Promoting adaptive behavior in persons with acquired brain injury, extensive motor and communication disabilities, and consciousness disorders

Research in Developmental Disabilities 33 (2012) 1964–1974

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Research in Developmental Disabilities

Promoting adaptive behavior in persons with acquired brain injury, extensive motor and communication disabilities, and consciousness disorders Giulio E. Lancioni a,*, Nirbhay N. Singh b, Mark F. O’Reilly c, Jeff Sigafoos d, Marta Olivetti Belardinelli e, Francesca Buonocunto f, Valentina Sacco f, Jorge Navarro f, Crocifissa Lanzilotti f, Marina De Tommaso a, Marisa Megna a, Francesco Badagliacca g a

University of Bari, Italy American Health and Wellness Institute, Raleigh, NC, USA c Meadows Center for Preventing Educational Risk, University of Texas at Austin, TX, USA d Victoria University of Wellington, New Zealand e ‘‘Sapienza’’ University of Rome, Italy f S. Raffaele Rehabilitation Center, Ceglie Messapica, Italy g ISPE Residential Care Center, Mola di Bari, Italy b

A R T I C L E I N F O

A B S T R A C T

Article history: Received 27 May 2012 Accepted 29 May 2012 Available online 26 June 2012

These two studies extended the evidence on the use of technology-based intervention packages to promote adaptive behavior in persons with acquired brain injury and multiple disabilities. Study I involved five participants in a minimally conscious state who were provided with intervention packages based on specific arrangements of optic, tilt, or pressure microswitches (linked to preferred environmental stimuli) and eyelid, toe and finger responses. Study II involved three participants who were emerging from a minimally conscious state and were provided with intervention packages based on computer presentations of stimulus options (i.e., preferred stimuli, functional caregiver’s procedures, and non-preferred stimuli) and pressure microswitches to choose among them. Intervention data of Study I showed that the participants acquired relatively high levels of microswitch responding (thus engaging widely with preferred environmental stimuli) and kept that responding consistent except for one case. Intervention data of Study II showed that the participants were active in choosing among preferred stimuli and positive caregivers’ procedures, but generally abstained from non-preferred stimuli. The results were discussed in terms of the successful use of fairly new/infrequent microswitchresponse arrangements (Study I) and the profitable inclusion of functional caregiver’s procedures among the options available to choice (Study II). ß 2012 Elsevier Ltd. All rights reserved.

Keywords: Adaptive behavior Acquired brain injury Multiple disabilities Consciousness disorders Technology

1. Introduction Persons with acquired brain injury, extensive motor and multiple disabilities, and minimally conscious state may be quite passive and isolated, even if potentially capable of some adaptive behavior (e.g., engagement with environmental

* Corresponding author at: Department of Neuroscience and Sense Organs, University of Bari, Via Quintino Sella 268, 70100 Bari, Italy. E-mail address: [email protected] (G.E. Lancioni). 0891-4222/$ – see front matter ß 2012 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.ridd.2012.05.027

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events or basic communication) (Canedo, Grix, & Nicoletti, 2002; Coleman & Pickard, 2011; Giacino & Kalmar, 2005; Giacino & Trott, 2004; Lancioni, Bosco, et al., 2010; Lancioni, O’Reilly, et al., 2009; Laureys & Boly, 2007; Spivey, 2007). A similar type of frustrating and under achieving experience may also be endured by persons with comparably extensive brain injury and motor and communication disabilities, who are emerging from a situation of minimal consciousness and becoming gradually more aware of their surroundings (Lancioni, Singh, O’Reilly, Sigafoos, et al., 2012; NakaseRichardson, Yablon, Sherer, Nick, & Evans, 2009; Rispoli, Machalicek, & Lang, 2010; Taylor, Aird, Tate, & Lammi, 2007). Indeed, a limited motor repertoire and absence of verbal or other functional communication output can make these persons inadequate in dealing with environmental events and interactions in spite of their higher levels of awareness (Cavinato et al., 2009; Katz, Polyak, Coughlan, Nichols, & Roche, 2009; Lancioni, O’Reilly, et al., 2011; Leisman & Kock, 2009; Noe´ et al., 2012). Intervention strategies such as transcranial magnetic stimulation and general sensory (e.g., musical) stimulation may produce some positive alertness effects for both groups of persons in that they increase the amount of input the persons receive and help them avoid risks of stimulus deprivation and general impoverishment (Dimyan & Cohen, 2010; Formisano et al., 2001; Lancioni, Bosco, et al., 2010; Lapitskaya, Coleman, Nielsen, Gosseries, & Noordhout, 2009; Magee, 2005, 2007; Pape et al., 2009). In spite of their potential usefulness, the aforementioned strategies may not have a direct and immediate bearing on the development and consolidation of adaptive behavior, that is, on the persons’ engagement with and control of environmental events or communication and choice efforts (Lancioni, Bosco, et al., 2010). One way to help them develop and consolidate adaptive behavior consists of the use of assistive technology combined ¨ stegren, 2011; Chantry & with behavioral (motivational) strategies (Bauer, Elsaesser, & Arthanat, 2011; Borg, Larson, & O Dunford, 2010; Lancioni, O’Reilly, et al., 2010; Lancioni, O’Reilly, et al., 2011). Specifically, one might envisage the use of technology-based intervention packages to assist in (a) bridging the gap between the person’s behavioral repertoire and the abilities required for the type of adaptive responding targeted and (b) motivating the person to engage in adaptive responding through positive environmental contingencies (Bauer et al., 2011; Catania, 2007; Kazdin, 2001; Lancioni, Singh, et al., 2010; Lancioni, Singh, et al., 2011; Lancioni, Singh, O’Reilly, Sigafoos, Buonocunto, et al., 2011; Reichle, 2011; Shih, 2011). Two main types of technology-based intervention packages may be mentioned here, that is, (a) packages relying on microswitches that allow the person direct access to (engagement with) specific/preferred environmental stimuli, and (b) packages relying on computer presentations of stimulus options and microswitches that allow the person to choose among those options and access (engage with) them (Lancioni, O’Reilly, et al., 2010; Lancioni, Singh, et al., 2010; Lancioni, Singh, O’Reilly, Signorino, et al., 2010). The two studies reported here were aimed at extending the evidence available on the use of the aforementioned technology-based intervention packages with new participants with acquired brain injury and multiple disabilities. Study I involved five participants in a minimally conscious state. Three of them were provided with intervention packages based on optic microswitches placed on their cheekbone and activated via eye-blinking responses performed with the help of a mini paper sticker, which was attached to their eyelid. Only five other participants had previously used this microswitch arrangement (Lancioni, O’Reilly, et al., 2011; Lancioni, Singh, O’Reilly, Sigafoos, Ricci, et al., 2012). The fourth participant used an intervention package based on tilt microswitches fixed to his right foot’s big toe and activated through a small movement of the toe. This response had been used only with three other participants previously (Lancioni, O’Reilly, et al., 2009; Lancioni, Singh, et al., 2009; Lancioni, Singh, O’Reilly, Sigafoos, et al., 2012). The fifth participant used a pressure microswitch fixed inside his hand and activated through a small finger pressure (i.e., used an adapted microswitch-response combination; see Lancioni, Bosco, et al., 2010). Study II involved three participants who were emerging from a minimally conscious state and were provided with intervention packages based on computer presentations of stimulus options and pressure microswitches fixed inside their hands. The stimulus options also included various functional procedures performed by a caregiver (e.g., clearing the participant’s tracheal cannula and washing his or her face), which had never been targeted in previous studies (Lancioni, Singh, et al., 2010; Lancioni, Singh, O’Reilly, Signorino, et al., 2010). The participants’ responses were small hand-closure movements that activated the pressure microswitch devices. 2. Study I 2.1. Method 2.1.1. Participants The five adults participating in this study (Miriam, Nigel, William, Thomas, and Claude) were in special rehabilitation or care centers and had a diagnosis of minimally conscious state following brain injury and coma. All patients showed extensive motor impairment with lack of body and head control, and absence of speech or any other form of communication. Moreover, they used a gastrostomy tube for enteral nutrition as well as a tracheostomy tube and a urinary catheter. Miriam was 37 years old and her condition was subsequent to frontal oligodendroglioma removal about 1 year prior to this study. The neurosurgery was followed by a coma lasting about 2 weeks. This developed into a vegetative state lasting about 6 months. Eventually, her condition progressed into a minimally conscious state. Her total score on the JFK Coma Recovery Scale-Revised (CRS-R) was 8 with partial scores ranging from zero (oromotor/verbal subscale) to 2 (arousal, auditory, and motor subscales) (Kalmar & Giacino, 2005; Lombardi, Gatta, Sacco, Muratori, & Carolei, 2007).

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Nigel was 45 years old and had been involved in a road accident resulting in severe brain injury about 7 months prior to this study. He suffered a right fronto-temporal-parietal subdural hematoma and right frontal hemorrhage. The hematoma was evacuated after decompressive craniotomy. His coma lasted about 3 weeks and was replaced by a vegetative state lasting about 3 months and eventually evolving into a minimally conscious state. His total score on the CRS-R was 10, with partial scores ranging from zero (communication subscale) to 5 (motor subscale). William was 64 years old and his condition was the consequence of intraparenchymal hemorrhage with right temporoparietal hematoma, which had occurred about 2 years prior to this study. The hematoma was evacuated after decompressive craniotomy. His coma developed into a vegetative state within 2 weeks. This state remained largely unaltered for 7 months and then gradually changed into a minimally conscious state. His total score on the CRS-R was 9, with partial scores of 1 (motor, visual, and communication subscales) and 2 (oromotor/verbal, arousal, and auditory subscales). Thomas was 61 years old and had been involved in a road accident resulting in severe brain injury with diffuse axonal damage about 7 months prior to this study. His coma lasted less than 1 week and was replaced by a vegetative state that lasted about 4 months. Eventually, his general condition evolved into a minimally conscious state. His total score on the CRSR was 13, with partial scores ranging from 1 (oromotor/verbal and communication subscales) to 5 (motor subscale). Claude was 78 years old and his condition was the consequence of primary intracerebral hemorrhage with right temporoparietal hematoma, which had occurred about 3 months prior to this study. The hematoma was evacuated after decompressive craniotomy. His coma lasted 1 week and then developed into a vegetative state that lasted about 4 weeks. Eventually, his general condition evolved into a minimally conscious state. His total score on the CRS-R was 9, with partial scores varying from zero (communication subscale) to 3 (visual subscale). The participants’ families had signed a formal consent for their involvement in this study, which had been approved by a scientific and ethics committee. 2.1.2. Settings, adaptive responses, technology, and stimuli The study was carried out in the participants’ rooms (i.e., in the rehabilitation or care centers in which they were). The adaptive responses of Miriam, William, and Thomas consisted of protracted eyelid closures, that is, closures longer than 0.8 s (see Lancioni, Singh, O’Reilly, Sigafoos, Ricci, et al., 2012). The adaptive response of Nigel consisted of a small finger pressure performed with the left hand, which was kept virtually closed. Finally, the adaptive response of Claude consisted of a small downward movement of the big toe of his right foot. The responses selected were considered the most suitable for the participants and, given their relatively low frequencies, adequate for documenting a possible behavioral change/increase during the intervention phases of the study (see below). The microswitch used for the eyelid-closure responses matched that used by Lancioni, Singh, O’Reilly, Sigafoos, Ricci, et al. (2012). It involved an optic sensor including an infrared light-emitting diode and an infrared light-detection unit. It was fixed with medical tape above the participant’s cheekbone (i.e., fairly distant from the eye and not interfering with visual functioning). To ensure that the sensor would detect eyelid closures reliably, the participant wore a mini paper sticker on the eyelid. Fig. 1 provides a schematic representation of the position of the optic sensor and of the sticker. The microswitch used for Nigel consisted of a small pressure layer adapted inside the palm of his left hand, which he kept practically closed. The microswitch was activated when Nigel exercised a slight pressure on the layer with his fingers, which were already touching it. The microswitch used for the big toe of Claude involved a combination of two tilt devices and was activated as the toe was moved downward (Lancioni, Singh, O’Reilly, Sigafoos, et al., 2012). Microswitch activations triggered a computer-aided control system that regulated the presentation of stimuli for periods of 10 or 15 s during the intervention phases of the study. The stimuli had been recommended by the participants’ families

Fig. 1. Schematic representation of the position of the optic sensor and of the paper sticker.

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and were selected after a brief stimulus preference screening (Lancioni, O’Reilly, et al., 2009). Preference screening for each participant involved 6–12 non-consecutive presentations of one or two 10-s clips of each of the stimuli recommended (e.g., songs and videos). Stimuli were selected for use during the study if the two research assistants involved in their presentation indicated that the participant responded to them by alerting, orienting, and fixating them (i.e., in case of videos) more than 50% of the times. The stimuli selected included a large range of songs and instrumental music pieces (for all participants), recordings of children’s voices or other family members and friends’ voices (for Miriam and Nigel), and videos of natural world scenes (for Thomas). 2.1.3. Experimental conditions Sessions lasted 5 min and were carried out three to 11 times a day, depending on the participants’ availability. The participants’ responses during the sessions were recorded automatically by the computer-aided control system. A new response was recorded only if (a) the 10- or 15-s stimulation for the previous response had ended (i.e., during intervention sessions) or (b) an equivalent, non-stimulation time period had elapsed from the previous response (i.e., during baseline sessions). Responses occurred with the help of prompting from the research assistant (see below) were subtracted from the session total. Interrater agreement on recording the instances of response prompting was assessed in 10–14 sessions for each participant by having two research assistants record them simultaneously. Agreement (with the two assistants reporting the same numbers of response prompting, which could also be zero) occurred in all but two of the sessions. Each participant was exposed to an ABAB design in which the A represented baseline phases and the B represented intervention phases (Barlow, Nock, & Hersen, 2009). Prior to the start of the sessions, the participants were prompted to emit the response selected for them. Prompting consisted of a research assistant tapping on the participant’s forehead or presenting a light air puff to the side of his or her face (for eyelid-closure responses) and physical guidance of finger pressure and toe movement. Response prompting was repeated during the sessions after periods of non-responding of 30–60 s. 2.1.3.1. Baseline (A) phase I. The first baseline (A) phase included four to eight sessions for the different participants. During the sessions, each participant was provided with his or her microswitch and the computer-aided control system. The responses were recorded, but they did not produce any stimulation. 2.1.3.2. Intervention (B) phase I. The first intervention phase included 53–71 sessions for the different participants. Conditions were as in the previous baseline phase except that responses were followed by 10- or 15-s stimulation periods (see above). The phase was introduced by four to seven practice sessions, in which response prompting was largely used to increase the participants’ experience of response-stimulation pairing. 2.1.3.3. Baseline (A) phase II. The second baseline (A) phase included 5–20 sessions for the different participants. Conditions were as in the first baseline (A) phase (with a larger number of sessions used for the participant with a slower response decline). 2.1.3.4. Intervention (B) phase II. The second intervention (B) phase included 73–128 sessions for the different participants. Conditions were as in the first intervention (B) phase except that no practice sessions were available. 2.2. Results

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Figs. 2–6 summarize the participants’ frequencies of independent responses during the different phases of the study. Data points are mean frequencies of independent responses over blocks of five sessions. Blocks of two to four sessions are

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Blocks of Sessions [ MIRIAM ] Fig. 2. Miriam’s data. Data points are mean frequencies of independent responses over blocks of five sessions. Blocks of two to four sessions are indicated with arrows.

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Fig. 3. Nigel’s data plotted as in Fig. 2.

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Fig. 4. William’s data plotted as in Fig. 2.

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indicated with arrows. During the first baseline (A) phase, the mean frequencies of responses per session varied between about three for Nigel (see Fig. 3) and close to six for Thomas (see Fig. 5). The first intervention (B) phase showed mean frequencies ranging from about eight responses per session for William (see Fig. 4) to about 10 responses per session for Miriam and Thomas (see Figs. 2 and 5). The second baseline (A) phase showed a rather rapid response decline with frequencies similar to those of the first baseline phase for all participants except Nigel. Nigel also presented a response decline, but that occurred more slowly, and his overall mean frequency of responses per session during the phase exceeded seven (see Fig. 3). The second intervention phase showed higher mean frequencies of responses (i.e., ranging from about 11 to nearly 14) per session for all participants except Nigel. Nigel’s mean frequency was about 10 during the first part (about 40–45 sessions) of the phase, declined slightly during the following 25 sessions, and dropped drastically during the last 15–20 sessions of the phase (see Fig. 3). This drop seemed to

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Blocks of Sessions [ CLAUDE ] Fig. 6. Claude’s data plotted as in Fig. 2.

coincide with the development of severe respiratory and urinary infections and the use of pharmacological intervention to tackle them. Responses carried out with the help of prompts (and not reported in the figures) occurred almost exclusively during the baseline sessions and the first intervention phase. 3. Study II 3.1. Method 3.1.1. Participants The three adults participating in this study (Florence, Ingrid, and Nicolas) were in a special rehabilitation center, had been described as emerging from a minimally conscious state (following brain injury and coma), and presented with extensive motor disabilities and lack of speech. Florence was 49 years old and her condition was subsequent to left fronto-parietal hemorrhage due to left parietal meningioma removal about 3 months prior to this study. Her general condition was characterized by right hemiplegia, use of nasogastric tube for enteral nutrition as well as tracheostomy tube and urinary catheter. She was rated at the sixth level of the Rancho Levels of Cognitive Functioning (i.e., based on the confusedappropriate response dimension; see Hagen, 1998). Ingrid was 84 years old and her condition was due to extensive left fronto-temporo-parietal ischemic lesion, which had occurred about 4 months prior to this study. Her general condition was characterized by right hemiplegia and absence of sphincteric control. She was rated at the fifth level of the Rancho Levels of Cognitive Functioning (i.e., based on the confused-inappropriate response dimension; see Hagen, 1998). Nicolas was 68 years old and his condition was due to right fronto-temporo-parietal ischemic stroke, which had occurred about 2 months prior to this study. His general condition was characterized by severe left hemiparesis and the use of nasogastric tube, tracheostomy tube and urinary catheter. He was rated at the fifth level of the Rancho Levels of Cognitive Functioning (i.e., based on the confused-inappropriate response dimension). The participants seemed interested in engaging with various stimulus events (i.e., alerted, oriented or smiled to them). Their families had signed a formal consent for their participation in this study, which had been approved by a scientific and ethics committee. 3.1.2. Settings, adaptive responses, and technology The study was carried out in the participants’ rooms (i.e., in the rehabilitation center in which they were). The adaptive response selected for all three participants consisted of a small hand-closure movement. This response was available in their repertoire and occurred at relatively low frequencies. Its occurrence was monitored through a pressure microswitch (similar to that used in Study I), which was embedded in a box-like structure placed inside their left or right hand. In addition to the aforementioned microswitch, the technology included a computer system that controlled a set of 19 stimulus events for each session. Twelve stimulus events were considered to be preferred by the participants (i.e., songs or videos), four stimulus events concerned caregiver’s functional procedures that the participants might desire/need (e.g., having the face washed or the tracheal cannula cleared/aspirated), and three stimulus events were considered to be nonpreferred (e.g., distorted sounds). The four events/procedures were presented during the initial part of the sessions and repeated at the end of them. The 12 (music and video) events considered preferred could change across sessions and were selected from a pool of over 20 events available for each participant (see below). The three events considered non-preferred were interspersed with the preferred ones and served to assess the purposefulness of the participants’ choice responses in relation to the events. In practice, participant’s choice would be considered purposeful if it targeted the preferred stimulus events and caregiver’s procedures and ignored (with rare exceptions) the non-preferred events. During intervention sessions (see below), the computer system produced the following sequence of operations for each stimulus event, that is, it (a) presented a sample of the stimulus for about 5 s (e.g., 5 s of a song or of a video showing and verbally announcing a caregiver’s procedure such as washing the participant’s face), (b) recorded the participant’s response

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in relation to the sample, that is, microswitch activation or lack thereof during the 6-s interval following its presentation, (c) turned on the stimulus (music or video) matching the sample for 20 or 25 s or called the caregiver to carry out the procedure shown and announced in the video/sample, in case of microswitch activation, and (d) proceeded with the presentation of the stimulus for another 20- or 25-s period or called the caregiver for the repetition/extension of the procedure if a new microswitch activation occurred within 6 s from the end of the previous stimulus presentation or previous procedure. A procedure would typically last about 30 s. A pause interval of about 10 s occurred between the end of a stimulus episode or procedure or the lack of responding to a sample and the presentation of the next sample. 3.1.3. Selection of stimulus events Interviews with the participants’ families and a brief stimulus preference screening were used for the selection of the preferred songs and videos as well as of the caregiver’s functional procedures to apply during the sessions. Preference screening on each song and video recommended by the families involved the presentation of one or two 10-s clips of it, at least 10 non-consecutive times. Preference screening on the caregiver’s procedures involved the performance of each of them for at least eight non-consecutive times. Their performance was timed in such a manner that the participant could more easily find them useful/desirable (e.g., clearing of the tracheal cannula would not be performed close to a previous occurrence of it). Songs and videos were retained for the study if the participant was showing his or her interest by alerting, orienting or smiling to the clips in about or more than 50% of their presentations (Lancioni, Singh, O’Reilly, Sigafoos, Buonocunto, et al., 2011). Caregiver’s procedures were retained if the participant seemed to have the aforementioned (apparently positive) reactions in over 50% of their executions. By the end of the selection, participants had a total of over 20 stimuli between songs and videos. A total of five procedures were also selected. They consisted of tracheal cannula clearing/ aspiration, face washing, hair combing, arms/legs massaging, and bed’s linen resetting. The non-preferred stimuli included three different types of distorted sound that were considered to be tedious/annoying. 3.1.4. Experimental conditions The study was carried out according to a non-concurrent multiple baseline design across participants (Barlow et al., 2009). Specifically, participants were exposed to the intervention phase after different numbers of baseline sessions. The data from the sessions, which were automatically recorded through the computer system, involved the frequencies of microswitch activations performed in relation to the preferred (song and video) stimuli, the caregiver’s procedures, and the non-preferred stimuli (see above). During intervention, those activations could occur in relation to the samples of stimuli and procedures as well as immediately after the regular presentation of those stimuli and procedures (see above). During baseline, microswitch activations could occur only in relation to the samples of stimuli and procedures (see below). Sessions occurred once or twice a day and lasted until all stimulus samples had been presented. Conditions and agreement for responses (microswitch activations) occurring after prompting (see below) were as in Study I. 3.1.4.1. Baseline. The baseline included two, four and six sessions for the three participants, respectively. The computer system presented the samples of the stimulus events/procedures included in the sessions (see Technology) and recorded whether the participant responded to them (i.e., by microswitch activation) during the following 6-s intervals. Responses did not have consequences. Prior to each session, the participants were prompted to respond (activate their microswitch) in relation to the sample of a preferred stimulus event but no consequences occurred. The same prompting was provided during the session if the participants failed to respond to five or six consecutive samples of preferred stimulus events. 3.1.4.2. Intervention. The intervention included 50, 63, and 52 sessions for the three participants, respectively. General conditions were as in baseline, except that the computer system proceeded with the sequence of steps described in the Technology section. That is, the participants’ responding to samples was followed by the occurrence of the matching events/procedures; the participants’ responding immediately after the end of the events/procedures led to their continuation/repetition (see above). The intervention phase was preceded by three or five introductory sessions, in which the participants were prompted to activate the microswitch in relation to samples of the preferred stimulus events and of the caregiver’s procedures, and also after the full occurrence of some of those events/procedures. The responses had always consequences. 3.2. Results The three panels of Fig. 7 show the participants’ mean frequencies of responses (microswitch activations) for preferred stimulus events (songs and videos) per session, over blocks of two sessions. Single sessions are indicated with arrows. The three panels of Fig. 8 show the participants’ mean frequencies of responses (microswitch activations) for caregiver’s procedures per session, over the same blocks of sessions (or single sessions) plotted in Fig. 7. During the baseline phase, the participants’ mean frequencies of responses per session were below seven in relation to the preferred stimulus events (see Fig. 7) and two or below two in relation to the caregiver’s procedures (see Fig. 8). During the intervention phase, their mean frequencies of responses per session were about 55, 36, and 24 in relation to the preferred stimuli (see Fig. 7) and about five, four, and three in relation to the caregiver’s procedures (see Fig. 8). They tended to perform various responses (asking for repetition/continuation) in relation to several of the preferred stimuli chosen. The participants’ responses in relation to

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non-preferred stimuli (not reported in the figures) occurred only sporadically and, in particular, during the baseline and initial part of the intervention. 4. Discussion The intervention data of Study I indicate that the participants acquired relatively high levels of microswitch responding, thus showing an increase in their general activity and their engagement with environmental stimuli that they could now control (Canedo et al., 2002; Lancioni, Bosco, et al., 2010; Lancioni, Singh, et al., 2010; Whyte, 2007). The final drop in performance shown by Nigel might be interpreted as a consequence of his respiratory and urinary infections and the medication provided to curb them. It would have been useful to continue the intervention after his recovery from infections to determine whether early responding could be restored. However, this was not possible as Nigel was transferred to a different rehabilitation center. The use of a technology-based package involving microswitches suitable for minimal responses may be considered a unique opportunity to allow persons with pervasive motor and communication disabilities as well as consciousness disorders to interact with and enjoy the immediate environment. Indeed, their limited motor repertoire would not allow them to develop any active, direct access to their environment. General stimulation programs, although beneficial in increasing their input, would not promote the acquisition of adaptive responding and self-determination (Lancioni, Bosco, et al., 2010). Such an acquisition, which could be seen as a discrimination of the positive function of responding (i.e., an association of responding with the environmental events following it), might be considered a vital learning process (Catania, 2007; Lancioni, O’Reilly, et al., 2010). Fostering response acquisition (learning) could be critically important to promote the persons’ recovery of higher levels of environmental awareness (consciousness) and thus could contribute to the person’s rehabilitation program (Bosco et al., 2010; Carter, Trainor, Owens, Sweden, & Sun, 2010; Lancioni, Bosco, et al., 2010; Spivey, 2007). Although the experimental design used with the participants of Study I could not definitely clarify whether their response increase reflected a learning process, evidence is available to suggest that that was the case (Bosco et al., 2009, 2010; Lancioni, Bosco, et al., 2010). With regard to the microswitches, the data reported seem to emphasize their suitability and thus extend the preliminary, positive evidence on them. New research would need to focus on upgrading some of those microswitches, developing new microswitches, and assessing programs that involve combinations of microswitches. Upgrading microswitches would consist of ensuring more satisfactory designs that would make their use easier and more effective for a larger number of persons (Baker & Moon, 2008; Bauer et al., 2011). Developing new microswitches would consist of building new devices that could be more efficient in monitoring small responses and less intrusive for the persons using them (Leung & Chau, 2010; Shih, Chang, & Shih, 2010). Among the new devices, one could include camera-based technology. This technology may allow the monitoring of small eyelid and lip responses through the use of one or two small color marks (rather than through support frames and sensors) on the participants’ face and head (Leung & Chau, 2010). Using combinations of microswitches would allow a person to use more than one response, thus extending the level of activity engagement and broadening the range of sensory input (preferred stimulation) obtained (Lancioni, Bosco, et al., 2010; Lancioni, O’Reilly, et al., 2009). The intervention data of Study II indicate that the participants were active in choosing among preferred stimuli and functional/positive caregivers’ procedures, but generally abstained from non-preferred stimuli. These data support those of previous studies in this area (Lancioni, Singh, et al., 2010; Lancioni, Singh, O’Reilly, Sigafoos, Buonocunto, et al., 2011) and add new evidence on (a) the possibility of incorporating functional procedures among the stimulus options presented to the participants, and (b) the opportunity for the participants to satisfy any necessity/desire related to those procedures. The possibility of including functional caregivers’ procedures among the choice options can be highly valuable for two main reasons. First, it represents an environmental enrichment (i.e., an extension of engagement and communication opportunities) over what previous programs provided. In fact, it allows the participant not only to choose among a series of conventional (preferred) stimuli and engage with them, but also to access a number of care opportunities that might be specifically desirable (needed) at some point in time. Requesting and accessing these opportunities may significantly upgrade the participant’s adaptive behavior (Jumisko, Lexell, & So¨derberg, 2009). Second, the possibility of accessing procedures that satisfy relevant desires/needs could justify an extended availability of the computer system with potentially longer sessions. Indeed the participant could enjoy longer periods of positive engagement with environmental stimuli without the risk of being forced to postpone care procedures becoming relevant or even pressing during the course of the session (Lancioni, Singh, et al., 2010). Envisaging longer sessions with a large variety of preferred stimuli interspersed with the availability of functional procedures would be more realistic and acceptable provided that the participant could stop the sessions any time he or she wanted (Friedman, Wamsley, Liebel, Saad, & Eggert, 2009). To make this possible, one would need to consider a slight extension of the software used in the program applied in Study II. Such an extension would allow the participant to halt the session by using a variation of the microswitch response that he or she already possesses (Chantry & Dunford, 2010). A series of two or more microswitch activations to be performed within a 3-s interval could be a possible response variation adopted to halt the session. Participants recovering from disorders of consciousness, who progress to levels of functioning higher than those reported in Study II, could be exposed to more advanced forms of computer-based packages (e.g., Lancioni, Singh, O’Reilly, Ferlisi, et al., 2012). One such package could start with a computer screen showing four to six pictorial representations (e.g., a radio,

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a television, and persons). Each of these representations could be automatically scanned (highlighted) for a few seconds. The participant’s selection of one of the representations through microswitch activation would open a second screen with a variety of stimulus options belonging to the stimulus category chosen. If the participant had chosen the radio category, for instance, the second screen could show 10 pictures illustrating different combinations of singers and songs. Choice of one of those pictures would lead the computer system to play the singer-song combination chosen. In conclusion, the data of the two studies provided additional evidence about the possibility of promoting adaptive behavior in persons with acquired brain injury and multiple disabilities. In particular, they stressed the applicability and usefulness of fairly new/infrequent microswitch-response arrangements (Study I) and the profitable inclusion of functional caregiver’s procedures among the options available to choice (Study II). New research could be directed at (a) extending the assessment of those intervention packages with other participants, (b) upgrading some of the existing microswitches and developing new ones for persons in a minimally conscious state and with only minimal motor behavior, (c) assessing the feasibility of longer sessions with persons emerging from a minimally conscious state and the possibility of enabling them to interrupt those sessions, and (d) carrying out a social validation assessment with staff and family members providing their opinions about the forms of adaptive behavior reported and their possible communication and emotional implications in daily life (Callahan, Henson, & Cowan, 2008; Kazdin, 2001; Kennedy, 2005; Lancioni, O’Reilly, et al., 2011).

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