants with multiple disabilities. Study II served to carry out a validation assessment of the new program’s effects employing two groups of 72 raters, which involved new physiotherapists and physiotherapists with work experience, respectively. Physiotherapists were considered to represent relevant, expert raters. Their rating was based on videotapes of the three participants of the present Study I and of the three participants exposed to the last program in the Lancioni et al. (2007) study. Rating was carried out according to a four-item questionnaire, which covered posture and rehabilitation aspects. 2. Study I 2.1. Method 2.1.1. Participants The three participants (Sid, Tricia, and Luke) were 7.8, 9.2, and 16.9 years old, respectively, had encephalopathy and spastic tetraparesis, and were in a wheelchair. They showed reduced (or minimal) hand, arm and leg movements, with limited trunk and head control, and their head tended to be tilted forward. They were rated in the severe or profound intellectual disability range (albeit no formal psychological assessment or IQ scores were available for them). Tricia and Luke were also diagnosed with epilepsy and received antiepileptic medication, which was reportedly effective in controlling their seizures. All of them had typical hearing, but presented with total blindness (Luke) or minimal residual vision (Sid and Tricia; cf. Geruschat, 1992). Sid and Luke had no previous experience with microswitches while Tricia had been successfully exposed to a program involving microswitches for chin- and hand-movement responses, which continued parallel to this study. The participants lived at home with their parents and attended daily educational services focusing mainly on physiotherapy and general stimulation procedures. Parents had provided informed consent for their participation in this study. 2.1.2. Adaptive responses, head position, microswitch clusters, control system, and stimuli The adaptive response selected for Sid was foot lifting. The adaptive response selected for Tricia and Luke was hand stroking. This consisted of passing the left hand on the table area in front of her (Tricia) or the right hand over the left hand (Luke). The microswitches were tilt devices for the lifting response and touch and pressure sensors for hand stroking. Appropriate head position consisted of keeping it upright rather than tilting it forward as the participants tended to do. The microswitch clusters consisted of combinations of the tilt or touch and pressure sensors used for the adaptive response (see above) with a tilt microswitch used for the head position. This tilt microswitch was attached to a headband that the participants wore and was activated when the head was upright and deactivated as the head was tilted forward.
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The microswitch clusters were linked to a battery-powered, electronic control system that (a) turned on one or more preferred stimuli in connection with responding (i.e., according to the procedural conditions described below) and (b) recorded the data (see below). Preferred stimuli were selected through a stimulus preference screening (Crawford & Schuster, 1993; Lancioni et al., 2002). The screening covered multiple stimuli; each stimulus was presented 15–35 nonconsecutive times. Only the stimuli that were followed by a participant’s positive reactions (i.e., alerting, orienting, and/or smiling) in over two-thirds of the presentations were selected for the study. Such stimuli included various types of music, noise and chimes, television clips, voices and object sounds, and a variety of vibratory inputs. 2.1.3. Experimental conditions The measures recorded were the frequencies of adaptive responses, the frequencies of those responses combined with upright head position, the length of time such position was kept during the stimulation that followed responding (i.e., each adaptive response or adaptive responses with head upright; see below) and through the sessions. All measures were automatically recorded via four counters fitted to the electronic control system. Each participant followed an ABB1 sequence in which A represented the baseline, B represented the intervention for the adaptive response, and B1 represented the intervention for the adaptive response and head upright (Richards, Taylor, Ramasamy, & Richards, 1999). The B1 started after variable lengths of the B phase, in line with a non-concurrent multiple baseline design across participants (Barlow et al., 2006). At the beginning of the B1, 10 sessions were used which included three to six instances of physical guidance by a research assistant for promoting head upright during adaptive responses. To control for the overall impact of these sessions, matching guidance sessions were also used during the B phase (see below). A post-intervention check occurred 1 month after the B1. Sessions lasted 5 min for Sid and 10 min for Tricia and Luke (according to staff and parents’ advice), and occurred 3–15 times a day depending on the participants’ availability. 2.1.4. Baseline (A phase) The baseline phase included 19, 9, and 7 sessions for the three participants, respectively. The microswitch cluster and the control system were available, but no stimuli were scheduled for the adaptive responses. At the start of the sessions, the participants were guided to perform an adaptive response with no stimulus consequence for it. 2.1.5. Intervention for adaptive responses (B phase) The B phase included 299, 62, and 70 sessions for the three participants, respectively. Conditions were as in baseline except that adaptive responses activated preferred stimuli for 8 s regardless of whether or not (a) such responses occurred in the presence of head upright and (b) head upright remained present during the stimulus presentation. Before the last 15 or 20 sessions of the B phase, 10 sessions with guidance instances were used (see above). 2.1.6. Intervention for adaptive responses and head upright (B1 phase) The B1 phase included 189, 64 and 109 sessions for the three participants, respectively. During this phase, two changes occurred compared to the B phase. First, adaptive responses produced preferred stimuli only if they occurred in the presence of head upright. Second, the stimuli lasted the 8-s interval scheduled only if head upright was maintained during that interval. Loss of head control led to stimulus interruption. An 8-s duration was scheduled for the stimuli (in this phase as well as in the B phase) instead of the 9-s duration scheduled by Lancioni et al. (2007) because
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it was considered more suited for the present participants. At the start of the B1 phase, 10 sessions with guidance instances were used (see above). 2.1.7. Post-intervention check The participants continued to receive sessions such as those of the B1 phase regularly. Twentyone (Sid) or 14 (Tricia and Luke) of those sessions, recorded 1 month after the end of the B1 phase, served as the post-intervention check. 2.2. Results Figs. 1–3 summarize the data for Sid, Tricia, and Luke, respectively. The upper graph of each figure shows the mean frequencies of adaptive responses and the mean frequencies of those responses that occurred with the head upright (i.e., successful responses) through blocks of sessions, across all phases of the study. The lower graph shows (a) the mean session time (in min) elapsed with the head upright through the aforementioned blocks of sessions, and (b) the mean stimulation time (in s) per adaptive response (B phase) or successful response (B1 phase and postintervention check) elapsed with the head upright through the same blocks of sessions. During the baseline (A phase), the participants’ mean frequencies of adaptive responses were about seven or eight per session. About or less than half of those responses occurred with the head
Fig. 1. The upper graph shows Sid’s mean frequencies of foot-lifting responses (gray bars) as well as the mean frequencies of those responses performed with head upright (black circles) over blocks of sessions. Two blocks are used for the baseline and post-intervention check and six blocks for each intervention phase. The number of sessions included in each block is indicated by the numeral above it. The lower graph shows Sid’s mean session time (min) elapsed with head upright (dotted bars) and the mean stimulation time per response (s) elapsed with head upright (black triangles) over the same blocks of sessions. The graphs do not include the sessions with physical guidance used toward the end of the B phase and the beginning of the B1 phase.
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Fig. 2. The two graphs show Tricia’s data plotted as in Fig. 1.
Fig. 3. The two graphs show Luke’s data plotted as in Fig. 1.
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upright. During the B phase, the mean frequencies of adaptive responses were about 16 per 5-min sessions for Sid and 28 or 30 per 10-min session for Tricia and Luke. Again, about or less than half of those responses occurred with head upright. There were no positive trends during the last 15 or 20 sessions of the phase (i.e., those occurring after the set of guidance sessions). The mean session time elapsed with head upright was about 1 min for Sid and about 2 and 4.5 min for Tricia and Luke. The mean stimulation time per response elapsed with the head upright was between 1 s (Tricia) and 3.9 s (Luke). During the B1 phase, the mean frequencies of adaptive responses were 17, 58, and 42 for the three participants, respectively. The mean frequencies of those responses occurred with head upright increased to about 13, 48 and 33, respectively. The mean session time elapsed with head upright exceeded 3 min (Sid) or 6.5 and 7.0 min (Tricia and Luke). The mean stimulation time per successful response elapsed with the head upright was about 7 s (Sid and Luke) and about 5 s (Tricia). The Kolmogorov–Smirnov test (Siegel & Castellan, 1988) showed that B and B1 data differed significantly ( p < .01) for all students on frequencies of responses with head upright as well as on session and stimulation time spent with head upright. The B1 data were retained at the post-intervention check. 3. Study II 3.1. Method 3.1.1. Raters The first group of raters included 72 persons completing their 3 years University curriculum in physiotherapy (i.e., new physiotherapists). There were 46 women and 26 men between 21 and 35 (M = 24) years of age. The second group of raters included 72 persons who had 3–20 years of physiotherapy work experience (i.e., professional physiotherapists) and were also completing a master degree in rehabilitation sciences. There were 56 women and 16 men between 27 and 55 (M = 43) years of age. The ratings of these groups were thought to represent an expert evaluation of the effects of the new microswitch-cluster program, with important implications for its applicability (Barlow et al., 2006; Kazdin, 2001). 3.1.2. Students and videotapes The three students participating in Study I as well as the three students with whom the program was initially assessed (Lancioni et al., 2007) were involved in this expert validation. In practice, videotapes of these six students were available for the raters of both groups to watch (see below). The characteristics and adaptive responses of the participants of Study I (i.e., Sid, Tricia, and Luke) are described above. The three participants of the previous study (i.e., Joe, Albert, and Roger) were 10.1, 8.6, and 20.8 years old, respectively, at the time of the study. They were diagnosed with encephalopathy, spastic tetraparesis, severe to profound intellectual disability and presented with total blindness (Joe and Albert) or minimal vision (Roger) and typical hearing. Twelve videotapes, two per student, were available. Each videotape of Sid, Tricia and Luke included four 1-min clips of sessions with synchronous stimulation (i.e., of the B1 phase) and four 1-min clips of sessions with non-synchronous stimulation (i.e., of the B phase). In half of the videotapes, the order was B1 clips followed by B clips; in the other half, the order was reversed. Videotapes of Joe, Albert and Roger differed from those mentioned above with regard to the clips with non-synchronous stimulation. These clips were taken from a preliminary version of the
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Table 1 Questionnaire items (1) How would you describe the student’s head posture in the two program conditions? (2) How would you describe the possible impact of the two program conditions on the student’s motor situation/ development? (3) How would you describe the possible impact of the two program conditions, if applied daily, on the student’s breathing and feeding processes? (4) How would you describe the possibility of integrating the two program conditions with a motor rehabilitation program?
cluster program in which the stimuli occurring for adaptive responses with head upright were not interrupted if the student lost his head control (see Section 1 of this article and Lancioni et al., 2007). Clips were considered highly representative of the participants’ levels of responding and head control by the later stages of the program conditions involved. 3.1.3. Procedure and questionnaire Each group of raters was divided into six subgroups of 12 members. Two subgroups of raters (one of new physiotherapists and one of professional physiotherapists) were employed for each student, that is, they watched one of the two videotapes of that student and then provided their ratings. Watching and rating occurred separately for the two subgroups. Before watching the videotape, the raters were told that they would see a student with multiple disabilities in two educational conditions involving the use of microswitches the activation of which produced occurrences of preferred stimuli. Thereafter, they rated these conditions on a four-item questionnaire, which covered posture and rehabilitation aspects (see Table 1). For each item, two scores were provided (one for each condition). The scores could vary between 1 and 5, which indicated least and most positive values, respectively. 3.2. Results Table 2 reports the new physiotherapists’ ratings (i.e., means and standard deviations) for the four-item questionnaire across the two program conditions. Table 3 reports the professional physiotherapists’ ratings for the same items and program conditions. The Wilcoxon matchedpairs signed-rank test showed that the scores for the program condition involving synchronous stimulation were significantly higher (i.e., more positive) than those for the program condition with non-synchronous stimulation on all items, for both groups of raters (z > 5, p < .001; Siegel Table 2 New physiotherapists’ mean ratings (M) and standard deviations (S.D.) for the questionnaire items across program conditions Items
Program conditions Synchronous stimulation
1 2 3 4
Non-synchronous stimulation
M
S.D.
M
S.D.
3.6 3.7 3.9 3.9
0.8 0.7 0.9 0.7
2.3 2.8 2.9 3.2
0.9 0.9 0.9 0.8
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Table 3 Professional physiotherapists’ mean ratings (M) and standard deviations (S.D.) for the questionnaire items across program conditions Items
Program conditions Synchronous stimulation
1 2 3 4
Non-synchronous stimulation
M
S.D.
M
S.D.
3.8 4.0 4.3 4.1
0.8 0.6 0.7 0.7
2.4 2.9 2.7 3.1
0.9 0.8 1.1 0.8
& Castellan, 1988). A comparison between the scoring of the two groups (i.e., new physiotherapists versus professional physiotherapists) using the Mann–Whitney U-test showed significant differences on the first three items (z > 2, p < .05; Siegel & Castellan, 1988). Specifically, the professional physiotherapists had significantly higher scoring for the synchronous reinforcement condition. A reliability analysis of the scores obtained for the four items of the questionnaire (using Cronbach’s alpha; Cronbach, 1951) revealed that such items formed a so-called scale (alpha > .70). All items had a positive (but not 1.0) item-total correlation. 4. General discussion The results of Study I supported previous data by Lancioni et al. (2007) and indicated that the three participants increased the overall frequency of adaptive responses and the frequency of those responses occurring with head upright. This head control was present through much/most of the scheduled stimulation time available for successful responses and through most of the session time. The results of Study II showed that the raters found the effects (possible implications) of this new program with synchronous stimulation more positive than those of the other intervention condition and also considered such program a useful complement to formal motor rehabilitation programs. All the items of the questionnaire seemed to add to the validation assessment in a relevant manner being positively correlated to the total. In light of these findings, several considerations may be forwarded. First, the results of Study I constitute essential evidence, which adds considerably to the data reported by Lancioni et al. (2007) and supports the overall applicability and dependability of the new program with persons with multiple disabilities (Barlow et al., 2006; Kazdin, 2001; Kennedy, 2005). The use of highly reinforcing stimuli only for responses that occurred with head upright and the presence of these stimuli for a relatively meaningful period of time or their premature interruption (i.e., depending on the participants’ maintenance or loss of head control) were apparently critical factors accounting for the program’s effectiveness (Borrero & Vollmer, 2002; Ecott & Chritchfield, 2004). Instrumental to this outcome were the concurrent monitoring of the responses and head position and the differential delivery of stimulation achieved with the microswitch clusters and the rest of the technology package (cf. Lancioni, O’Reilly, Campodonico, & Mantini, 2001; Lancioni et al., 2005a, 2005c; Kazdin, 2001). Second, the evidence of Study I together with the previous data reported by Lancioni et al. (2007) acquire critical practical relevance in light of the findings of the expert validation assessment. The raters indeed supported the positive evidence of the studies by underlining that
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the program with synchronous stimulation (a) had important beneficial impact on the participants’ posture, (b) could produce positive effects on the participants’ motor condition/ development, (c) could usefully influence the participants’ breathing and feeding, and (d) could be realistically and favorably integrated with formal motor rehabilitation approaches. This validation outcome may be considered highly relevant given that the raters could express a competent judgment of the situation and not simply a general social opinion about it (Lancioni et al., 2006). The fact that professional physiotherapists provided higher scores than new physiotherapists on the first three items of the questionnaire could suggest that their work experience (i.e., their awareness of the difficulties posed by the students) increased their appreciation of the program and its visible and likely effects (cf. Bartlett & Palisano, 2002). Third, in view of Study I, of the Lancioni et al. (2007) study as well as of the expert validation outcome, one can argue that the new program with synchronous stimulation may have an important role in education and rehabilitation services for students with multiple disabilities. It can help these students improve their overall condition in a very active manner. The improvement, in fact, relies on the students’ efforts and requires that such efforts are selfmanaged, that is, regulated by the students themselves (cf. Bartlett & Palisano, 2002; Ketelaar, Vermeer, Hart, van Petegem-van Beek, & Helders, 2001; Kramer, Ashton, & Brander, 1992). The latter point could be reassuring as to the fact that the efforts are produced because (a) they are not excessively demanding for the students and (b) are satisfactorily compensated by the stimulation that they generate (i.e., the stimulation is highly reinforcing and motivating for the students) (Gwinn et al., 2005). It follows that the program may be considered respectful of the students’ dignity and quality of life and may therefore be seen as a highly acceptable resource (Algozzine, Browder, Karvonen, Test, & Wood, 2001; Felce & Perry, 1995; Ketelaar et al., 2001; Lachapelle et al., 2005; Parette, Brothersson, & Blacke-Huer, 2000; Sullivan, Laverick, & Lewis, 1995; Wehmeyer & Schwartz, 1998). In view of the above, one may underscore the potential of programs combining microswitch clusters and synchronous stimulation to help students with multiple disabilities improve their overall condition. New research will need to (a) provide extra evidence with other students and other adaptive responses to combine with head position and (b) determine the real role of the new program and its relation to formal motor rehabilitation strategies within educational plans for persons with multiple disabilities. References Algozzine, B., Browder, D., Karvonen, M., Test, D. W., & Wood, W. M. (2001). Effects of intervention to promote selfdetermination for individuals with disabilities. Review of Educational Research, 71, 219–277. Barlow, D. H., Andrasik, F., & Hersen, M. (2006). Single-case experimental designs (3rd ed.). New York: Allyn & Bacon. Bartlett, D. J., & Palisano, R. J. (2002). Physical therapists’ perception of factors influencing the acquisition of motor abilities of children with cerebral palsy: Implications for clinical reasoning. Physical Therapy, 82, 237–248. Borrero, J. C., & Vollmer, T. R. (2002). An application of the matching law to severe problem behavior. Journal of Applied Behavior Analysis, 35, 13–27. Crawford, M. R., & Schuster, J. W. (1993). Using microswitches to teach toy use. Journal of Developmental and Physical Disabilities, 5, 349–368. Cronbach, L. J. (1951). Coefficient alpha and the internal structure of tests. Psychometrika, 16, 297–334. Cunningham, J., McDonnell, A., Easton, A., & Sturmey, P. (2003). Social validation data on three methods of physical restraint: Views of consumers, staff and students. Research in Developmental Disabilities, 24, 307–316. Ecott, C. L., & Critchfield, T. S. (2004). Noncontingent reinforcement, alternative reinforcement, and the matching law: A laboratory demonstration. Journal of Applied Behavior Analysis, 37, 249–265.
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Felce, D., & Perry, J. (1995). Quality of life: Its definition and measurement. Research in Developmental Disabilities, 16, 51–74. Fetters, L., & Kluzik, J. (1996). The effects of neurodevelopmental treatment versus practice on the reaching of children with spastic cerebral palsy. Physical Therapy, 76, 346–358. Geruschat, D. R. (1992). Using the Acuity Card Procedure to assess visual acuity in children with severe and multiple impairments. Journal of Visual Impairment and Blindness, 86, 25–27. Gwinn, M. M., Derby, K. M., Fisher, W., Kurtz, P., Fahs, A., Augustine, M., et al. (2005). Effects of increased response effort and reinforcer delay on choice and aberrant behavior. Behavior Modification, 29, 642–652. Kazdin, A. E. (2001). Behavior modification in applied settings (6th ed.). New York: Wadsworth. Kennedy, K. (2005). Single case designs for educational research. New York: Allyn & Bacon. Ketelaar, M., Vermeer, A., Hart, H., van Petegem-van Beek, E., & Helders, P. J. (2001). Effects of a functional therapy program on motor abilities of children with cerebral palsy. Physical Therapy, 81, 1534–1545. Kramer, J. F., Ashton, B., & Brander, R. (1992). Training of head control in the sitting and semi-prone positions. Child: Care, Health and Development, 18, 365–376. Lachapelle, Y., Wehmeyer, M. L., Haelewyck, M. C., Courbois, Y., Keith, K. D., Schalock, R., et al. (2005). The relationship between quality of life and self-determination: An international study. Journal of Intellectual Disability Research, 49, 740–744. Lancioni, G. E., O’Reilly, M. F., Campodonico, F., & Mantini, M. (2001). Promoting performance fluency in a person with profound multiple disability and blindness. Behavioural and Cognitive Psychotherapy, 29, 373–377. Lancioni, G. E., O’Reilly, M. F., Singh, N. N., Groeneweg, J., Bosco, A., Tota, A., et al. (2006). A social validation assessment of microswitch-based programs for persons with multiple disabilities employing teacher trainees and parents as raters. Journal of Developmental and Physical Disabilities, 18, 383–391. Lancioni, G. E., O’Reilly, M. F., Singh, N. N., Oliva, D., Piazzolla, G., Pirani, P., et al. (2002). Evaluating the use of multiple microswitches and responses for children with multiple disabilities. Journal of Intellectual Disability Research, 46, 346–351. Lancioni, G. E., O’Reilly, M. F., Singh, N. N., Oliva, D., Scalini, L., Vigo, C. M., et al. (2005a). Further evaluation of microswitch clusters to enhance hand response and head control in persons with multiple disabilities. Perceptual and Motor Skills, 100, 689–694. Lancioni, G. E., O’Reilly, M. F., Singh, N. N., Oliva, D., Scalini, L., Vigo, C. M., et al. (2005b). Microswitch clusters to enhance adaptive responses and head control: A programme extension for three children with multiple disabilities. Disability and Rehabilitation, 27, 637–641. Lancioni, G. E., O’Reilly, M. F., Singh, N. N., Oliva, D., Scalini, L., Vigo, C. M., et al. (2005c). Microswitch clusters to enhance hand responses and appropriate head position in two children with multiple disabilities. Pediatric Rehabilitation, 8, 59–62. Lancioni, G. E., Singh, N. N., O’Reilly, M. F., Oliva, D., Scalini, L., Vigo, C. M., et al. (2004). Microswitch clusters to support responding and appropriate posture of students with multiple disabilities: Three case evaluations. Disability and Rehabilitation, 26, 501–505. Lancioni, G. E., Singh, N. N., O’Reilly, M. F., Sigafoos, J., Didden, R., Oliva, D., et al. (2007). Fostering adaptive responses and head control in students with multiple disabilities through a microswitch-based program: Follow-up assessment and program revision. Research in Developmental Disabilities, 28, 187–196. Larnert, G., & Ekberg, O. (1995). Positioning improves the oral and pharyngeal swallowing function in children with cerebral palsy. Acta Paediatrica, 84, 689–692. Myhr, U., von Wendt, L., Norrlin, S., & Radell, U. (1995). Five-year follow-up of functional sitting position in children with cerebral palsy. Developmental Medicine and Child Neurology, 37, 587–596. Nwaobi, O. M., & Smith, P. D. (1986). Effects of adaptive seating on pulmonary function of children with cerebral palsy. Developmental Medicine and Child Neurology, 28, 351–354. Parette, H. P., Brotherson, M. J., & Blake-Huer, M. (2000). Giving families a voice in augmentative and alternative communication decision-making. Education and Training in Mental Retardation and Developmental Disabilities, 35, 177–190. Redstone, F. (2004). The effects of seating position on the respiratory patterns of preschoolers with cerebral palsy. International Journal of Rehabilitation Research, 27, 283–288. Redstone, F., & West, J. F. (2004). The importance of postural control for feeding. Pediatric Nursing, 30, 97–100. Richards, S. B., Taylor, R. L., Ramasamy, R., & Richards, R. Y. (1999). Single subject research: Applications in educational and clinical settings. London: Wadsworth. Siegel, S., & Castellan, N. J. (1988). Nonparametric statistics (2nd ed.). New York: McGraw-Hill.
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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. Wehmeyer, M., & Schwartz, M. (1998). The relationship between self-determination and quality of life for adults with mental retardation. Education and Training in Mental Retardation and Developmental Disabilities, 33, 3–12.
A microswitch-cluster program to foster adaptive responses and head control in students with multiple disabilities: Replication and validation assessment Giulio E. Lancioni a,*, Nirbhay N. Singh b, Mark F. O’Reilly c, Jeff Sigafoos d, Doretta Oliva e, Michela Gatti e, Francesco Manfredi a, Gianfranco Megna a, Maria L. La Martire a, Alessia Tota a, Angela Smaldone a, Jop Groeneweg f a University of Bari, Italy ONE Research Institute, United States c University of Texas at Austin, United States d University of Tasmania, Australia e Lega F. D’Oro Research Center, Italy f University of Leiden, The Netherlands b
Received 25 June 2007; accepted 28 June 2007
Abstract A program relying on microswitch clusters (i.e., combinations of microswitches) and preferred stimuli was recently developed to foster adaptive responses and head control in persons with multiple disabilities. In the last version of this program, preferred stimuli (a) are scheduled for adaptive responses occurring in combination with head control (i.e., head upright) and (b) last through the scheduled time only if head control is maintained for that time. The first of the present two studies was aimed at replicating this program with three new participants with multiple disabilities adding to the three reported by Lancioni et al. [Lancioni, G. E., Singh, N. N., O’Reilly, M. F., Sigafoos, J., Didden, R., Oliva, D., et al. (2007). Fostering adaptive responses and head control in students with multiple disabilities through a microswitch-based program: Follow-up assessment and program revision. Research in Developmental Disabilities, 28, 187–196]. The second of the two studies served to carry out an expert validation of the program’s effects on head control and general physical condition with the three participants of Study I as well as the three participants involved in the Lancioni et al. study mentioned above. The expert raters were 72 new physiotherapists and 72 experienced physiotherapists. The results of Study I supported previous data and indicated that the program was effective in helping the
* Corresponding author at: Department of Psychology, University of Bari, Via Quintino Sella 268, 70100 Bari, Italy. E-mail address: [email protected] (G.E. Lancioni). 0891-4222/$ – see front matter # 2007 Elsevier Ltd. All rights reserved. doi:10.1016/j.ridd.2007.06.007
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participants increase the frequency of adaptive responses in combination with head control and the length of such control. The results of Study II showed that the raters found the effects of the new program more positive than those of other intervention conditions and also considered such program a useful complement to formal motor rehabilitation programs. # 2007 Elsevier Ltd. All rights reserved. Keywords: Microswitch clusters; Adaptive responses; Head control; Multiple disabilities; Expert validation
1. Introduction Posture improvement is a clearly relevant objective for students who tend to have inappropriate body positions (e.g., head forward tilting) as well as dystonic/uncontrolled movements (Nwaobi & Smith, 1986; Redstone & West, 2004). Such improvement can have positive implications from a social and adaptive standpoint (facilitating acceptance and care) and also in terms of physical condition and well being (facilitating basic functions such as breathing) (Larnert & Ekberg, 1995; Myhr, von Wendt, Norrlin, & Radell, 1995; Redstone, 2004; Redstone & West, 2004). Recently, studies were directed at improving head position within an active context (i.e., in combination with adaptive/constructive responding) (Lancioni et al., 2004, 2005a, 2005b, 2005c). This integration of adaptive responding and head control is thought to represent substantial progress (developmentally and practically) over the exercise of any of those two skills separately (Fetters & Kluzik, 1996; Lancioni et al., 2005a). The studies were based on the use of microswitch clusters (i.e., combinations of microswitches), which allowed one to monitor concurrently the adaptive response and head position and to regulate preferred stimuli. For example, a microswitch cluster consisting of a sound-detecting device and a tilt microswitch at the participant’s head ensured that adaptive vocalization responses were followed by preferred stimuli only if they were combined with upright (correct) head position (cf. Lancioni et al., 2005c). The stimuli were presented for a preset time irrespective of whether the student kept the head upright for that entire period of time or not. The five students involved in those studies increased their adaptive responding and showed upright head position concomitant with most adaptive responses. A follow-up assessment was then carried out to (a) ascertain whether the students had maintained the combination of adaptive responding and upright head position over time and (b) measure their actual level of head control, that is, the length of time they kept the upright head position during the stimulation following successful responses (i.e., adaptive responses with upright head position) and throughout the sessions (Lancioni et al., 2007). The results of this assessment showed that all five students maintained satisfactory levels of adaptive responding and this mostly occurred together with head upright. Two of them kept the upright head position for nearly the entire stimulation periods that followed successful responses as well as much of the session time. The other three students, however, kept such position for small or intermediate portions of the stimulation periods and of the session time. For these three students, a new program version was applied, in which the stimulation used for each successful response was synchronous with the upright head position. The stimulation would continue for up to 9 s if the position was maintained for all that time and it would be interrupted if the position was not maintained. The results showed that all three students had an increase in head upright following successful responses as well as throughout the sessions
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(Lancioni et al., 2007). These results (a) highlighted the potential contribution of the new program in helping students with multiple disabilities improve their overall condition in a very active manner and (b) underlined the need for replication of such program with additional students and for external validation of the program’s effects on head control and general physical condition (Barlow, Andrasik, & Hersen, 2006; Cunningham, McDonnell, Easton, & Sturmey, 2003; Lancioni et al., 2006; Storey, 1996). The present two studies pursued the aforementioned goals. Specifically, Study I was an effort to replicate the new program with synchronous stimulation with three additional participants with multiple disabilities. Study II served to carry out a validation assessment of the new program’s effects employing two groups of 72 raters, which involved new physiotherapists and physiotherapists with work experience, respectively. Physiotherapists were considered to represent relevant, expert raters. Their rating was based on videotapes of the three participants of the present Study I and of the three participants exposed to the last program in the Lancioni et al. (2007) study. Rating was carried out according to a four-item questionnaire, which covered posture and rehabilitation aspects. 2. Study I 2.1. Method 2.1.1. Participants The three participants (Sid, Tricia, and Luke) were 7.8, 9.2, and 16.9 years old, respectively, had encephalopathy and spastic tetraparesis, and were in a wheelchair. They showed reduced (or minimal) hand, arm and leg movements, with limited trunk and head control, and their head tended to be tilted forward. They were rated in the severe or profound intellectual disability range (albeit no formal psychological assessment or IQ scores were available for them). Tricia and Luke were also diagnosed with epilepsy and received antiepileptic medication, which was reportedly effective in controlling their seizures. All of them had typical hearing, but presented with total blindness (Luke) or minimal residual vision (Sid and Tricia; cf. Geruschat, 1992). Sid and Luke had no previous experience with microswitches while Tricia had been successfully exposed to a program involving microswitches for chin- and hand-movement responses, which continued parallel to this study. The participants lived at home with their parents and attended daily educational services focusing mainly on physiotherapy and general stimulation procedures. Parents had provided informed consent for their participation in this study. 2.1.2. Adaptive responses, head position, microswitch clusters, control system, and stimuli The adaptive response selected for Sid was foot lifting. The adaptive response selected for Tricia and Luke was hand stroking. This consisted of passing the left hand on the table area in front of her (Tricia) or the right hand over the left hand (Luke). The microswitches were tilt devices for the lifting response and touch and pressure sensors for hand stroking. Appropriate head position consisted of keeping it upright rather than tilting it forward as the participants tended to do. The microswitch clusters consisted of combinations of the tilt or touch and pressure sensors used for the adaptive response (see above) with a tilt microswitch used for the head position. This tilt microswitch was attached to a headband that the participants wore and was activated when the head was upright and deactivated as the head was tilted forward.
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The microswitch clusters were linked to a battery-powered, electronic control system that (a) turned on one or more preferred stimuli in connection with responding (i.e., according to the procedural conditions described below) and (b) recorded the data (see below). Preferred stimuli were selected through a stimulus preference screening (Crawford & Schuster, 1993; Lancioni et al., 2002). The screening covered multiple stimuli; each stimulus was presented 15–35 nonconsecutive times. Only the stimuli that were followed by a participant’s positive reactions (i.e., alerting, orienting, and/or smiling) in over two-thirds of the presentations were selected for the study. Such stimuli included various types of music, noise and chimes, television clips, voices and object sounds, and a variety of vibratory inputs. 2.1.3. Experimental conditions The measures recorded were the frequencies of adaptive responses, the frequencies of those responses combined with upright head position, the length of time such position was kept during the stimulation that followed responding (i.e., each adaptive response or adaptive responses with head upright; see below) and through the sessions. All measures were automatically recorded via four counters fitted to the electronic control system. Each participant followed an ABB1 sequence in which A represented the baseline, B represented the intervention for the adaptive response, and B1 represented the intervention for the adaptive response and head upright (Richards, Taylor, Ramasamy, & Richards, 1999). The B1 started after variable lengths of the B phase, in line with a non-concurrent multiple baseline design across participants (Barlow et al., 2006). At the beginning of the B1, 10 sessions were used which included three to six instances of physical guidance by a research assistant for promoting head upright during adaptive responses. To control for the overall impact of these sessions, matching guidance sessions were also used during the B phase (see below). A post-intervention check occurred 1 month after the B1. Sessions lasted 5 min for Sid and 10 min for Tricia and Luke (according to staff and parents’ advice), and occurred 3–15 times a day depending on the participants’ availability. 2.1.4. Baseline (A phase) The baseline phase included 19, 9, and 7 sessions for the three participants, respectively. The microswitch cluster and the control system were available, but no stimuli were scheduled for the adaptive responses. At the start of the sessions, the participants were guided to perform an adaptive response with no stimulus consequence for it. 2.1.5. Intervention for adaptive responses (B phase) The B phase included 299, 62, and 70 sessions for the three participants, respectively. Conditions were as in baseline except that adaptive responses activated preferred stimuli for 8 s regardless of whether or not (a) such responses occurred in the presence of head upright and (b) head upright remained present during the stimulus presentation. Before the last 15 or 20 sessions of the B phase, 10 sessions with guidance instances were used (see above). 2.1.6. Intervention for adaptive responses and head upright (B1 phase) The B1 phase included 189, 64 and 109 sessions for the three participants, respectively. During this phase, two changes occurred compared to the B phase. First, adaptive responses produced preferred stimuli only if they occurred in the presence of head upright. Second, the stimuli lasted the 8-s interval scheduled only if head upright was maintained during that interval. Loss of head control led to stimulus interruption. An 8-s duration was scheduled for the stimuli (in this phase as well as in the B phase) instead of the 9-s duration scheduled by Lancioni et al. (2007) because
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it was considered more suited for the present participants. At the start of the B1 phase, 10 sessions with guidance instances were used (see above). 2.1.7. Post-intervention check The participants continued to receive sessions such as those of the B1 phase regularly. Twentyone (Sid) or 14 (Tricia and Luke) of those sessions, recorded 1 month after the end of the B1 phase, served as the post-intervention check. 2.2. Results Figs. 1–3 summarize the data for Sid, Tricia, and Luke, respectively. The upper graph of each figure shows the mean frequencies of adaptive responses and the mean frequencies of those responses that occurred with the head upright (i.e., successful responses) through blocks of sessions, across all phases of the study. The lower graph shows (a) the mean session time (in min) elapsed with the head upright through the aforementioned blocks of sessions, and (b) the mean stimulation time (in s) per adaptive response (B phase) or successful response (B1 phase and postintervention check) elapsed with the head upright through the same blocks of sessions. During the baseline (A phase), the participants’ mean frequencies of adaptive responses were about seven or eight per session. About or less than half of those responses occurred with the head
Fig. 1. The upper graph shows Sid’s mean frequencies of foot-lifting responses (gray bars) as well as the mean frequencies of those responses performed with head upright (black circles) over blocks of sessions. Two blocks are used for the baseline and post-intervention check and six blocks for each intervention phase. The number of sessions included in each block is indicated by the numeral above it. The lower graph shows Sid’s mean session time (min) elapsed with head upright (dotted bars) and the mean stimulation time per response (s) elapsed with head upright (black triangles) over the same blocks of sessions. The graphs do not include the sessions with physical guidance used toward the end of the B phase and the beginning of the B1 phase.
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Fig. 2. The two graphs show Tricia’s data plotted as in Fig. 1.
Fig. 3. The two graphs show Luke’s data plotted as in Fig. 1.
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upright. During the B phase, the mean frequencies of adaptive responses were about 16 per 5-min sessions for Sid and 28 or 30 per 10-min session for Tricia and Luke. Again, about or less than half of those responses occurred with head upright. There were no positive trends during the last 15 or 20 sessions of the phase (i.e., those occurring after the set of guidance sessions). The mean session time elapsed with head upright was about 1 min for Sid and about 2 and 4.5 min for Tricia and Luke. The mean stimulation time per response elapsed with the head upright was between 1 s (Tricia) and 3.9 s (Luke). During the B1 phase, the mean frequencies of adaptive responses were 17, 58, and 42 for the three participants, respectively. The mean frequencies of those responses occurred with head upright increased to about 13, 48 and 33, respectively. The mean session time elapsed with head upright exceeded 3 min (Sid) or 6.5 and 7.0 min (Tricia and Luke). The mean stimulation time per successful response elapsed with the head upright was about 7 s (Sid and Luke) and about 5 s (Tricia). The Kolmogorov–Smirnov test (Siegel & Castellan, 1988) showed that B and B1 data differed significantly ( p < .01) for all students on frequencies of responses with head upright as well as on session and stimulation time spent with head upright. The B1 data were retained at the post-intervention check. 3. Study II 3.1. Method 3.1.1. Raters The first group of raters included 72 persons completing their 3 years University curriculum in physiotherapy (i.e., new physiotherapists). There were 46 women and 26 men between 21 and 35 (M = 24) years of age. The second group of raters included 72 persons who had 3–20 years of physiotherapy work experience (i.e., professional physiotherapists) and were also completing a master degree in rehabilitation sciences. There were 56 women and 16 men between 27 and 55 (M = 43) years of age. The ratings of these groups were thought to represent an expert evaluation of the effects of the new microswitch-cluster program, with important implications for its applicability (Barlow et al., 2006; Kazdin, 2001). 3.1.2. Students and videotapes The three students participating in Study I as well as the three students with whom the program was initially assessed (Lancioni et al., 2007) were involved in this expert validation. In practice, videotapes of these six students were available for the raters of both groups to watch (see below). The characteristics and adaptive responses of the participants of Study I (i.e., Sid, Tricia, and Luke) are described above. The three participants of the previous study (i.e., Joe, Albert, and Roger) were 10.1, 8.6, and 20.8 years old, respectively, at the time of the study. They were diagnosed with encephalopathy, spastic tetraparesis, severe to profound intellectual disability and presented with total blindness (Joe and Albert) or minimal vision (Roger) and typical hearing. Twelve videotapes, two per student, were available. Each videotape of Sid, Tricia and Luke included four 1-min clips of sessions with synchronous stimulation (i.e., of the B1 phase) and four 1-min clips of sessions with non-synchronous stimulation (i.e., of the B phase). In half of the videotapes, the order was B1 clips followed by B clips; in the other half, the order was reversed. Videotapes of Joe, Albert and Roger differed from those mentioned above with regard to the clips with non-synchronous stimulation. These clips were taken from a preliminary version of the
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Table 1 Questionnaire items (1) How would you describe the student’s head posture in the two program conditions? (2) How would you describe the possible impact of the two program conditions on the student’s motor situation/ development? (3) How would you describe the possible impact of the two program conditions, if applied daily, on the student’s breathing and feeding processes? (4) How would you describe the possibility of integrating the two program conditions with a motor rehabilitation program?
cluster program in which the stimuli occurring for adaptive responses with head upright were not interrupted if the student lost his head control (see Section 1 of this article and Lancioni et al., 2007). Clips were considered highly representative of the participants’ levels of responding and head control by the later stages of the program conditions involved. 3.1.3. Procedure and questionnaire Each group of raters was divided into six subgroups of 12 members. Two subgroups of raters (one of new physiotherapists and one of professional physiotherapists) were employed for each student, that is, they watched one of the two videotapes of that student and then provided their ratings. Watching and rating occurred separately for the two subgroups. Before watching the videotape, the raters were told that they would see a student with multiple disabilities in two educational conditions involving the use of microswitches the activation of which produced occurrences of preferred stimuli. Thereafter, they rated these conditions on a four-item questionnaire, which covered posture and rehabilitation aspects (see Table 1). For each item, two scores were provided (one for each condition). The scores could vary between 1 and 5, which indicated least and most positive values, respectively. 3.2. Results Table 2 reports the new physiotherapists’ ratings (i.e., means and standard deviations) for the four-item questionnaire across the two program conditions. Table 3 reports the professional physiotherapists’ ratings for the same items and program conditions. The Wilcoxon matchedpairs signed-rank test showed that the scores for the program condition involving synchronous stimulation were significantly higher (i.e., more positive) than those for the program condition with non-synchronous stimulation on all items, for both groups of raters (z > 5, p < .001; Siegel Table 2 New physiotherapists’ mean ratings (M) and standard deviations (S.D.) for the questionnaire items across program conditions Items
Program conditions Synchronous stimulation
1 2 3 4
Non-synchronous stimulation
M
S.D.
M
S.D.
3.6 3.7 3.9 3.9
0.8 0.7 0.9 0.7
2.3 2.8 2.9 3.2
0.9 0.9 0.9 0.8
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Table 3 Professional physiotherapists’ mean ratings (M) and standard deviations (S.D.) for the questionnaire items across program conditions Items
Program conditions Synchronous stimulation
1 2 3 4
Non-synchronous stimulation
M
S.D.
M
S.D.
3.8 4.0 4.3 4.1
0.8 0.6 0.7 0.7
2.4 2.9 2.7 3.1
0.9 0.8 1.1 0.8
& Castellan, 1988). A comparison between the scoring of the two groups (i.e., new physiotherapists versus professional physiotherapists) using the Mann–Whitney U-test showed significant differences on the first three items (z > 2, p < .05; Siegel & Castellan, 1988). Specifically, the professional physiotherapists had significantly higher scoring for the synchronous reinforcement condition. A reliability analysis of the scores obtained for the four items of the questionnaire (using Cronbach’s alpha; Cronbach, 1951) revealed that such items formed a so-called scale (alpha > .70). All items had a positive (but not 1.0) item-total correlation. 4. General discussion The results of Study I supported previous data by Lancioni et al. (2007) and indicated that the three participants increased the overall frequency of adaptive responses and the frequency of those responses occurring with head upright. This head control was present through much/most of the scheduled stimulation time available for successful responses and through most of the session time. The results of Study II showed that the raters found the effects (possible implications) of this new program with synchronous stimulation more positive than those of the other intervention condition and also considered such program a useful complement to formal motor rehabilitation programs. All the items of the questionnaire seemed to add to the validation assessment in a relevant manner being positively correlated to the total. In light of these findings, several considerations may be forwarded. First, the results of Study I constitute essential evidence, which adds considerably to the data reported by Lancioni et al. (2007) and supports the overall applicability and dependability of the new program with persons with multiple disabilities (Barlow et al., 2006; Kazdin, 2001; Kennedy, 2005). The use of highly reinforcing stimuli only for responses that occurred with head upright and the presence of these stimuli for a relatively meaningful period of time or their premature interruption (i.e., depending on the participants’ maintenance or loss of head control) were apparently critical factors accounting for the program’s effectiveness (Borrero & Vollmer, 2002; Ecott & Chritchfield, 2004). Instrumental to this outcome were the concurrent monitoring of the responses and head position and the differential delivery of stimulation achieved with the microswitch clusters and the rest of the technology package (cf. Lancioni, O’Reilly, Campodonico, & Mantini, 2001; Lancioni et al., 2005a, 2005c; Kazdin, 2001). Second, the evidence of Study I together with the previous data reported by Lancioni et al. (2007) acquire critical practical relevance in light of the findings of the expert validation assessment. The raters indeed supported the positive evidence of the studies by underlining that
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the program with synchronous stimulation (a) had important beneficial impact on the participants’ posture, (b) could produce positive effects on the participants’ motor condition/ development, (c) could usefully influence the participants’ breathing and feeding, and (d) could be realistically and favorably integrated with formal motor rehabilitation approaches. This validation outcome may be considered highly relevant given that the raters could express a competent judgment of the situation and not simply a general social opinion about it (Lancioni et al., 2006). The fact that professional physiotherapists provided higher scores than new physiotherapists on the first three items of the questionnaire could suggest that their work experience (i.e., their awareness of the difficulties posed by the students) increased their appreciation of the program and its visible and likely effects (cf. Bartlett & Palisano, 2002). Third, in view of Study I, of the Lancioni et al. (2007) study as well as of the expert validation outcome, one can argue that the new program with synchronous stimulation may have an important role in education and rehabilitation services for students with multiple disabilities. It can help these students improve their overall condition in a very active manner. The improvement, in fact, relies on the students’ efforts and requires that such efforts are selfmanaged, that is, regulated by the students themselves (cf. Bartlett & Palisano, 2002; Ketelaar, Vermeer, Hart, van Petegem-van Beek, & Helders, 2001; Kramer, Ashton, & Brander, 1992). The latter point could be reassuring as to the fact that the efforts are produced because (a) they are not excessively demanding for the students and (b) are satisfactorily compensated by the stimulation that they generate (i.e., the stimulation is highly reinforcing and motivating for the students) (Gwinn et al., 2005). It follows that the program may be considered respectful of the students’ dignity and quality of life and may therefore be seen as a highly acceptable resource (Algozzine, Browder, Karvonen, Test, & Wood, 2001; Felce & Perry, 1995; Ketelaar et al., 2001; Lachapelle et al., 2005; Parette, Brothersson, & Blacke-Huer, 2000; Sullivan, Laverick, & Lewis, 1995; Wehmeyer & Schwartz, 1998). In view of the above, one may underscore the potential of programs combining microswitch clusters and synchronous stimulation to help students with multiple disabilities improve their overall condition. New research will need to (a) provide extra evidence with other students and other adaptive responses to combine with head position and (b) determine the real role of the new program and its relation to formal motor rehabilitation strategies within educational plans for persons with multiple disabilities. References Algozzine, B., Browder, D., Karvonen, M., Test, D. W., & Wood, W. M. (2001). Effects of intervention to promote selfdetermination for individuals with disabilities. Review of Educational Research, 71, 219–277. Barlow, D. H., Andrasik, F., & Hersen, M. (2006). Single-case experimental designs (3rd ed.). New York: Allyn & Bacon. Bartlett, D. J., & Palisano, R. J. (2002). Physical therapists’ perception of factors influencing the acquisition of motor abilities of children with cerebral palsy: Implications for clinical reasoning. Physical Therapy, 82, 237–248. Borrero, J. C., & Vollmer, T. R. (2002). An application of the matching law to severe problem behavior. Journal of Applied Behavior Analysis, 35, 13–27. Crawford, M. R., & Schuster, J. W. (1993). Using microswitches to teach toy use. Journal of Developmental and Physical Disabilities, 5, 349–368. Cronbach, L. J. (1951). Coefficient alpha and the internal structure of tests. Psychometrika, 16, 297–334. Cunningham, J., McDonnell, A., Easton, A., & Sturmey, P. (2003). Social validation data on three methods of physical restraint: Views of consumers, staff and students. Research in Developmental Disabilities, 24, 307–316. Ecott, C. L., & Critchfield, T. S. (2004). Noncontingent reinforcement, alternative reinforcement, and the matching law: A laboratory demonstration. Journal of Applied Behavior Analysis, 37, 249–265.
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Felce, D., & Perry, J. (1995). Quality of life: Its definition and measurement. Research in Developmental Disabilities, 16, 51–74. Fetters, L., & Kluzik, J. (1996). The effects of neurodevelopmental treatment versus practice on the reaching of children with spastic cerebral palsy. Physical Therapy, 76, 346–358. Geruschat, D. R. (1992). Using the Acuity Card Procedure to assess visual acuity in children with severe and multiple impairments. Journal of Visual Impairment and Blindness, 86, 25–27. Gwinn, M. M., Derby, K. M., Fisher, W., Kurtz, P., Fahs, A., Augustine, M., et al. (2005). Effects of increased response effort and reinforcer delay on choice and aberrant behavior. Behavior Modification, 29, 642–652. Kazdin, A. E. (2001). Behavior modification in applied settings (6th ed.). New York: Wadsworth. Kennedy, K. (2005). Single case designs for educational research. New York: Allyn & Bacon. Ketelaar, M., Vermeer, A., Hart, H., van Petegem-van Beek, E., & Helders, P. J. (2001). Effects of a functional therapy program on motor abilities of children with cerebral palsy. Physical Therapy, 81, 1534–1545. Kramer, J. F., Ashton, B., & Brander, R. (1992). Training of head control in the sitting and semi-prone positions. Child: Care, Health and Development, 18, 365–376. Lachapelle, Y., Wehmeyer, M. L., Haelewyck, M. C., Courbois, Y., Keith, K. D., Schalock, R., et al. (2005). The relationship between quality of life and self-determination: An international study. Journal of Intellectual Disability Research, 49, 740–744. Lancioni, G. E., O’Reilly, M. F., Campodonico, F., & Mantini, M. (2001). Promoting performance fluency in a person with profound multiple disability and blindness. Behavioural and Cognitive Psychotherapy, 29, 373–377. Lancioni, G. E., O’Reilly, M. F., Singh, N. N., Groeneweg, J., Bosco, A., Tota, A., et al. (2006). A social validation assessment of microswitch-based programs for persons with multiple disabilities employing teacher trainees and parents as raters. Journal of Developmental and Physical Disabilities, 18, 383–391. Lancioni, G. E., O’Reilly, M. F., Singh, N. N., Oliva, D., Piazzolla, G., Pirani, P., et al. (2002). Evaluating the use of multiple microswitches and responses for children with multiple disabilities. Journal of Intellectual Disability Research, 46, 346–351. Lancioni, G. E., O’Reilly, M. F., Singh, N. N., Oliva, D., Scalini, L., Vigo, C. M., et al. (2005a). Further evaluation of microswitch clusters to enhance hand response and head control in persons with multiple disabilities. Perceptual and Motor Skills, 100, 689–694. Lancioni, G. E., O’Reilly, M. F., Singh, N. N., Oliva, D., Scalini, L., Vigo, C. M., et al. (2005b). Microswitch clusters to enhance adaptive responses and head control: A programme extension for three children with multiple disabilities. Disability and Rehabilitation, 27, 637–641. Lancioni, G. E., O’Reilly, M. F., Singh, N. N., Oliva, D., Scalini, L., Vigo, C. M., et al. (2005c). Microswitch clusters to enhance hand responses and appropriate head position in two children with multiple disabilities. Pediatric Rehabilitation, 8, 59–62. Lancioni, G. E., Singh, N. N., O’Reilly, M. F., Oliva, D., Scalini, L., Vigo, C. M., et al. (2004). Microswitch clusters to support responding and appropriate posture of students with multiple disabilities: Three case evaluations. Disability and Rehabilitation, 26, 501–505. Lancioni, G. E., Singh, N. N., O’Reilly, M. F., Sigafoos, J., Didden, R., Oliva, D., et al. (2007). Fostering adaptive responses and head control in students with multiple disabilities through a microswitch-based program: Follow-up assessment and program revision. Research in Developmental Disabilities, 28, 187–196. Larnert, G., & Ekberg, O. (1995). Positioning improves the oral and pharyngeal swallowing function in children with cerebral palsy. Acta Paediatrica, 84, 689–692. Myhr, U., von Wendt, L., Norrlin, S., & Radell, U. (1995). Five-year follow-up of functional sitting position in children with cerebral palsy. Developmental Medicine and Child Neurology, 37, 587–596. Nwaobi, O. M., & Smith, P. D. (1986). Effects of adaptive seating on pulmonary function of children with cerebral palsy. Developmental Medicine and Child Neurology, 28, 351–354. Parette, H. P., Brotherson, M. J., & Blake-Huer, M. (2000). Giving families a voice in augmentative and alternative communication decision-making. Education and Training in Mental Retardation and Developmental Disabilities, 35, 177–190. Redstone, F. (2004). The effects of seating position on the respiratory patterns of preschoolers with cerebral palsy. International Journal of Rehabilitation Research, 27, 283–288. Redstone, F., & West, J. F. (2004). The importance of postural control for feeding. Pediatric Nursing, 30, 97–100. Richards, S. B., Taylor, R. L., Ramasamy, R., & Richards, R. Y. (1999). Single subject research: Applications in educational and clinical settings. London: Wadsworth. Siegel, S., & Castellan, N. J. (1988). Nonparametric statistics (2nd ed.). New York: McGraw-Hill.
384
G.E. Lancioni et al. / Research in Developmental Disabilities 29 (2008) 373–384
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. Wehmeyer, M., & Schwartz, M. (1998). The relationship between self-determination and quality of life for adults with mental retardation. Education and Training in Mental Retardation and Developmental Disabilities, 33, 3–12.