Technology-aided leisure and communication opportunities for two post-coma persons emerged from a minimally conscious state and affected by multiple disabilities

Research in Developmental Disabilities 34 (2013) 809–816

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Research in Developmental Disabilities

Technology-aided leisure and communication opportunities for two post-coma persons emerged from a minimally conscious state and affected by multiple disabilities Giulio E. Lancioni a,*, Mark F. O’Reilly b, Nirbhay N. Singh c, Jeff Sigafoos d, Francesca Buonocunto e, Valentina Sacco e, Jorge Navarro e, Crocifissa Lanzilotti e, Marina De Tommaso a, Marisa Megna a, Doretta Oliva f a

University of Bari, Italy Meadows Center for Preventing Educational Risk, University of Texas at Austin, TX, USA c American Health and Wellness Institute, Raleigh, NC, USA d Wellington Victoria University, New Zealand e S. Raffaele Rehabilitation Center, Ceglie Messapica, Italy f Lega F. D’Oro Research Center, Osimo, Italy b

A R T I C L E I N F O

A B S T R A C T

Article history: Received 14 October 2012 Accepted 18 October 2012 Available online 5 December 2012

This study assessed technology-aided programs for helping two post-coma persons, who had emerged from a minimally conscious state and were affected by multiple disabilities, to (a) engage with leisure stimuli and request caregiver’s procedures, (b) send out and listen to text messages for communication with distant partners, and (c) combine leisure engagement and procedure requests with text messaging within the same sessions. The program for leisure engagement and procedure requests relied on the use of a portable computer with commercial software, and a microswitch for the participants’ response. The program for text messaging communication involved the use of a portable computer, a GSM modem, a microswitch for the participants’ response, and specifically developed software. Results indicated that the participants were successful at each of the three stages of the study, thus providing relevant evidence concerning performance achievements only minimally documented. The implications of the findings in terms of technology and practical opportunities for post-coma persons with multiple disabilities are discussed. ß 2012 Elsevier Ltd. All rights reserved.

Keywords: Leisure engagement Communication Emergence from minimally conscious state Multiple disabilities Technology Text messaging system

1. Introduction Post-coma persons emerging from a minimally conscious state may present with extensive motor impairment and lack of verbal communication (Cattelani, Zettin, & Zoccolotti, 2010; Lancioni, Singh, O’Reilly, Sigafoos, et al., 2012; NakaseRichardson, Yablon, Sherer, Nick, & Evans, 2009; Rispoli, Machalicek, & Lang, 2010; Taylor, Aird, Tate, & Lammi, 2007). These conditions can seriously curtail their opportunities of engagement and social interaction (Cavinato et al., 2009; Katz, Polyak, Coughlan, Nichols, & Roche, 2009; Lancioni, O’Reilly, Singh, Buonocunto, et al., 2011; Leisman & Kock, 2009; Noe´ et al., 2012). Intervention efforts with these persons would need to tackle their occupation and communication difficulties (failures) and would need to resort to the use of technology-aided program solutions to bypass or reduce the impact of their disabilities

* 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.2012.10.008

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¨ stegren, 2011; Chantry & Dunford, 2010; Lancioni, O’Reilly, Singh, (Bauer, Elsaesser, & Arthanat, 2011; Borg, Larson, & O Buonocunto, et al., 2011; Lancioni, O’Reilly, Singh, Sigafoos, Buonocunto, et al., 2011; Lancioni, O’Reilly, et al., 2012; Lancioni, Sigafoos, O’Reilly, & Singh, 2012) A first intervention step might be based on the use of a technology package that allows the person to (a) access a variety of stimulus events (e.g., songs and videos) normally viewed as leisure engagement events and (b) request caregiver’s functional procedures that he or she may desire/need (e.g., having the face washed or the position changed) (Lancioni, Singh, O’Reilly, Green, et al., 2012; Lancioni, Singh, O’Reilly, Sigafoos, Olivetti Belardinelli, et al., 2012). Such a package could include a computer with specific software that presents pictorial images and verbal labels for the categories of stimuli and caregiver’s procedures and a microswitch (i.e., a technical interface connecting the individual with the computer) through which the persons can access those categories of stimuli and procedures and subsequently choose among the options available for them (Lancioni, Singh, O’Reilly, Green, et al., 2012). A second intervention step in the effort to reduce the impact of these persons’ disabilities might involve the use of a technology enabling them to communicate with relevant partners via text messaging. Such a technology would allow the person to (a) choose the partners to contact and the messages to send them and (b) have the partners’ messages read out to him or her (Lancioni, O’Reilly, Singh, Sigafoos, Oliva, et al., 2011; Lancioni, O’Reilly, et al., 2012; Lancioni, Singh, O’Reilly, Sigafoos, Signorino, et al., 2010). All these communication opportunities would be operated through a microswitch requiring a simple motor response, possibly the same response as the one required for operating the first package (i.e., the one with stimulus events and caregiver’s procedures) (Lancioni, Singh, O’Reilly, Green, et al., 2012). A further step in the intervention process with these persons could involve the simultaneous employment of the two technology solutions described above so as to allow each person to engage in leisure activities or requests of caregiver’s procedures as well as in text messaging communication (Lancioni, Singh, O’Reilly, Sigafoos, Ferlisi, et al., 2012). The technology for the first step has been positively assessed in the form described above only with a young man with pervasive motor impairment and moderate intellectual disability (Lancioni, Singh, O’Reilly, Green, et al., 2012). The technology for the second step has been positively assessed with seven post-coma patients emerged from a minimally conscious state (e.g., Lancioni, O’Reilly, Singh, Buonocunto, et al., 2011; Lancioni, Singh, et al., 2011). The combination of the two technologies has only been used with a man with amyotrophic lateral sclerosis (Lancioni, Singh, O’Reilly, Sigafoos, Ferlisi, et al., 2012). In light of the above, new research efforts would seem necessary to extend the existing evidence particularly (a) on the usability and effectiveness of the technology described for the first step and (b) on the potential impact of the simultaneous availability of the two technologies. The present study aimed to address these points with two post-coma persons who had emerged from a minimally conscious state and were affected by multiple disabilities. During the study, the participants’ performance was assessed with the first-step technology for managing stimulus events and caregiver’s procedures, the second-step technology for text messaging communication, and the third-step combination of the two technologies. 2. Method 2.1. Participants The participants were a woman and a man (Myrtle and Keith) of 44 and 24 years of age, respectively. Myrtle had suffered aneurysm rupture of the left middle cerebral artery with subsequent intracranial hemorrhage and coma about 3 months prior to the beginning of this study. A brain computed tomography scan had shown left fronto-temporal hematoma with midline shift. Angiographic arterial embolization was carried out and the hematoma was evacuated after fronto-temporalparietal decompressive craniotomy. The coma lasted about 3 weeks and was replaced by a vegetative state, which changed into a minimally conscious state within about 4 weeks. By the time of the study, Myrtle had clearly emerged from this state and showed accurate ‘‘yes’’ and ‘‘no’’ responses (i.e., small hand or eyelid movements) to a variety of questions. She presented with right hemiplegia and initial tendon-muscle retractions and possessed minimal head and trunk control. She had normal breathing functions, relied on oral feeding (liquid or partially liquid nutrients), and was fitted with a urinary catheter. She had no speech and was rated at the sixth level of the Rancho Levels of Cognitive Functioning (i.e., based on the confusedappropriate response dimension; see Hagen, 1998). Keith had been diagnosed with pyruvate dehydrogenase deficiency (Brown, 2012; Prasad, Rupar, & Prasad, 2011) at the age of 4 years. He presented a complex neurological syndrome characterized by myoclonus, cerebellar ataxia, and mild intellectual disability. About 3.5 months prior to the start of this study, he had suffered repeated status epilepticus with subsequent coma, which lasted about 2 weeks. Magnetic resonance imaging had shown left insular and bilateral frontal subacute ischemic lesions, and bilateral cerebellar gliotic and atrophic lesions. His general recovery had been consistent and clear and by the start of the study, he showed accurate ‘‘yes’’ and ‘‘no’’ responses (i.e., with minimal head or eyelid movements) to a variety of questions and was rated at the sixth level of the Rancho Levels of Cognitive Functioning (i.e., at the same level as Myrtle). He had no speech, presented with severe tetraparesis, tremor ataxia and minimal head and trunk control, and had been provided with tracheostomy and gastrostomy tubes and a urinary catheter. Both participants seemed to enjoy accessing stimulus events (e.g., songs) and receiving caregiver’s procedures (e.g., washing and massaging). They were also reported to be interested in listening to voice messages or phone calls from relevant partners (e.g., friends) and plausibly in sending messages to those partners. Their families had signed a formal consent for their participation in this study, which had been approved by a scientific and ethics committee.

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2.2. Setting, sessions, and data collection The study was carried out in the participants’ rooms at the medical rehabilitation center in which they were. Baseline sessions lasted 10 min for both participants. Intervention sessions lasted 20 min for Myrtle and 10 min for Keith. Sessions focused on (a) selection of (engagement with) leisure stimuli and request of caregiver’s functional procedures, (b) text messaging, or (c) both of the above. For leisure stimuli and requests, recording concerned the frequencies of videos and songs that the participants activated and of caregiver’s procedures that they requested within the sessions. For text messaging, recording concerned the frequencies of messages that the participants sent out and of messages that they received and listened to. For each of the leisure stimuli, procedures, or messages recorded, the observer was to specify whether the participants performed independently or with guidance from the research assistant supervising the sessions (see below). Inter-observer reliability was assessed with the two observers recording the aforementioned measures simultaneously (but independently) for about 20% of the sessions. The mean percentages of agreement on the single measures (computed by dividing the total number of agreements by the total number of agreements and disagreements and multiplying by 100) exceeded 95. 2.3. Stimulus events and caregiver’s procedures The stimulus events (songs and videos) used during the sessions had been recommended by the participants’ families and supported through a brief stimulus preference screening. The screening involved 5–10 presentations of one or two small samples of each stimulus event. The events used during the study were those that, according to the two research assistants conducting the screening, were producing positive reactions (e.g., alerting and smiling) in about 50% or more of the presentations. The caregiver’s procedures were selected on the basis of (a) the participants’ positive reactions in over half of the seven or eight presentation trials of such procedures (e.g., face washing, arms/legs massaging) or (b) the participants’ need for or frequent (conventional) use of those procedures within their daily context (e.g., tracheal cannula clearing/ aspiration and position changing). 2.4. Technology-aided programs and response The program concerning the leisure stimulus engagement and procedure requests involved the use of a portable computer with commercial software (i.e., Clicker 5 software; Crick House, Moulton Park, Northampton NN3 6LF, England), a microswitch for the participants’ response, and an interface connecting the microswitch to the computer. The computer screen initially showed three picture boxes that were sequentially scanned through a red light encirclement lasting 6 s. The boxes represented: ‘‘Songs’’, ‘‘Videos’’ and ‘‘Requests’’. Selecting the ‘‘Requests’’ box (i.e., activating the touch/pressure microswitch when such a box was encircled by the light) opened a new screen with six different options. The options included: face washing, hair combing, arms/legs massaging, position changing, and blanket setting (for both participants), and yoghurt eating (for Myrtle) and tracheal cannula clearing (for Keith). The options were sequentially scanned and verbally announced by the computer. The participants could choose the option they wanted by activating the microswitch in connection with its scanning/announcement. Choosing an option led the computer to verbalize the occurrence of such a choice so the caregivers could perform what was being requested for 1–2 min. Selecting the ‘‘Songs’’ box opened a screen with eight pictures of different songs and singers. The pictures were sequentially scanned and, at the same time, the related singers and song titles were verbally announced. Selecting a song led the computer to play it. Selecting the ‘‘videos’’ box opened a screen with eight pictures of short (3 min) videos of sport activities, comedy and cartoons, or family events. The scanning/announcement and selection of videos matched those described for the songs. The participant could interrupt songs and videos at any time of their presentation through microswitch activation. The microswitch consisted of a touch/ pressure pad, which was on a tray in front of the participant and could be activated through a simple hand movement. The program for text messaging communication involved the use of a portable computer, a GSM modem, a microswitch for the participants’ response, an interface connecting the microswitch to the computer, and specifically developed software (written with Borland Delphi Developer Studio, from Inprise Corporation, 2005) (see Lancioni, O’Reilly, et al., 2012). The microswitch and related response matched those used for the first program. The initial microswitch activation triggered the computer to verbally ask whether the message was to be sent to the ‘‘family’’, ‘‘friends’’ or ‘‘relatives’’ (Myrtle) or ‘‘family’’, ‘‘friends’’ or ‘‘staff’’ (Keith). Selection of one of the groups (i.e., microswitch activation within 5 s from its mention) led the computer to present (verbalize) the names of the persons included in the group (i.e., three to five names). Selection of a name through microswitch activation (see above) led the computer to present/verbalize the message topics available. For each person there were four or five message topics, such as telling about one’s own condition, asking about work/study or other daily activities, sending love/greetings and asking for visits. The computer verbalized each message topic individually. If the participants responded within 5 s from a topic announcement, the computer started to verbalize the three to six messages available for that topic (e.g., ‘‘I love you and miss you’’, and ‘‘when can you visit me?’’; see also Lancioni, O’Reilly, Singh, Sigafoos, et al., 2011). The computer verbalized the messages individually. If the participants responded within 5 s from the end of a message, the computer sent that message out and verbalized that it had done so. An incoming message was signaled through beeps and a verbal announcement, which could be repeated. Microswitch activation led the computer to verbalize the name of the sender and to read out the message.

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2.5. Experimental conditions The study started with baseline on leisure stimulus engagement and procedure requests as well as on text messaging communication. Then intervention focused on leisure stimulus engagement and procedure requests. This was followed by new baseline and intervention on text messaging communication, according to a multiple probe across behaviors design (Barlow, Nock, & Hersen, 2009). During the last period of the study, the participants had access to both program conditions within each session. That is, the technology for leisure engagement and procedure requests and the technology for text messaging were simultaneously available and the participants could use both at will. 2.5.1. Baseline on leisure stimulus engagement and procedure requests Two 10-min baseline sessions were carried out in which the participants had the technology package except for the microswitch. They were provided with a regular mouse to choose among the categories of stimulus events and caregiver’s procedures and eventually among the options of the category selected (see Lancioni, Singh, O’Reilly, Green, et al., 2012). Failure to use the mouse for a period of 3–4 min led the research assistant responsible of the session to ask whether they wanted to access the stimuli or a caregiver’s procedure and then showed a response sequence involving the selection of a category and the choice of one of the options of that category (see Technology section). 2.5.2. Baseline on text messaging communication At each of the four 10-min sessions available (i.e., two at the start of the study and two after the intervention on leisure stimulus engagement and procedure requests), the research assistant provided the participants with a cell phone and asked them whether they wanted to send a greeting message to the husband (Myrtle) or to the brother (Keith) (see Lancioni, O’Reilly, Singh, Buonocunto, et al., 2011). Then she arranged such a message and sent it out for them. When a message for the participant arrived, the research assistant read it to him or her. 2.5.3. Intervention on leisure stimulus engagement and procedure requests The intervention was introduced by five and eight practice sessions aimed at familiarizing the participants with the technology-aided program. The research assistant guided them through the selection of the different boxes and enabled them to experience the various options available for each of them. The practice sessions were followed by 37 and 41 regular intervention sessions for the two participants, respectively, during which guidance was available only in case of difficulties/ failures (i.e., the participants failing to choose an option of the second screen for about 1 min). 2.5.4. Intervention on text messaging communication The text messaging technology was introduced through six and eight practice sessions. During those sessions, the research assistant provided the necessary guidance to ensure that the participants (a) could make the steps required for sending messages (i.e., selecting the partners and the messages for them, and sending out those messages) and (b) have incoming messages read out to them. The practice sessions were followed by 22 and 21 regular sessions (see above). 2.5.5. Intervention on leisure stimulus engagement and procedure requests and on text messaging communication The participants had both technology packages, including the two microswitches required to operate them. Procedural conditions for operating the two packages were the same as those described above. This phase started with an introductory/ practice session and continued with 75 and 88 regular intervention sessions. During these sessions, the two packages could also be operated with some overlap. For example, the participants could have the computer of the second program read out an incoming message while the computer of the first program was still showing a video or playing a song. 3. Results Figs. 1 and 2 summarize the participants’ independent performance (i.e., without any guidance from the research assistant) on the two target measures (behaviors), that is, leisure stimulus engagement and procedure requests and text messaging communication. The first/left section of each figure reports the initial baseline data for the two target measures, respectively (one bar for each target measure). The second section of the figures reports the intervention data for leisure stimulus engagement and procedure requests (two blocks of sessions represented by two gray bars). The third section reports the second baseline data for text messaging communication. The fourth section reports the intervention data for text messaging communication (two blocks of sessions represented by two bars with black and white portions indicating messages sent out and messages listened to, respectively). The final section reports the intervention data for the two target measures together (four blocks of sessions represented by four bars whose black, white, and gray portions indicate messages sent out, messages listened to, and leisure stimulus engagement and procedure requests, respectively). The number of sessions included in each block/bar is indicated by the numeral above it. During the initial baseline (two sessions on each target measure), the participants’ mean frequencies of responses were zero. That is, the participants (a) did not produce any independent selection of stimulus events or request of caregiver’s procedures and (b) did not independently send any message or listen to any incoming message. During the intervention on the first target measure (37 20-min sessions and 41 10-min sessions for the two participants, respectively) the mean

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Blocks of Sessions [ MYRTLE ] Fig. 1. Myrtle’s data. The first/left section of the figure reports the initial baseline data for the two target measures, respectively (one bar for each target measure). The second section of the figure reports the intervention data for leisure stimulus engagement and procedure requests (two blocks of sessions represented by two gray bars). The third section reports the second baseline data for text messaging communication. The fourth section reports the intervention data for text messaging communication (two blocks of sessions represented by two bars with black and white portions indicating messages sent out and messages listened to, respectively). The final section reports the intervention data for the two target measures together (four blocks of sessions represented by four bars whose black, white, and gray portions indicate messages sent out, messages listened to, and leisure stimulus engagement and procedure requests, respectively). The number of sessions included in each block/bar is indicated by the numeral above it.

frequencies of responses, that is, of stimulus events selected and procedures requested per session were about four and half for Myrtle and two for Keith. The subsequent baseline on the second target measure (two sessions) showed zero levels of responding for messages sent out and listened to. During the intervention on this target measure (22 and 21 sessions of 20 and 10 min, respectively), the mean frequencies of responses, that is, of messages sent out and messages listen to per session were about four and three for the two participants, respectively. The messages sent out (black portion of the bars) represented more than half of the total for both participants. During the final intervention phase (75 and 88 sessions of 20 and 10 min, respectively), the combined mean frequencies of responses, that is, messages plus stimulus events and procedures per session were above seven and four for the two participants, respectively. The increase in the overall response frequencies per session compared to the previous intervention phases seemed partially due to (a) the possibility of dealing with messages (in particular listening to incoming messages) in overlap with songs or videos and (b) some interruptions of these stimuli (i.e., apparently once preferred sections had passed). Responses performed with guidance of the research assistant (i.e., not independently), and thus not reported in the figures, were only sporadically present in the first two intervention phases. 4. Discussion

Mean Frequencies

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The data indicate that two post-coma persons, who had emerged from a minimally conscious state and were affected by multiple disabilities, could use technology-aided programs to (a) engage with leisure stimuli and request caregiver’s

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Blocks of Sessions [ KEITH ] Fig. 2. Keith’s data plotted as in Fig. 1.

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procedures, (b) send out and listen to text messages for communication with distant partners, and (c) combine leisure stimulus engagement and procedure requests with text messaging within the same sessions. This evidence is particularly relevant, as only minimal data existed with regard to the first and the third points mentioned above, and those data moreover did not concern post-coma individuals emerged from a minimally conscious state (Lancioni, Singh, O’Reilly, Green, et al., 2012; Lancioni, Singh, O’Reilly, Sigafoos, Ferlisi, et al., 2012). In light of this evidence, a number of considerations may be put forward. First, it would be difficult to overstate the relevance of allowing persons with extensive motor disabilities and lack of speech or other conventional communication means to engage with a variety of stimulus events and to request caregiver’s procedures (Davies, Mudge, Ameratunga, & Stott, 2010; Ha¨ggstro¨m & Lund, 2008; Katz et al., 2009; Lancioni, O’Reilly, et al., 2012). These opportunities, which would be out of reach without the availability of specific technology-aided intervention programs, enable them to be positively engaged, to increase sensory input and exposure to preferred stimulus events, and to ensure the satisfaction of needs/desires with the direct involvement of the caregiver. The implications of such an achievement could be considered particularly relevant in terms of social status and overall quality of life (Brown, Schalock, & Brown, 2009; Jumisko, Lexell, & So¨derberg, 2009; Lachapelle et al., 2005; McDougall, Evans, & Baldwin, 2010; Ripat & Woodgate, 2011). Second, the possibility of combining the technology for accessing stimulus events and making requests with the technology for text messaging can be viewed as a critical accomplishment. The two technologies together ensure that the person (a) is independently active with leisure events, (b) interacts with the caregiver over desires and needs with the possibility of satisfying them when most convenient for him or her, and (c) ensures consistent contact with distant partners who have a relevant role in his or her social and affective sphere (Fyrberg, Marchioni, & Emanuelson, 2007; Lancioni, Singh, O’Reilly, Sigafoos, Ferlisi, et al., 2012; Rispoli et al., 2010; Rousseaux, Ve´rigneaux, & Kozlowski, 2010; Spivey, 2007). The previous study that combined these technologies for a person with amyotrophic lateral sclerosis proceeded with an integration of their functioning so that only one at the time could be activated (Lancioni, Singh, O’Reilly, Sigafoos, Ferlisi, et al., 2012). In this study, the two technologies were used in parallel rather than being integrated. A parallel arrangement was thought to allow flexibility in the participant’s operation; and possible overlaps (e.g., activating the microswitch of the messaging program to have a message read out when a video of the first program was being shown) were considered more functional than confusing. Although no specific assessment of this aspect was conducted, the data and informal reports indicated that participants remained largely successful through situations of overlap. Third, the high response frequencies observed during the last intervention period in which the two technologies were available, as opposed to each of the previous intervention periods, could have two general explanations. The greater variety of opportunities available might have increased the participants’ motivation to be actively engaged in different operations and thus increased their overall responding. Also, the overlaps and video/song interruptions occurring during the sessions of the last period might have contributed to increase the final response frequencies. A third possible explanation for the response increase and general performance improvement could be linked to an overall functional progress that the participants’ situation seemed to show during this study (i.e., a period of about 3 months). Fourth, the data obtained with the use of the two technologies appear largely encouraging as to the possibility of offering practical opportunities to persons, who like the participants of this study, are marginalized by their disabilities. Obviously the technologies have a cost. At present, estimates of about 1000 US dollars may be provided for the first type of technology (i.e., the one used for leisure stimulus engagement and procedure requests) and estimates of about 2000 US dollars may be provided for the second type of technology (i.e., the one for text messaging). These costs would be considered practically affordable in most contexts, and particularly, in rehabilitation centers, which have specific budgets available for rehabilitation material (Borg et al., 2011; Hubbard Winkler et al., 2010; Israena, Dubsok, & Pan-Ngum, 2008; Wallace, 2011). The acquisition of these technologies might be easily justified on a cost–benefit analysis; in fact, they could be used for large parts of the day and/or for different participants (Dahlin & Ryde´n, 2011; Lancioni, Sigafoos, et al., 2012b). Fifth, extending the use of the technologies to additional individuals would be essential to determine their general applicability and dependability and to identify ways of upgrading them (Barlow et al., 2009; Kennedy, 2005). The upgrading process should lead one to build technologies that can be easily adjusted to the characteristics of the participants and thus have wider applicability and effectiveness (Shih, Wang, Chang, & Kung, 2012). Aspects on which the technologies need to be flexible concern the types and the number of microswitches through which the participants respond (i.e., activate the programs) (Posatskiy & Chau, 2012). The microswitch types could vary from simple touch/pressure pads on the wheelchair tray to be activated with hand movements (for participants with better motor functioning) to optic sensors near the participants’ eye or mouth to be activated with eyelid or lip movements (for participants with minimal motor behavior). The number of microswitches to use is also connected to the motor condition of the participants and the responses available. In practice, it would be difficult to use two different microswitches when the participant has only minimal motor behavior. In that case, the same microswitch could serve to activate the different technologies based on response variations. For example, a 1-s eyelid closure could be used to activate one technology while repeated eyelid closures could be used as the response to activate the second technology (Lancioni, Singh, O’Reilly, Sigafoos, Didden, et al., 2010). Sixth, the aforementioned research efforts directed at extending the number of participants and upgrading the technology could be combined with the assessment of participants’ preferences as well as social validation assessments involving caregivers and rehabilitation staff as social raters (Callahan, Henson, & Cowan, 2008; Kazdin, 2001; Scherer, Craddock, & Mackeogh, 2011). These two types of assessment could be critical to (a) determine the perception of the

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