Post-coma persons with extensive multiple disabilities use microswitch technology to access selected stimulus events or operate a radio device

Research in Developmental Disabilities 32 (2011) 1638–1645

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Research in Developmental Disabilities

Post-coma persons with extensive multiple disabilities use microswitch technology to access selected stimulus events or operate a radio device Giulio E. Lancioni a,*, Nirbhay N. Singh b, Mark F. O’Reilly c, Jeff Sigafoos d, Gloria Alberti e, Doretta Oliva e, Gianfranco Megna f, Carla Iliceto g, Sabino Damiani g, Irene Ricci h, Antonella Spica h a

Department of Psychology, University of Bari, Via Quintino Sella 268, 70100 Bari, Italy ONE Research Institute, Midlothian, VA, USA Meadows Center for Preventing Educational Risk, University of Texas at Austin, TX, USA d Victoria University of Wellington, New Zealand e Lega F. D’Oro Research Center, Lesmo and Osimo, Italy f University of Bari, and Bari University Hospital, Italy g Bari University Hospital, Italy h S. Raffaele Care Center, Modugno, Italy b c

A R T I C L E I N F O

A B S T R A C T

Article history: Received 10 February 2011 Accepted 12 February 2011 Available online 12 March 2011

The present two studies extended research evidence on the use of microswitch technology by post-coma persons with multiple disabilities. Specifically, Study I examined whether three adults with a diagnosis of minimally conscious state and multiple disabilities could use microswitches as tools to access brief, selected stimulus events. Study II assessed whether an adult, who had emerged from a minimally conscious state but was affected by multiple disabilities, could manage the use of a radio device via a microswitch-aided program. Results showed that the participants of Study I had a significant increase of microswitch responding during the intervention phases. The participant of Study II learned to change radio stations and seemed to spend different amounts of session time on the different stations available (suggesting preferences among the programs characterizing them). The importance of microswitch technology for assisting post-coma persons with multiple disabilities to positively engage with their environment was discussed. ß 2011 Elsevier Ltd. All rights reserved.

Keywords: Post-coma Assistive technology Microswitches Minimally conscious state Multiple disabilities

1. Introduction Post-coma persons with multiple (consciousness/communication and neuro-motor) disabilities pose serious challenges to rehabilitation and care centers as well as to family contexts (Bekinschtein et al., 2005; Bernat, 2006; Bernat, 2009; Bernat & Rottenberg, 2007; Chua, Ng, Yap, & Bok, 2007; Giacino, 2004; Giacino & Kalmar, 2005; Giacino & Smart, 2007; Giacino & Trott, 2004; Lancioni, Bosco, et al., 2010; Schnakers et al., 2009). In addition to requiring specialized medical and physiotherapeutic attention, these persons need special help to acquire some constructive interaction with environmental stimuli (Keren, Reznik, & Groswasser, 2001; Lancioni, O’Reilly, et al., 2009; Leong, 2002; Naude´ & Hughes, 2005; Noda, Maeda, & Yoshino, 2004; Sara`, Pistoia, Mura, Onorati, & Govoni, 2009). In fact, their condition precludes them any opportunity to manipulate/ manage stimulus sources on their own and, thus, they need assistive technology to develop some forms of positive engagement/interaction with those sources (Coleman, 2005; Giacino & Trott, 2004; Lancioni, Bosco, et al., 2010; Lancioni, O’Reilly, et al., 2009; Lancioni et al., 2009b).

* Corresponding author. E-mail address: [email protected] (G.E. Lancioni). 0891-4222/$ – see front matter ß 2011 Elsevier Ltd. All rights reserved. doi:10.1016/j.ridd.2011.02.016

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Positive environmental engagement for persons who are in a minimally conscious state, lack any specific communication mode, and are affected by pervasive neuro-motor disabilities may consist in activating and enjoying positive stimulus events through the use of personalized/experimental microswitches (Holburn, Nguyen, & Vietze, 2004; Lancioni, Bosco, et al., 2010; Lancioni, O’Reilly, et al., 2009; Lancioni et al., 2009b; Naude´ & Hughes, 2005). For example, the person might learn to use (a) a touch sensitive microswitch that detects his or her finger movements and is connected to a timing device and a music player or (b) an optic microswitch that detects his or her eyelid movements and is linked to a timing device and a video player (Lancioni, O’Reilly, et al., 2010). Simple/minimal movements of the fingers or full/prolonged closure of the eyelid would enable the person to activate the music or video player and obtain brief periods of preferred stimulation. Positive environmental engagement for persons who have emerged from a minimally conscious state, but are still affected by extensive communication and neuro-motor disabilities, might involve forms of leisure activity supported by assistive technology (Lancioni, Singh, O’Reilly, Sigafoos, Oliva, et al., 2010). For example, the persons might learn to manage the use of television or radio devices through microswitch-based programs (Lancioni, Bosco, et al., 2010). These programs would ensure that microswitch activations produced through simple motor responses could change television or radio channels/stations and also turn ‘‘off’’ and ‘‘on’’ these devices. The realization that assistive technology is critical for helping post-coma persons with extensive multiple disabilities to engage with their environment profitably has motivated recent research initiatives aimed at promoting those engagement opportunities (Lancioni, Bosco, et al., 2010). Several studies were directed at adapting and assessing microswitch technology alone or in combination with Voice Output Communication Aids (VOCAs) to allow post-coma patients (approximately 15) to seek stimulation or caregiver’s contact on their own initiative (e.g., Lancioni, Olivetti Belardinelli, Stasolla, et al., 2008; Lancioni, O’Reilly, et al., 2009; Lancioni et al., 2009a, 2009b; Lancioni, Singh, O’Reilly, Sigafoos, Buonocunto, et al., 2010). One study was conducted with the aim of enabling a patient to manage television use (Lancioni, Singh, O’Reilly, Sigafoos, Oliva, et al., 2010). The present two studies were aimed at extending the research evidence in the area. Specifically, Study I extended the assessment of microswitch technology to allow three adults with a diagnosis of minimally conscious state and multiple disabilities to use such technology to access brief (selected) stimulus events independently. The technology used with them included a touch-sensitive pad microswitch, an adapted optic microswitch, and a non-contact, camera-based microswitch. The first microswitch had been used only once while the last had never been used with this population (Lancioni, Bellini, et al., 2010; Lancioni, Bosco, et al., 2010). Study II was an effort to set up a technology-aided program to enable an adult, who had emerged from a minimally conscious state but was affected by multiple disabilities, to manage the use of a radio device. 2. Study I 2.1. Method 2.1.1. Participants The participants (Christine, Anne, and Lindsey) were 74, 77, and 67 years of age, respectively. Christine had suffered cerebral aneurysm rupture and consequent coma about 7 months prior to the beginning of this study. A brain computed tomography (CT) scan showed extensive subarachnoid hemorrhage spreading through the frontal lobes. The aneurysm rupture was treated through embolization and the haematoma was evacuated surgically via bifrontal craniotomy. The coma developed into a vegetative state, which remained so until almost the beginning of this study and eventually evolved into a minimally conscious state. Her total score on the JFK Coma Recovery Scale-Revised during this study was 7; with partial scores of zero on the oromotor/verbal and communication subscales, 1 on the arousal subscale, and 2 on the auditory, visual, and motor subscales (Kalmar & Giacino, 2005; Lombardi, Gatta, Sacco, Muratori, & Carolei, 2007). She presented with tetraparesis, lack of head and trunk control, and fecal and urinary incontinence, and used a gastrostomy tube for enteral nutrition, as well as a tracheostomy tube. Anne also had suffered cerebral aneurysm rupture with consequent coma about 4 months prior to the beginning of this study. A brain CT scan showed extensive subarachnoid hemorrhage with haematoma in the left frontal region. The aneurysm rupture was treated through embolization and the haematoma was evacuated surgically. The coma condition was replaced by a vegetative state, which in turn developed into a minimally conscious state. Her total score on the JFK Coma Recovery Scale-Revised at the start of this study was 12; with partial scores of zero on the communication subscale, 1 on the auditory subscale, 2 on the arousal, oromotor/verbal, and visual subscales, and 5 on the motor subscale. She presented with left hemiparesis with reduced head control, lack of trunk control, and minimal movement of the right hand. She had fecal and urinary incontinence and used gastrostomy and tracheostomy tubes. Lindsey had suffered primary intraparenchymal hemorrhage with subsequent coma about 18 months prior to the beginning of this study. A brain CT scan showed an extensive haematoma at the level of the right basal nuclei, with ventricular compression. The haematoma was evacuated via right temporal-parietal craniotomy. The coma developed into a vegetative state, which only slowly evolved into a minimally conscious state. His total score on the JFK Coma Recovery ScaleRevised at the start of this study was 14; with partial scores of 1 on the oromotor/verbal and communication subscales, and 3 on the arousal, motor, auditory, and visual subscales. He presented with tetraparesis with reduced head control and lack of trunk control. He also had fecal and urinary incontinence and used gastrostomy and tracheostomy tubes. The families of all three participants had provided informed consent for their involvement in this study, which had been approved by a scientific and ethics committee.

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2.1.2. Position, responses, technology, and stimuli During the sessions, Christine and Anne were lying in bed. Lindsey could be in bed or in a special wheelchair (i.e., in a reclined position). One response was selected for each participant. The response was already present (at low frequencies) in the participant’s repertoire, seemed fairly feasible for him or her to perform, and could be reliably monitored through specific, experimental microswitch technology (see also Lancioni, Bosco, et al., 2010). Christine’s response consisted of a full eyelid closure, which was recorded through a new camera-based microswitch (never used with post-coma patients), which relied on a computer with CPU, a USB video camera with a 16-mm lens, color markers, and a specific software program (see Lancioni, Bellini, et al., 2010). Christine was provided with a blue color spot greater than 1.5 cm2 on her left eyelid. The camera was focused on her face from a distance of about 1 m and the computer analyzed her face pictograms every 200–300 ms. If the blue area showed an increase of about 50% compared to its standard size (i.e., the pre-acquired size measure corresponding to a situation of eyelid open), the computer (a) recorded an eyelid closure response, and (b) activated a 10–15 s stimulation period consisting of preferred music and body massage (i.e., except during the baseline phases; see below). Anne’s response consisted of finger movements, that is, any small changes she made with regard to her fingers/hand position. These changes were detected through a touch-sensitive pad microswitch on which Anne’s right hand was placed. This microswitch had previously been used with only one post-coma patient (see Lancioni, O’Reilly, et al., 2010). Each square inch of the pad was an independent touch-sensitive device. So whenever a small movement occurred affecting one of the independent touch-sensitive devices, the microswitch was activated. This activation triggered a microprocessor-based electronic control system, which in turn started 10 s of preferred music and body massage stimulation (except in baseline; see below). Lindsey’s response consisted of a protracted (i.e., 1-s) eyelid closure recorded through an optic sensor/microswitch, which was fixed to his eyeglasses’ frame (Lancioni, O’Reilly, et al., 2009). The activation of the microswitch triggered a microprocessor-based electronic control system, which in turn started 15 s of preferred music except during baseline. The music and song segments used for the three participants originated from samples of about 15 popular musical pieces recommended by the participants’ families (as highly preferred by the patients before their brain injury) and selected after brief stimulus preference screening. The screening involved the presentation of at least one segment per musical piece for 5– 10 non-consecutive times (Lancioni, O’Reilly, et al., 2010). The pieces were retained for the study, based on alerting/orienting reactions observed in about 50% of the presentations. The massage stimulation consisted of light stroking of Christine’s arms, hands, and shoulders and of Anne’s shoulders, head and neck. This form of stimulation was added to the musical events, on the assumption that it might be pleasant and increase the positive (motivating) value of the musical events per se (Lancioni, Bosco, et al., 2010). 2.1.3. Experimental conditions Sessions took place in the medical-rehabilitation centers in which the participants were temporarily residing, lasted 5 min, and were carried out 4–11 times a day based principally on the participants’ availability. Data collection concerned the participants’ microswitch responses, which were automatically recorded via the electronic control system or computer device (see above). A response was recorded if it occurred after the 10–15 s stimulation for the previous response had ended (intervention phases) or after an equivalent or longer period from the previous response had elapsed (baseline phases). Response prompting (i.e., physical guidance of finger movements or a light air-puff on the corner of the eye for eyelid closure) occurred prior to the sessions and during the sessions, that is, after 30–60 s had elapsed with no responding from the participants. Responses occurring after prompting were subtracted from the session total by the research assistants in charge of the sessions. Interrater reliability on this measure was checked over a total of 51 sessions. Agreement, with the two raters reporting the same number of prompt-related responses (which could also be zero), occurred in 49 of those 51 sessions. The study was carried out according to an ABAB sequence for each participant (Barlow, Nock, & Hersen, 2009), with the A representing baseline phases and the B intervention phases. 2.1.3.1. First baseline (A) phase. This phase included six sessions for Christine and Anne and five sessions for Lindsey. Christine was provided a blue spot on her left eyelid and the camera-based microswitch technology was available to record her responses but did not activate any stimulation on them. Similarly, no body massages occurred for those responses. Anne had the touch-sensitive microswitch and the related control system for recording hand movements. Yet, neither musical stimulation nor body massages were available for the responses. Lindsey had the optic microswitch and the control system for recording his eyelid responses. Responses were not followed by stimulation. 2.1.3.2. First intervention (B) phase. This phase was introduced by five or six practice sessions. During these sessions, prompting from the research assistant could occur at intervals of 30 s or less to increase the frequency of the responses and their pairings with the musical stimuli (Lindsey) or musical stimuli and massage (Christine and Anne), which were scheduled for them. The first intervention (B) phase included 127, 94, and 74 sessions for the three participants, respectively. These sessions differed from the baseline sessions only in that the responses were followed by stimulation. 2.1.3.3. Second baseline (A) phase. This phase included five or six sessions for Christine and Anne and nine sessions for Lindsey. Conditions were as in the first baseline phase.

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2.1.3.4. Second intervention (B) phase. This phase included 87, 75, and 86 sessions for the three participants, respectively. It differed from the first intervention phase in that (a) there were no introductory/practice sessions, and (b) the body massages for Christine and Anne occurred on an intermittent basis (i.e., for about 45% of the responses). 3. Results Figs. 1–3 summarize the data of the three participants (i.e., the responses they performed independent of prompting). Data points represent mean frequencies of responses over blocks of four sessions (or blocks of three or two sessions if an arrow is present). During the first baseline (A) phase, the mean frequencies of responses per session varied from slightly above eight (Anne) to about five (Christine and Lindsey). During the first intervention (B) phase, the mean response frequencies per session were between about 10 (Christine) and 13 (Anne and Lindsey). During the second baseline (A) phase, all three participants showed declines in their responding. During the second intervention (B) phase, their mean response frequencies per session were between about 13 (Christine and Lindsey) and 17 (Anne). The difference between the baseline response frequencies (i.e., both A phases) and the intervention response frequencies (i.e., both B phases) was statistically significant (p < .01) for each participant on the Kolmogorov–Smirnov test (Siegel & Castellan, 1988). 4. Study II 4.1. Method

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4.1.1. Participant The participant (Lucas) was 51 years old and attended a care and rehabilitation center due to his multiple disabilities related to acquired brain injury. In fact, Lucas had suffered aneurysm rupture with consequent coma and brain surgery about 8 years prior to the beginning of this study. A brain CT scan carried out a few months after the surgery showed extensive signs of cerebral damage in the right frontal-opercular region, ‘‘ex-vacuo’’ dilation of the frontal horn of the right lateral ventricle and two small [()TD$FIG]

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thalamic lacunae. At the time of this study, Lucas’ condition was characterized by minimal visual functioning, anosognosia, urinary incontinence, left hemiparesis, and severe reduction of any fine motor coordination. He was in a wheelchair and also showed apathy, depressive mood, and virtual mutism. Prior to this study, Lucas was satisfactorily involved in technology-based programs aimed at ensuring messaging opportunities and basic indoor orientation. Psychological estimates of his intellectual functioning provided at the start of those programs suggested a borderline condition, while his Vineland age equivalents were below 4 years on Daily Living Skills and Socialization (Sparrow, Balla, & Cicchetti, 1984). His participation in this study was thought to be practically beneficial and pleasant for him, as he was known to enjoy listening to the radio and to depend on others for operating it. The study had been approved by a scientific and ethics committee, and Lucas had agreed to participate in it. Moreover, his legal representative had signed a consent form for him. 4.1.2. Position, technology, and response During the sessions, Lucas sat in his wheelchair or on the couch with a conventional radio or the technology set up for this study, which included a modified radio device, a microprocessor-based electronic control unit, a microswitch, and an amplified MP3 player with recorded verbal messages. The microswitch was a pressure sensor that Lucas could activate with a simple hand-movement response. The radio was a digital device in which 10 stations were pre-selected on the basis of their different characteristics in terms of prevailing programs. The stations were characterized by (i) religion (sermons and prayers), (ii) Italian music with commentaries, (iii) uninterrupted music, (iv) classic music and local news, (v) music and songs of the 1970s–1990s, (vi) newly released songs, (vii) disco music, (viii) politics, (ix) big orchestras’ pieces, and (x) comedy. The radio’s operation functions were linked to (and controlled by) the microprocessor-based electronic unit. This unit was provided with specific software that served to carry out the operations decided by Lucas through the microswitch. Each session with the technology started with the radio on (i.e., tuned on the first of the 10 pre-selected stations). To change station (i.e., to tune on the next one of the pre-selected series), Lucas was required to activate the microswitch and thereby trigger the aforementioned electronic unit. The same operation could be repeated with the same effects anytime Lucas wanted to move to the next station, with one exception. That is, if he was tuned on the tenth station, a change caused the radio to turn off. A new microswitch activation after that caused the radio to turn on again and tune on the first of the 10 stations. The turn-off option was included as a way to allow Lucas to interrupt the radio engagement if he so desired. After periods of 3 min spent on the same station, a verbal message emitted by the MP3 player would ask Lucas whether he liked (wanted to listen to) that station. This message option was used to reduce the risk that remaining on a same station could be due to a loss of attention (decline in alertness). 4.1.3. Sessions and data collection Baseline sessions lasted 10 min (as Lucas was not expected to use a radio without technology; see below). Intervention sessions lasted 30 min (i.e., a time interval that was considered optimal based on previous observations) or until Lucas turned off the radio and kept it off for 2 min, whichever came first. The measures recorded consisted of (a) the sessions’ length, (b) the number of station changes, and (c) the total (cumulative) amount of time that Lucas spent listening to each station. The measures were recorded by one rater (or by two raters in about 25% of the intervention sessions). Agreement allowed (a) a 1-min discrepancy between the raters on the length of the sessions and the total amount of time spent with each station, and (b) a difference of two changes on recording the number of station changes. With those criteria, agreement on all measures was reported in about 95% of the sessions in which two raters were employed. 4.1.4. Experimental conditions The study was conducted according to an ABAB experimental design, in which the A represented baseline phases without the technology and the B intervention phases with the technology (Barlow et al., 2009).

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Blocks of Sessions Fig. 4. Lucas’ data. The black squares represent the mean frequencies of station changes over blocks of sessions. The numbers of sessions included in the blocks are indicated by the numerals above the squares. The bars indicate the mean percentages of session time spent on the three stations most listened to over the same blocks of sessions. Each bar is divided into three sections representing those three most-listened-to stations (identified with Roman numerals) and the related mean percentages of listening time.

4.1.4.1. First and second baseline (A) phases. Each of the two baseline phases included two 10-min sessions. During those sessions, a conventional radio was on. The research assistant could ask Lucas whether he wanted to listen to the same station or wanted her to change station for him. 4.1.4.2. First and second intervention (B) phases. The two intervention phases included 59 and 78 sessions, respectively. The first phase was introduced by three practice sessions of about 15 min, during which the research assistant helped Lucas to use the technology through the operations allowed (see above). During the subsequent (regular) intervention sessions of the first phase and those of the second phase, Lucas was to use the technology on his own. 5. Results Fig. 4 summarizes Lucas’ data concerning the frequencies of station changes performed over blocks of sessions (black squares) and the percentages of session time spent on the three stations most listened to (stacked bars) over the same blocks of sessions. Each bar is divided into three sections representing the three most listened to stations (identified with the same Roman numerals used above) and the related percentages of listening time. For example, the first bar of the first intervention (B) phase involves the fifth station (which was listened to for a mean of about 32% of the session time), and the second and third stations (each of which was listened to for a mean of about 12% of the session time). All three stations together accounted for a cumulative mean of about 56% of the session time. This cumulative percentage of time is represented by the bar in its entirety (which portrays the sum of the three specific percentages). The length of the sessions is not reported in the figure, as it was 10 min for each of the four baseline sessions and 30 min for all but three intervention sessions. During the first baseline (A) phase, Lucas did not make any independent station change and thus no usable data were available regarding the amount of session time spent on different stations. During the first intervention (B) phase, Lucas had a mean of about 20 station changes per session. The most listened to station was the fifth, which covered the largest or second largest percentage of session time in the four blocks of sessions of the phase (see the first four intervention bars of the figure). During the second baseline (A) phase, the data matched those obtained in the first baseline. During the second intervention (B) phase, Lucas had a mean of about 25 station changes per session. The most listened to station was the eighth. The percentage of time spent on it was the largest or second largest in four of the five blocks of sessions of the phase (see Fig. 4). The fifth station remained broadly listened to, in line with the data of the first intervention phase. 6. Discussion The results of Study I provide general support to previous data on the usability of microswitch-aided programs with persons with minimally conscious state and multiple disabilities (Lancioni, Bosco, et al., 2010; Lancioni, O’Reilly, et al., 2009; Lancioni et al., 2009a, 2009b; Lancioni, Singh, O’Reilly, Sigafoos, Buonocunto, et al., 2010). They also provide relevant (needed) evidence on the suitability of specific forms of microswitches that were never used before with these persons (i.e., the camera-based device) or were used only minimally (i.e., the touch sensitive pad). The results of Study II represent a new piece of evidence as to the possibility of establishing leisure engagement with post-coma persons who have successfully emerged from a minimally conscious state but remain largely limited in their adaptive achievement due to their extensive neuro-motor and communication disabilities (Lancioni, Bosco, et al., 2010; Lancioni et al., 2011; Lancioni, Singh, O’Reilly, Sigafoos, Buonocunto, et al., 2010).

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Offering post-coma persons with a minimal conscious state and multiple disabilities a strategy (i.e., a microswitch-based program) to seek stimulation events through active engagement may be considered a relevant achievement (Lancioni, Bosco, et al., 2010). Indeed, this strategy allows the persons an active role as opposed to alternative strategies such as general sensory stimulation and music therapy in which the stimulation process is essentially controlled by the therapist and the patient remains at the receiving end of it (Coleman, 2005; Elliott & Walker, 2005; Lancioni, Bosco, et al., 2010; Wilson, Harpur, & McConnell, 2007). Pursuing an active role may be seen to be helpful in different ways, that is, in (a) developing and consolidating some form of response involvement, (b) promoting learning (association) opportunities, (c) establishing basic self-determination, and (d) motivating the practice of basic forms of interaction/communication, and thereby facilitating the general rehabilitation plan (Lancioni, O’Reilly, et al., 2009; Lancioni et al., 2009a, 2009b; Lancioni, Singh, O’Reilly, Sigafoos, Buonocunto, et al., 2010; McNaughton & Bryen, 2007; Tsuchiya & Adolphs, 2007; Wales & Waite, 2005; Wilson et al., 2007). The importance of extending the assessment of totally or partially new microswitch solutions for persons with very limited motor behavior cannot be overstated (Baker & Moon, 2008; Naude´ & Hughes, 2005). Only the availability of suitable technological solutions may provide scope and opportunities for intervention programs with these persons (Lancioni, O’Reilly, et al., 2010; Mumford & Wilson, 2009). The availability of alternative solutions and variations thereof may be considered an essential resource for serving a wide range of persons with different characteristics and needs (Copley & Ziviani, 2007; Standen, Camm, Battersby, Brown, & Harrison, 2011). The consolidation of responding, alertness, and self-determination with the reported microswitch-aided programs may produce a general improvement in the patients’ overall behavior and awareness and possibly justify a program extension with them. Such an extension might be conceived as (a) the introduction of a second microswitch for another minimal response to follow with different (but still pleasant) stimulus events, or (b) the introduction of a VOCA requiring a minimal motor expression to ask for contact with and special attention from the caregiver (Lancioni, Bosco, et al., 2010; Lancioni, Olivetti Belardinelli, Oliva, et al., 2008; Lancioni, O’Reilly, et al., 2009; Lancioni et al., 2009b). Offering a patient who has emerged from a minimally conscious state but is limited in his or her occupational and interaction opportunities a technology-aided program to manage the use of a radio may be seen as important for two immediate reasons. First, this program would provide the patient a practically relevant exposure to a variety of stimulation, information, and communication inputs in a relatively simple and highly controllable manner (Ha¨ggstro¨m & Lund, 2008; Jumisko, Lexell, & So¨derberg, 2009). Second, the use of a radio as part of the leisure engagement could be considered highly normalizing (i.e., it constitutes, in fact, an engagement largely practiced also by persons without disabilities) and with good opportunities to improve the social image of the patient and his or her acceptability within the context (Lancioni, Singh, O’Reilly, Sigafoos, Oliva, et al., 2010). The possibility of setting up such a program and using it constructively, as indicated above, may be largely realistic for families and rehabilitation contexts alike, given the fact that its cost is fairly contained (i.e., around or below US$1000). The same type of technology, with minimal adjustments, could also be applied to television devices. Consequently, one could plan to establish management of a radio device or a television device, based on what is considered more suitable/interesting for the patient. In some situations, one may enable the patient to manage both types of devices and use them during different parts of the day. Development of technological solutions and application strategies that would allow these patients a more active role and a more advanced environmental engagement may be considered of great practical relevance and useful for the rehabilitation process (Eriksson, Kottorp, Borg, & Tham, 2009; Lancioni, Singh, O’Reilly, Sigafoos, Oliva, et al., 2010). In fact, the management of these devices may increase alertness, promote awareness, information, and knowledge, and enhance communication abilities (Rohling, Faust, Beverly, & Demakis, 2009; Wehman, Gentry, West, & Arrango-Lasprilla, 2009). In conclusion, the data of these two studies and of the previous studies in this area may be viewed as a broad encouragement toward the development and application of assistive technologies for helping persons whose multiple disabilities pose serious questions to families and rehabilitation contexts. New research should focus on (a) extending the evidence available on these technologies, (b) developing new, advanced technologies for occupation and communication (e.g., adapted messaging technologies), and (d) conducting social validation assessments of technological tools, application strategies, and behavioral changes (Callahan, Henson, & Cowan, 2008; Cattelani, Zettin, & Zoccolotti, 2010; Kazdin, 2001; Kennedy, 2005). References Baker, P. M., & Moon, N. W. (2008). Wireless technologies and accessibility for people with disabilities: Findings from a policy research instrument. Assistive Technology, 20, 149–156. Barlow, D. H., Nock, M., & Hersen, M. (2009). 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