Helping three persons with multiple disabilities acquire independent dressing through assistive technology.
Attempts were recently made to curb the problem of dependency in personal care tasks with the use of assistive technology, which ensured a combination of verbal prompting and preferred stimuli that were automatically delivered on positive performance (see Lancioni et al., 2002, 2006). Three participants were involved in the intervention programs described in these studies, and they all learned to dress themselves. Although these results are encouraging, two aspects of the technology that was used in the interventions raise some questions. First, prompts were delivered at preset intervals, rather than upon the failure to respond of participants. The latter condition would appear preferable in terms of effectiveness and respect for the dignity of participants (Lancioni, O'Reilly, Seedhouse, Furniss, & Cunha, 2000). Second, the prompts and reinforcing stimuli were all auditory. The possibility of using various types of prompts and reinforcing events would be essential for the generalizability of the approach.
The goal of the study presented here was to help three new participants with multiple disabilities acquire independent dressing through an upgraded version of the technology. This technology provided prompts only for the failure to respond and included auditory, visual, and vibratory stimuli as reinforcing events or prompts.
The participants, Sylvie, Floyd, and Alan (all names are pseudonyms), were 37, 27, and 29 years old, respectively. They had encephalopathy with a level of functioning estimated to be in the profound range of intellectual disability. Their age equivalents for their daily living skills were about 3 years or younger on the Vineland Adaptive Behavior Scales-Interview Edition (Sparrow, Balla, & Cicchetti, 1984). Sylvie was deaf and had minimal residual vision that allowed her to enjoy light displays and find fairly large objects within about 1 meter (about 39 inches) in front of her and at the center of her visual field. Floyd was totally blind and had typical hearing. Alan was totally blind and deaf and, contrary to the other participants, nonambulatory. These differences in sensory-motor conditions (representative of common variations among individuals with multiple disabilities) allowed for adaptations and a broader evaluation of the assistive technology used in the intervention presented here. All three participants were considered capable of performing the steps of the dressing task, even though Alan needed some physical support to complete the responses of putting on his underpants and pants because of his physical condition. In spite of their general abilities, the three participants still tended to have breaks in performance that required interventions by staff members. Approval for this research was granted by the Scientific and Ethics Committee of the Lega F. D'Oro, Osimo, Italy. The participants were not capable of signing an informed consent form, so their parents did it for them in accordance with Italian law.
Setting, dressing task, recording, and reliability
The study was carried out in the participants' bedrooms by research assistants who were familiar with the topic of personal care tasks and the delicate issue of respect for the participants' dignity. Sylvie's dressing sequence consisted of taking and putting on her underpants, undershirt, one sock, the other sock, T-shirt, pants, pullover sweatshirt, right shoe, and left shoe. For Floyd and Alan, the sequence did not include the sweatshirt. The number of items put on by the participants independent of the research assistants' verbal or physical guidance (which excluded the aforementioned physical support for Alan) and the time required to complete the task were recorded. Interrater reliability was checked in about 20% of the participants' dressing occasions. Agreement, which allowed for a discrepancy of 30 seconds for the task time and required the same "independent" or "dependent" score on each task item, occurred in more than 92% of the occasions that were checked.
Positions of the participants and items
Sylvie and Floyd sat on a chair in front of a dresser that held all the items required for dressing. Alan sat beside (in contact with) a low table with a large container on it. At the bottom of that container, there was a shoebox with his shoes. On top of the shoebox, there were his clothing items. For Floyd, his underpants, undershirt, first sock, second sock, T-shirt, pants, right shoe, and left shoe were distributed (from top to bottom) in the eight drawers of the dresser. For Sylvie, who had a ninth item (a pullover sweatshirt), both shoes were in a single drawer. All the dresser drawers were open at the start of the task, and Floyd and Sylvie were able to access only the top drawer and take the first item (underpants). Then, they would close the drawer and put on the item. Their next response consisted of accessing the top drawer of the seven still open, taking the second item, and then putting it on. The same process was repeated at each of the following drawers. For Alan, the clothing items were piled inside the container, with the underpants on top and the pants at the bottom of the pile (above the shoebox with the shoes).
Technology and stimuli
The technology that was used for Sylvie involved an optic sensor linked to an electronic control system, which regulated a multicolor light display and a mini-vibrator. The optic sensor was placed on top of the dresser and was activated when Sylvie removed an item from a drawer, thus uncovering reflecting material that was attached to the bottom of the drawer. This activation led the control system to turn on the preferred light display for 14 seconds. Sylvie's failure to remove an item after a period of about 60 seconds led the control system to activate a mini-vibrator (prompt), which Sylvia wore at her wrist, for 5 seconds. The vibrator and control system were linked by radio signals. If Sylvie did not respond to the vibration within 10 seconds by removing an item from a drawer, a new vibratory event occurred. Sylvie's failure to respond to this second event led to the use of physical guidance by a research assistant.
The technology used for Floyd varied from that described for Sylvie only in that the control system was linked to two tape players, which presented 14 seconds of preferred music, songs, or excited praise at the removal of an item from the drawer, and a verbal encouragement (prompt) if he failed to respond. The technology used for Alan included an optic sensor fixed to the container on the table. Activating the sensor, through the removal of a clothing item or shoe from the container, led the control system to turn on preferred vibratory stimulation at the back of Alan' s chair for 14 seconds. Alan's failure to remove a clothing item or a shoe for a time period of about 60 seconds led the control system to activate a pulse-vibrator (prompt) attached to the table for 4 or 5 seconds.
The stimuli that occurred on the removal of the items from the dresser or container and that were considered preferred by the participants (lights for Sylvie; music, songs, and praise for Floyd; and vibration at the back of the chair for Alan) were selected following advice from the staff and a brief screening. The screening consisted of presenting the stimuli recommended by the staff to the participants at least 10 times nonconsecutively. Only those stimuli that produced positive reactions (such as alerting, orienting, or smiling) in more than two-thirds of the presentations were retained for the study.
The study was conducted according to a multiple baseline design for all the participants (Richards, Taylor, Ramasamy, & Richards, 1999). Consistent with the conditions available prior to the study, Sylvie had one dressing occasion per day (morning), and Floyd and Alan had two dressing occasions per day (morning and afternoon). The performance of the participants for the various items of the dressing task was scored as independent when the item was put on without guidance from a research assistant (with the aforementioned exceptions for Alan) and dependent when it required guidance.
Baseline. The baseline condition included 6, 14, and 18 dressing occasions for the three participants (Sylvie, Floyd, and Alan), respectively. The positions of the participants and the dressing items were as was described earlier. However, during the baseline phase, the technology used in the intervention phase was not available, and guidance by a research assistant occurred if a participant had a break in performance of 60-120 seconds.
Intervention. The intervention condition included 81, 156, and 140 dressing occasions for the three participants (Sylvie, Floyd, and Alan), respectively. These occasions were spread over periods exceeding 3.5 months. Procedural conditions differed from those used during the baseline in that the technology was available and worked as was specified earlier.
[FIGURE 1 OMITTED]
The three graphs of Figure 1 summarize the data for the three participants during the baseline and intervention periods. During the baseline, the participants (Sylvie, Floyd, and Alan) put on independently about 60%, 50%, and 30% of the dressing items, respectively. Their average times for completing the sequence were 8 to 13 minutes. During the intervention, each participant became capable of performing the dressing sequence with only occasional guidance from the research assistants, and the time they required to perform it decreased markedly. The mean amount of time required for the dressing task during the second half of the intervention periods was fewer than 6 minutes for all the participants. The differences in the percentages of dressing items put on independently and the amount of time required for dressing between the baseline and intervention were statistically significant for all the participants (17 < .01) on the Kolmogorov-Smirnov test (Siegel & Castellan, 1988).
The data, which largely support and extend those that were previously reported in this area (Lancioni et al., 2002, 2006), appear encouraging with regard to the possibility of using technological solutions to promote daily self-help skills (see, for example, Lancioni, Smaldone, O'Reilly, Singh, & Oliva, 2005; Wilson, Reid, & Green, 2006). The technology that was applied in this study allowed the use of various types of preferred stimuli as plausible reinforcing events and provided prompts only following the participants' failure to respond. The former option can be viewed as critical for generalizing the use of the technology to persons with different characteristics, preferences, and physical or sensory conditions (Sewell et al., 1998). The latter option can be considered important for increasing the effectiveness of the prompt while reducing its fixed-interval (often irrelevant) occurrence and promoting social image and independence of the participants (see, for example, Lancioni et al., 2000; Wilson et al., 2006). Informal reports suggested that prompts continued to occur, albeit at relatively low (sporadic) levels, through the final stages of the intervention, with usually successful outcomes.
The innovative aspects of the technology and the fact that it seems simple to apply by parents and staff may allow the technology to be adopted within the home and care contexts (Copley & Ziviani, 2005; Parette, 1997). The cost of the technology (about U.S. $1,200), however, may be excessive for some. To mitigate the cost issue, one may argue that such technology could be used for a long period of time without extra expenses and could be shared among participants.
Whether participants would eventually become independent of the technology remains an open question. Persons with multiple disabilities may more easily maintain high motivation and fluency in performance with the preferred stimuli and occasional prompting that the technology provides (Lancioni et al., 2000, 2005; Scherer, 2005). Researchers may need to conduct direct and systematic replications of this study to clarify the aforementioned question and to refine the technology and its general applicability.
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Giulio E. Lancioni, Ph.D., professor, Department of Psychology, University of Bari, Via Quintino Sella 268, 70100 Bari, Italy; e-mail: <g. email@example.com>. Mark F. O'Reilly, Ph.D., professor, Department of Special Education, University of Texas at Austin, Mail Code D 5300, Austin, TX 78712; e-mail: <firstname.lastname@example.org>. Nirbhay N. Singh, Ph.D., senior scientist, ONE Research Institute, P.O. Box 4657, Midlothian, VA 23112; e-mail: <email@example.com>. Jeff Sigafoos, Ph.D., School of Education, University of Tasmania, Hobart, Tasmania 7001, Australia; e-mail: <firstname.lastname@example.org>. Doretta Oliva, M.A., research coordinator, Lega F. D'Oro Research Center, Via Montecerno 1, 60027 Osimo, Italy; e-mail: <oliva.d.@legadelfilodoro.it>. Francesca Campodonico, B.A., research assistant, Lega F. D'Oro Research Center; e-mail: <email@example.com>. Jop Groeneweg, Ph.D., assistant professor, Department of Psychology, University of Leiden, P.O. Box 9555, 2300 RB, Leiden, the Netherlands; e-mail: <firstname.lastname@example.org>. Address all correspondence to Dr. Lancioni.