Persons with multiple disabilities increase adaptive responding and control inadequate posture or behavior through programs based on microswitch-cluster technology

Research in Developmental Disabilities 34 (2013) 3411–3420

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Research in Developmental Disabilities

Persons with multiple disabilities increase adaptive responding and control inadequate posture or behavior through programs based on microswitch-cluster technology Giulio E. Lancioni a,*, Nirbhay N. Singh b, Mark F. O’Reilly c, Jeff Sigafoos d, Doretta Oliva e, Adele Boccasini e, Maria L. La Martire e, Fiora D’Amico f, Giovanni Sasanelli f a

University of Bari, Italy Medical College of Georgia, Georgia Regents University, Augusta, USA c University of Texas at Austin, USA d Victoria University of Wellington, New Zealand e Lega F. D’Oro Research Center, Osimo, Italy f S. Raffaele Care Center, Alberobello, Italy b

A R T I C L E I N F O

A B S T R A C T

Article history: Received 7 July 2013 Accepted 9 July 2013 Available online 3 August 2013

Study I used typical microswitch-cluster programs to promote adaptive responding (i.e., object manipulation) and reduce inappropriate head or head–trunk forward leaning with a boy and a woman with multiple disabilities. Optic, tilt, and vibration microswitches were used to record their adaptive responses while optic and tilt microswitches monitored their posture. The study included an ABB1AB1 sequence, in which A represented baseline phases, B represented an intervention phase in which adaptive responses were always followed by preferred stimulation, and B1 represented intervention phases in which the adaptive responses led to preferred stimulation only if the inappropriate posture was absent. Study II assessed a non-typical, new microswitch-cluster program to promote two adaptive responses (i.e., mouth cleaning to reduce drooling effects and object assembling) with a man with multiple disabilities. Initially, the man received preferred stimulation for each cleaning response. Then, he received stimulation only if mouth cleaning was preceded by object assembling. The results of Study I showed that both participants had large increases in adaptive responding and a drastic reduction in inappropriate posture during the B1 phases and a 2-week post-intervention check. The results of Study II showed that the man learned to control drooling effects through mouth cleaning and used object assembling to extend constructive engagement and interspace cleaning responses functionally. The practical implications of the findings are discussed. ß 2013 Elsevier Ltd. All rights reserved.

Keywords: Microswitch-cluster technology Adaptive responding Inappropriate posture Problem behavior Multiple disabilities

1. Introduction Persons with severe to profound intellectual and multiple disabilities may frequently display inappropriate postures, such as head forward or sideward leaning, and forms of problem behavior, such as hand mouthing or drooling (Kurtz, Boelter, Jarmolowicz, Chin, & Hagopian, 2011; Lancioni, Singh, O’Reilly, & Sigafoos, 2005; LeBlanc, Patel, & Carr, 2000; Matson,

* Corresponding author at: Department of Neuroscience and Sense Organs, University of Bari, Via Quintino Sella 268, 70100 Bari, Italy. Tel.: +39 0805521410. E-mail addresses: [email protected], [email protected] (G.E. Lancioni). 0891-4222/$ – see front matter ß 2013 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.ridd.2013.07.014

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Minshawi, Gonzalez, & Mayville, 2006; May & Kennedy, 2010; Vrijmoeth, Monbaliu, Lagast, & Prinzie, 2012). The presence of inappropriate postures or problem behaviors in the persons’ repertoire may seriously complicate their situation and interfere with their already limited adaptive responding, cause health concerns and injuries, and hamper their social image and their overall acceptance by others (Cooper, 2012; Horowitz, Matson, Hattier, Tureck, & Bamburg, 2013; Lancioni, Singh, O’Reilly, Sigafoos, Oliva, Pidala, et al., 2007; Matson & LoVullo, 2008). Given the aforementioned complications, the general recommendation for professionals in the education/rehabilitation areas is to apply intervention strategies to curb inappropriate postures and problem behaviors (Ball & Fazil, 2013; Hagopian, Paclawskyj, & Kuhn, 2005; LaVigna & Willis, 2012; Moore, Fisher, & Pennington, 2004; Richman, 2008; Smith & Matson, 2010). The intervention strategies available include, among others, noncontingent stimulation (environmental enrichment) with or without prompting, contingent reinforcement events (e.g., differential reinforcement of other behavior or of alternative behavior), response cost, and programs based on microswitch clusters (Carroll, Rapp, Rieck, & Siewert, 2011; Chowdhury & Benson, 2011; Lancioni et al., 2013; Lindberg, Iwata, Roscoe, Worsdell, & Hanley, 2003; Matson & LoVullo, 2008; Petscher, Rey, & Bailey, 2009; Vogl & Rapp, 2011). The use of microswitch clusters is based on the recognition that educational/rehabilitation intervention with persons with profound and multiple disabilities needs to encompass the dual goal of reducing negative aspects (i.e., inadequate postures or behaviors) and promoting constructive responding in order to have a positive clinical impact (Lancioni et al., 2006; Lancioni, Singh, O’Reilly, Sigafoos, Didden, Oliva, et al., 2008). Typical programs based on microswitch clusters allow one to (a) monitor concurrently negative aspects and constructive responding, and (b) deliver preferred stimuli automatically on constructive responding occurring in the absence of the negative aspects (Lancioni et al., 2006). For example, a program for a person with hand mouthing or head leaning and inactivity would be set up to monitor both constructive responding (e.g., object manipulation) and hand mouthing or head leaning. Efforts would initially be directed at delivering preferred stimulation for each constructive response, irrespective of whether this occurs in the presence of hand mouthing or head leaning. When the constructive response has consolidated, the program can introduce two variations, that is, (a) constructive responses emitted in the presence of hand mouthing or head leaning would not be followed by preferred stimulation, and (b) the stimulation presented for a constructive response would be interrupted prematurely if hand mouthing or head leaning appears (Lancioni, O’Reilly, et al., 2011; Lancioni, Singh, O’Reilly, Sigafoos, Oliva, Severini, et al., 2007). A number of studies have been carried out using typical microswitch-cluster programs such as those mentioned above to promote constructive responding and deal with inappropriate postures, such as head leaning or dystonic back arching, and problem behaviors such as hand mouthing and eye poking (Lancioni, Singh, O’Reilly, Sigafoos, Didden, et al., 2009). The results have been generally positive and indicated relevant improvement in the level of constructive responding as well as in the control of the inappropriate posture or problem behavior (Lancioni, Singh, O’Reilly, Sigafoos, Didden, Smaldone, et al., 2008; Lancioni, Singh, O’Reilly, Sigafoos, Oliva, et al., 2008; Lancioni, Smaldone, et al., 2007). The present two studies were to extend the assessment of microswitch-cluster programs. Study I used typical microswitch-cluster programs to promote constructive responding and reduce inappropriate head or head-trunk forward leaning with a boy with congenital multiple disabilities and a woman with post-coma multiple disabilities including dementia, respectively. Study II assessed a non-typical, new microswitch-cluster program to promote two forms of constructive activity with a man with multiple disabilities. One form consisted of a mouth-cleaning response that was instrumental to reduce the impact of his problem behavior (i.e., drooling). The second form was an object-assembling response, which served to (a) extend the constructive engagement of the participant and (b) allow a largely programmable and functional interval between cleaning responses (i.e., an interval that could ensure successful control of drooling effects and avoid risks of skin irritation and/or inadequate social image; see Lancioni, Singh, et al., 2011). Initially, the participant received stimulation for each cleaning response. When this response was consolidated, the participant received stimulation for the cleaning response only if this was preceded by an object-assembling response.

2. Study I 2.1. Method 2.1.1. Participants The participants (Kenny and Celine) were 10 and 64 years old, respectively. Kenny was born prematurely and had a diagnosis of congenital encephalopathy with spastic tetraparesis, severe visual impairment due to optic atrophy, epilepsy partially controlled through medication, lack of speech or any other form of communication, lack of interaction with objects, and absence of fecal and urinary control. He was considered to function within the profound intellectual disability range, although no IQ scores were available and no formal testing was possible. He was generally passive and withdrawn, and sat with his head leaning forward. He attended a daily school program in which he was provided with physiotherapy and general stimulation (e.g., music and massage). The main goals for parents and staff were to (a) promote constructive response engagement and thus enhance his level of activity and self-determination, and (b) strengthen his motor condition and help him control his head position. They were highly favorable to the use of the microswitch-cluster program proposed in this study and thought that it could be a helpful component of Kenny’s general education package.

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Celine had a diagnosis of neurodegenerative condition with decline in all spheres of functioning. This condition had apparently been set in motion by a stroke and subsequent coma that Celine had suffered about 5 years prior to the beginning of this study. She was reported to score below 10 on the Mini-Mental State Examination (Folstein, Folstein, & McHugh, 1975). She presented with left hemiparesis and was non-ambulatory. Her speech was minimal, apparently confused, and difficult to understand. She did no have sphincteric control, was provided with anti-psychotic and anti-depressive medication, and lived in a care center. She tended to be passive and sit with her head and trunk leaning on the table. Staff considered any effort to make her active and to improve her posture largely useful for her and her social context. The families of both participants had provided informed consent for their involvement in this study, which had been approved by a scientific and ethics committee. 2.1.2. Adaptive response and inappropriate posture The adaptive response selected for Kenny consisted of touching objects (i.e., plastic and wooden toys) attached to a horizontal bar placed in front of him. The adaptive response selected for Celine consisted of moving different daily objects across the table. Kenny’s inappropriate posture consisted of leaning his head forward rather than keeping it upward. He responded to light physical prompting to correct his posture. Celine’s inappropriate posture involved head and trunk forward leaning. In general, she sat with her head and trunk leaning on the table, resting her head on her hands. She responded to verbal prompting to correct her posture. 2.1.3. Microswitch-cluster technology and stimuli The microswitch-cluster technology for Kenny included (a) tilt and optic microswitches connected with the objects attached to the horizontal bar in front of him that were activated when he touched/manipulated those objects, (b) an optic microswitch attached to the wheelchair’s headrest that was activated when Kenny’s head was at a distance of less than 10 cm from it, and (c) a computer control system, which was connected to the microswitches and to vibratory devices, and also contained pre-arranged files with music stimuli and other auditory stimuli. The microswitch-cluster technology used for Celine included (a) a vibration microswitch that was activated when Celine moved objects on the table, (b) an optic microswitch on her wheelchair’s back that was activated when Celine’s trunk was at a distance of less than 6 cm from it, (c) a tilt microswitch attached to a wire frame, which was fixed at her left ear and was activated when her head deviated less than 358 from an ideal straight line, and (d) a computer control system, which was connected to the microswitches and contained pre-arranged files with music stimuli. The stimuli used during the intervention phases of the study, contingent on the adaptive responses, included (a) songs, audio-recordings of familiar voices and noises, and vibratory inputs for Kenny, and (b) songs for Celine. The stimuli were selected through stimulus preference screening procedures. These procedures consisted of presenting a 10-s segment of each song and audio-recording, or a 5-s sample of each vibratory input for 8–20 non-consecutive times spread over several sessions. The stimuli were retained if the two research assistants who worked together during the screening agreed that they produced positive reactions (e.g., orienting or smiling) in about 60% or more of the presentations. 2.1.4. Experimental conditions Sessions lasted 10 min for Kenny and 5 min for Celine (i.e., based on staff’s recommendations) and were carried out three to six or seven times a day. Recording concerned (a) the frequencies of adaptive responses, (b) the frequencies of those responses occurred without the presence of the inappropriate posture, (c) the session time elapsed without the presence of the inappropriate posture, and (d) the total stimulation time (i.e., cumulative time including all stimulation events) per session. The measures were recorded automatically through the computer system. The study was carried out according to an ABB1AB1 design (Barlow, Nock, & Hersen, 2009; Lancioni et al., 2013), in which A represented baseline phases, B represented the intervention phase targeting the adaptive responses irrespective of the inappropriate posture, and B1 represented the intervention phases targeting the adaptive responses and the inappropriate posture. Two weeks after the end of the second B1, a post-intervention check was carried out. 2.1.4.1. Baseline (A) phases. The baseline phases included five and eight sessions for Kenny and four and five sessions for Celine. The microswitch clusters and the computer system were available, but the adaptive responses were not followed by stimulation. Before the start of the sessions, the participants were prompted verbally and physically to perform an adaptive response. Prompting could be repeated two more times during the sessions after periods of no responding. 2.1.4.2. Intervention (B) phase. The B phase included 46 sessions for Kenny and 24 sessions for Celine. Conditions were as in baseline except that adaptive responses were followed by 8 and 10 s of preferred stimulation for the two participants, respectively, regardless of whether their posture was appropriate at the occurrence of the adaptive responses and during the stimulation. Prior to the phase, the participants received five and two introductory sessions, respectively, in which the research assistant used frequent prompting to provide them extended experience of the adaptive response and the preferred stimulation. 2.1.4.3. Intervention (B1) phases. The first B1 phase was preceded by six introductory sessions in which prompting from the research assistant was used to ensure the absence of the inappropriate posture during the adaptive responses and the

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stimulation that followed those responses. Following the introductory sessions, the first B1 phase included 28 and 41 regular sessions for the two participants, respectively. Those sessions presented two variations compared to those of the B phase. First, the adaptive responses produced positive stimulation only if they occurred in the absence of the inappropriate posture. Second, the stimulation following the aforementioned adaptive responses lasted the 8 s or 10 s scheduled only if the inappropriate posture did not occur during that period. Otherwise, the stimulation was interrupted. The second B1 phase included 84 and 107 sessions for the two participants, respectively. They were identical to those of the first B1 phase and were not preceded by introductory sessions. 2.1.4.4. Post-intervention check. The participants continued to receive sessions such as those of the B1 phases. Twelve of those sessions carried out 2 weeks after the end of the second B1 phase were used as the post-intervention check. 2.2. Results

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Figs. 1 and 2 summarize the data of the two participants during the baseline and intervention phases. The gray bars and black circles of the upper panel of each figure show the mean frequencies of adaptive responses and the mean frequencies of those responses performed without the presence of the inappropriate posture per session over blocks of sessions, respectively. The gray bars and black circles of the lower panel of the figures show the mean cumulative time without inappropriate behavior and the mean cumulative stimulation time per session, over the aforementioned blocks of sessions. The numbers of sessions included in the blocks (bars-circles) are indicated by the numerals in the upper panel of the figures. During the first baseline phase, the participants’ mean frequencies of adaptive responses were about or below five per session. The mean frequencies of adaptive responses without the presence of the inappropriate posture were close to (or virtually) zero. The mean session time without the inappropriate posture was less than 1 min for both participants. During the Intervention (B) phase, the mean frequencies of adaptive responses were about 24 and 17 per sessions for the two participants, respectively. Their mean frequencies of adaptive responses free from the inappropriate posture were below 10 and below 5. Their mean session time without the inappropriate posture amounted to about 1.5 and less than 1 min, respectively. Their mean stimulation time per session was about 3 min. During the first B1 phase, the mean frequencies of adaptive responses were about 40 and slightly above 20 per session, respectively. The mean frequencies of adaptive responses occurring without the presence of the inappropriate posture were about 30 and close to 20. The mean session time without inappropriate posture was above 4.5 and 3.5 min, respectively. The mean stimulation time per session was about 3 and 2.5 min. During the second baseline phase, the mean frequencies of responses were about 10 and below 5 per session, respectively. The mean session time without inappropriate posture was slightly above 2 and 1 min. During the second B1 phase and the post-intervention check (not reported in the figures), the participants’ performance improved over the levels of the first B1 phase.

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Blocks of Sessions [ KENNY ] Fig. 1. Kenny’s data. The gray bars and black circles of the upper panel show the mean frequencies of adaptive responses and the mean frequencies of those responses performed without the presence of the inappropriate posture per session over blocks of sessions, respectively. The gray bars and black circles of the lower panel of the figures show the mean cumulative time without inappropriate behavior and the mean cumulative stimulation time per session, over the aforementioned blocks of sessions. The numbers of sessions included in the blocks are indicated by the numerals in the upper panel.

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3. Study II 3.1. Method 3.1.1. Participant The participant (Thomas) was 27 years old. He had a diagnosis of congenital encephalopathy and presented with spastic tetraparesis, which reduced his ambulation opportunities and his manual dexterity. He understood a variety of simple instructions concerning daily activities, but had no speech abilities except for a few interpretable sounds. His active communication occurred through the selection of pictorial representations (i.e., photo of objects and activities portraying what he wanted to obtain or do). He was rated to function within the severe intellectual disability range, but no IQ scores were available. Drooling had been a problem for him from the early years of his life and had increased with age. In fact, he had large production of saliva, did not swallow, and did not spontaneously clean his mouth. So, he tended to be frequently wet with negative medical, practical, and social implications. Finding a strategy to reduce the impact of his drooling was considered highly desirable by his family and by the staff of the center for persons with multiple disabilities that he attended. The best approach to this goal was thought to involve the acquisition of a self-managed mouth-cleaning response to be performed at reasonable intervals during his vocational or recreational activities. His legal representative had provided a formal consent for his participation in this study, which had been approved by a scientific and ethics committee. 3.1.2. Drooling and adaptive responses Drooling was defined as a loss of saliva that provoked chin wetness (i.e., wetness below Thomas’ lower lip). The two adaptive responses selected for use during the intervention program consisted of (a) mouth-cleaning through a cloth, and (b) object assembling (e.g., water pipes). The first of these adaptive responses was aimed at reducing the effects of drooling and possibly maintaining Thomas’ mouth and chin dry. The second of the adaptive responses was introduced only after Thomas had consolidated the first adaptive (mouth-cleaning) response. It was to be carried out prior to the performance of the cleaning response and it served as a prerequisite to ensure that such a cleaning response would lead to a brief period of preferred stimulation. The role of the assembling response was to (a) extend the constructive engagement of the participant in functional activities and (b) allow a largely programmable interval between cleaning responses. A program relying exclusively on the cleaning response would most likely lead to an inter-response interval similar to the length of the stimulation following the single response emissions (i.e., the duration of the contingent/reinforcing stimulation). A short stimulation could lead to frequent responding with possibly negative consequences in terms of skin irritation and social image (Lancioni, Singh, et al., 2011; Van der Burg, Didden, Engbers, Jongerius, & Rotteveel, 2009). A relatively long stimulation could avoid the aforementioned risks but could lead to stimulus satiation with possible negative consequences for the consistency of responding (Kazdin, 2001; Lancioni, Singh, et al., 2011). The introduction of a second response to precede cleaning could ensure that even a relatively brief stimulation period would be sufficient to extend the intervals between cleaning instances and avoid all the risks mentioned above.

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3.1.3. Microswitch-cluster technology and stimuli The microswitch-cluster technology consisted of a microswitch for the mouth-cleaning response and a microswitch for the object-assembling response connected to a computer-aided system. This system was provided with specific software and musical stimuli delivered via an earplug that Thomas used (see below). The microswitch for the mouth-cleaning response was a light-dependent resistor (i.e., a 4-mm wide, sensitive button-like device; see Lancioni, O’Reilly, et al., 2007) held through a thin wire fixed to the throat and ending under the chin. Thomas activated this microswitch by covering the light-dependent area with the cloth used for the cleaning response. The microswitch for the assembling response was an optic sensor fixed across the opening of an object container and was activated by dropping assembled objects into such container. The stimuli were selected as in Study I and included a variety of popular songs. 3.1.4. Experimental conditions Sessions lasted 15 min and were carried out two to four times a day. Recording concerned the (a) frequencies of mouthcleaning responses (b) frequencies of object-assembling responses, and (c) percentages of observation intervals with chin wetness. The first two responses were automatically recorded through the computer system. Chin wetness was recorded by research assistants according to a momentary time sampling strategy with 15-s intervals. In practice the research assistants observed Thomas at the end of each interval and scored whether his chin was wet or dry. Interrater reliability was assessed during 20% of the sessions. The percentages of agreement (computed for the single sessions by dividing the lower number of recording intervals with the same score by the total number of intervals and multiplying by 100) were within the 85–100 range, with the mean exceeding 90. The study was carried out according to an ABB1AB1B2 design (Barlow et al., 2009; Lancioni et al., 2013), in which A represented baseline phases, B represented the intervention phase targeting the mouthcleaning response alone, B1 represented the intervention phases targeting the mouth-cleaning response and a twocomponent assembling response, and B2 matched the B1 except for an extension of the assembling response. Two weeks after the end of the B2, a post-intervention check was carried out. 3.1.4.1. Baseline (A) phases. The first baseline phase included six sessions, in which Thomas was provided with the microswitch for the mouth-cleaning response and the computer system and was prompted to respond prior to the start of the sessions and once or twice during the sessions if he failed to respond for more than 2 min. Responses were not followed by stimulation. The second baseline phase (three sessions) differed in that Thomas was also provided with the material for the object-assembling response (see B1 phases). 3.1.4.2. Intervention (B) phase. The B phase included 10 sessions during which conditions were as in the first baseline except that mouth-cleaning responses were followed by 10–15 s of preferred stimulation. The first B session was preceded by one introductory session in which the research assistant used frequent prompting to ensure extended experience of the mouthcleaning response and the preferred stimulation. 3.1.4.3. Intervention (B1) phases. The first B1 phase was preceded by five introductory sessions in which prompting from the research assistant was used to ensure extended and successful practice of both adaptive responses in the required sequence. In addition to the microswitch for the mouth-cleaning response and the computer system used in the first baseline and the B phase, the material available during the sessions included three containers, familiar objects, and the second microswitch. In one of the containers, Thomas found two of the three components of the objects, such as water pipes or thermos, already assembled. In the second container, Thomas found the third component needed to complete the aforementioned objects. The third container served to store the objects completed and was equipped with an optic microswitch that was activated as Thomas dropped one such object. Activation of this microswitch ensured that the subsequent mouth-cleaning response (and activation of the chin microswitch) would produce 10 s of preferred stimulation. Following the introductory sessions, the first B1 phase included 21 regular sessions without prompting from the research assistant. The second B1 phase included 14 sessions, which were identical to those of the first B1 phase and were not preceded by introductory sessions. 3.1.4.4. Intervention (B2) phase. Conditions were as at the end of the B1 with one exception, that is, Thomas was to assemble all three components of the objects available. The B2 phase involved 82 regular intervention sessions, which were preceded by one introductory session (see first B1 phase). 3.1.4.5. Post-intervention check. Thomas continued to receive sessions such as those of the B2 phase. Six of those sessions carried out 2 weeks after the end of the B2 phase were used as the post-intervention check. 3.2. Results Fig. 3 summarizes Thomas’ data during the baseline and intervention phases. The gray bars and black circles represent mean frequencies of mouth-cleaning responses and mean percentages of observation intervals with chin wetness per session over blocks of sessions (or a single session during the second baseline), respectively. During the first baseline phase, the mean frequency of mouth-cleaning responses was close to zero. The mean percentage of observation intervals with chin wetness was above 50. During the B phase, the mean frequency of mouth-cleaning responses per session increased to above

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Sessions [ THOMAS ] Fig. 3. Thomas’ data. The gray bars and black circles represent mean frequencies of mouth-cleaning responses and mean percentages of observation intervals with chin wetness per session over blocks of sessions (or a single session during the second baseline), respectively. During the B1 and B2 phases, the frequencies of mouth-cleaning responses matched the frequencies of object-assembling responses not reported in the figure.

40 and the mean percentage of observation intervals with chin wetness declined to zero by the last five sessions. During the first B1 phase, the mean frequency of mouth-cleaning responses per session was about 25 (each preceded by an assembly response) and the mean percentage of observation intervals with chin wetness was virtually zero. The frequency and percentage values reversed during the second baseline and returned to the first B1 levels during the second B1 phase. During the B2 phase and the following post-intervention check (not reported in the figure), the mean frequency of mouth-cleaning responses per session was about 16 (each preceded by an extended assembly response) and the mean percentage of intervals with chin wetness was about zero.

4. Discussion The results of the two studies provide encouraging evidence as to the potential benefits of programs based on microswitch-cluster technology. Study I extended the use of typical microswitch-cluster programs to promote constructive responding and reduce inappropriate head or head–trunk posture with a boy with congenital multiple disabilities and a woman with post-coma multiple disabilities including dementia. Study II assessed a non-typical, microswitch-cluster program to promote two forms of constructive activity with a man with multiple disabilities. One of these forms consisted of a mouth-cleaning response that was instrumental to reduce the impact of his problem behavior (i.e., drooling). The second form was an object-assembling response, which served to (a) extend the constructive engagement of the man and (b) build a functional interval between cleaning responses (i.e., an interval that could ensure successful control of drooling effects and avoid risks of skin irritation and/or inadequate social image). In light of these results, a number of considerations might be made. First, typical microswitch-cluster programs can be considered highly respectful of the participants’ input/stimulation needs and in line with the efforts of the education or rehabilitation/care contexts to reduce their inappropriate posture and problem behavior. The participants are not forced into abandoning such posture/behavior (which is considered to have a positive function that maintains its presence in their repertoire; see Lancioni, Singh, O’Reilly, & Sigafoos, 2009). They are first allowed to discover the possible enjoyment/satisfaction of accessing preferred environmental stimulation through a simple adaptive response, which is not incompatible with the posture/behavior to be reduced. Only when the adaptive response has increased and the stimulation has become a relevant and extended input, the participants are required to make their choice between such input and the consequences of their inadequate posture/behavior (Lancioni, O’Reilly, et al., 2011). When the environmental stimulation input has become highly relevant/extended, the participants are likely to (a) want to maintain it and thus (b) show high levels of self-control to inhibit their inadequate posture/behavior for relatively large portions of their engagement time (Lancioni, Singh, O’Reilly, & Sigafoos, 2009). Second, the possibility of success for typical microswitch-cluster programs would largely depend on the strength of the environmental stimulation used contingent on the adaptive response, the simplicity (low cost) of the adaptive response, the manageability of the inadequate posture/behavior, and the suitability of the microswitch cluster. A strong environmental stimulation can have a realistic chance of competing favorably with the effects of the inadequate posture/behavior, irrespective of whether such stimulation produces effects similar to those of the inadequate posture/behavior or not (Lancioni et al., 2006; Lanovaz, Fletcher, & Rapp, 2009; Saylor, Sidener, Reeve, Fetherston, & Progar, 2012). The manageability of the inadequate posture/behavior can be measured in terms of readiness with which it responds to verbal or physical prompts. The suitability of the microswitch cluster can be determined by how easily it matches the situation of the participant to monitor the adaptive response and the inadequate posture/behavior and deliver the environmental stimulation (Lancioni, O’Reilly, et al., 2011). The positive results of Study I would suggest that favorable conditions were available with regard to each of the four aspects mentioned above.

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Third, typical microswitch-cluster programs can also be viewed as highly practical solutions for rather complex intervention conditions (Lancioni, Sigafoos, O’Reilly, & Singh, 2012). Indeed, monitoring two or more measures simultaneously and providing environmental stimulation when the intervention conditions ask for it and preventing its occurrence or interrupting it in the other situations could be far too difficult and costly for staff or research assistants to implement. The availability of microswitch-cluster technology connected with a computer system can deal with all the requirements rather easily and reliably and with minimal staff time investment. These practical advantages of microswitchcluster programs may be considered affordable within education/rehabilitation centers as well as within home contexts due ¨ stergren, 2011; De Joode, van to the fact that the technology is largely inexpensive and relatively easy to use (Borg, Larson, & O Heugten, Verhey, & van Boxtel, 2010; Lancioni, O’Reilly, et al., 2011). Fourth, the microswitch-cluster program used in Study II can be viewed as an extension and variation in the employment of the microswitch technology with potentially beneficial practical implications. In previous microswitch research with persons with drooling and chin wetness, the intervention was focused on (a) teaching the participants a mouth-cleaning response that would curb the effects of drooling and (b) strengthening/maintaining such response with positive stimulation (Lancioni, Singh, et al., 2011). The microswitch monitored the response and triggered computer-mediated stimulation contingent on it. The problem with this approach was that the participants would reach high response frequencies with risks of skin irritation and of inadequate social image. To limit those risks, the approach was to have a relatively long stimulation period following each mouth-cleaning response. To avoid possible stimulus satiation, the strategy was to maintain the first part of the stimulation at normal intensity and reduce the second part to a relatively neutral level (Lancioni, Singh, et al., 2011). In Study II, the microswitch-cluster technology allowed to increase the interval between mouth-cleaning responses with the inclusion of functional adaptive responding (i.e., object assembling). Such responding, which could be later extended, was valued within the participant’s context and helped him improve his general occupation and social status (Beadle-Brown, Hutchinson, & Mansell, 2008; Crites & Howard, 2011; Mahoney & Roberts, 2009; Wolfensberger, 2011). Fifth, the achievements reported in Study II, in terms of chin wetness control and object assembling, could hardly be imagined as possible without the use of microswitch-cluster technology. Again, those achievements were obtained with minimal staff involvement and largely affordable cost (i.e., the technology package can be realized for a cost below 1000 US dollars). One might argue that this new type of microswitch-cluster program can also be used in situations of inadequate posture or conventional problem behavior such as hand mouthing. For example, one might initially establish an adaptive (object-manipulation) response and have this response followed by positive stimulation regardless of the inadequate posture/behavior. Subsequently, the response will produce positive stimulation only in case of adequate posture/behavior. Eventually, the object manipulation response can lead to positive stimulation not only if accompanied by adequate posture/ behavior but also if preceded by another adaptive response. Sixth, the achievement of positive results within programs such as those reported in Study I and in Study II reflect two highly relevant personal conditions, that is, self-determination and enjoyment (Duttlinger, Ayres, Bevill-Davis, & Douglas, 2013; Parsons, Reid, Bentley, Inman, & Lattimore, 2012; Sheppard & Unsworth, 2011). Indeed, the participants were not forced by restrictive methods to perform their adaptive responses and abstain from their inadequate posture or correct the consequences of their problem behavior. Rather, they performed independently (i.e., apparently motivated by their personal enjoyment of the stimulation available for the constructive responding) (Brown, Schalock, & Brown, 2009; Friedman, Wamsley, Liebel, Saad, & Eggert, 2009; Scherer, Craddock, & Mackeogh, 2011; Sunderland, Catalano, & Kendall, 2009). While no direct data collection on participants’ mood took place, various informal reports underlined their indices of happiness during the sessions (Dillon & Carr, 2007; Lancioni, Singh, O’Reilly, Oliva, & Basili, 2005). In conclusion, the positive results of the two studies represent encouraging evidence as to the role of microswitch-cluster technology in intervention programs for persons with multiple disabilities. 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