Perceptual & Motor Skills: Physical Development & Measurement 2014, 119, 1, 320-331. © Perceptual & Motor Skills 2014
CASE STUDIES OF TECHNOLOGY FOR ADULTS WITH MULTIPLE DISABILITIES TO MAKE TELEPHONE CALLS INDEPENDENTLY1 GIULIO E. LANCIONI
NIRBHAY N. SINGH
University of Bari, Italy
Medical College of Georgia Georgia Regents University
MARK F. O'REILLY
JEFF SIGAFOOS
University of Texas at Austin, USA
Victoria University of Wellington, New Zealand
ADELE BOCCASINI AND MARIA L. LA MARTIRE
RUSSELL LANG
Lega F. D’Oro Research Center, Osimo and Molfetta, Italy
Texas State University San Marcos, Texas
Summary.—Recent literature has shown the possibility of enabling individuals with multiple disabilities to make telephone calls independently via computeraided telephone technology. These two case studies assessed a modified version of such technology and a commercial alternative to it for a woman and a man with multiple disabilities, respectively. The modified version used in Study 1 (a) presented the names of the persons available for a call and (b) reminded the participant of the response she needed to perform (i.e., pressing a microswitch) if she wanted to call any of those names/persons. The commercial device used in Study 2 was a Galaxy S3 (Samsung) equipped with the S-voice module, which allowed the participant to activate phone calls by uttering the word “Call” followed by the name of the persons he wanted to call. The results of the studies showed that the participants learned to make phone calls independently using the technology/device available. Implications of the results are discussed.
Intervention programs for persons with multiple (e.g., intellectual and motor or visual) disabilities must deal with many challenges to possibly increase the persons' functional engagement, communication, and social behavior (Van Naarden Braun, Yeargin-Allsopp, & Lollar, 2009; Koyama & Wang, 2011; Hua, Woods-Groves, Kaldenberg, & Scheidecker, 2013; Travis & Sturmey, 2013; Hutchins & Prelock, 2014). The use of technology has become an increasingly important part of those programs, i.e., a condition to enhance their effectiveness and improve the chances of positive outcomes (Borg, Larsson, & Östergren, 2011; Mechling, 2011; De Joode, Van Boxtel, Verhey, & Van Heugten, 2012; Luckasson & Schalock, 2012; Hoppestad, 2013; Lancioni, Sigafoos, O'Reilly, & Singh, 2013; Näslund & Gardelli, 2013). Address correspondence to G. E. Lancioni, Department of Neuroscience and Sense Organs, University of Bari, Via Quintino Sella 268, 70100 Bari, Italy or e-mail (giulio.lancioni@uniba. it). 1
DOI 10.2466/15.PMS.119c14z4
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ISSN 0031-5125
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For example, technology-aided intervention programs have been developed and successfully applied for (a) guiding participants to perform sequences of activity steps through pictorial or verbal instructions (e.g., Lancioni, Singh, O'Reilly, Sigafoos, Oliva, Smaldone, et al., 2011), (b) enabling participants to choose text messages to send to family members or friends and have any messages from these people read out (e.g., Lancioni, O'Reilly, Singh, Green, Oliva, Buonocunto, et al., 2012), and (c) allowing participants to make phone calls without any need to remember, find, or dial the numbers of the persons they want to reach (e.g., Lancioni, O'Reilly, Singh, & Oliva, 2011). The aforementioned technology-aided program for allowing participants to make phone calls independently involved the use of a computer with dedicated software and a microswitch that the participants could activate with a simple hand response or via mouth or head movements (Lancioni, O’Reilly, Singh, & Oliva, 2011; Lancioni, Singh, O'Reilly, Sigafoos, Oliva, & Campodonico, 2013). Each phone call started with the participants' microswitch activation, which led the computer system to (a) acknowledge that they could call and (b) list the groups of persons available for a call (e.g., family and friends). The participants' selection of a group (i.e., by activating their microswitch within a few seconds from the computer listing it) led the computer to present the names of the persons available in that group. Microswitch activation within a few seconds from the utterance of a person's name led the computer to place a call to that person. All six participants with multiple disabilities involved in the assessment of this program learned to make phone calls independently (Lancioni, O’Reilly, Singh, & Oliva, 2011; Lancioni, O'Reilly, Singh, Sigafoos, Oliva, Alberti, et al., 2011; Lancioni, Singh, O’Reilly, Sigafoos, Oliva, et al., 2013). The same program was also effective with persons with traumatic or degenerative brain damage (Lancioni, Singh, O'Reilly, Sigafoos, Buonocunto, Sacco, et al., 2013; Perilli, Lancioni, Laporta, Paparella, Caffò, Singh, et al., 2013). The two single-case studies reported here were conceived as part of the general intervention (education/rehabilitation) efforts required for individuals with multiple disabilities. In particular, they were designed to extend the assessment of technology solutions for helping these individuals make phone calls independently. Study 1 involved a woman with moderate intellectual disability and visual and motor impairments. She was considered unable to use a conventional telephone and was partially unsuited for the aforementioned technology-aided program. One problem with such a program was that she could listen to the presentation of groups/persons but could also fail (i.e., forget) to select the one she wanted to call in time, with the consequence that the presentation was to be repeated or the caregiver had to intervene. Given the situation, the program
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was modified and she received reminders about the microswitch response needed to make a selection and start a call. Study 2 involved a man with mild to moderate intellectual disability and total blindness. Given his clear speech, the study assessed whether he could use a commercial device (i.e., a Galaxy S3 smart phone, by Samsung) equipped with the S-voice module, which responds to verbal input. Indeed, such device can place a call to a person if his or her name is presented in a recognizable manner and matches a name (and a number) already stored in its database. The assumption was that the man could learn to (a) use some personal identification words to enter and instruct the device and (b) present the names of the persons to call in a clear manner so that the device could match them to the names and numbers stored in its database (Ayres, Mechling, & Sansosti, 2013). Study 1 METHOD Participant The participant (Frances) was 38 yr. old and attended a center for persons with multiple disabilities, in which she was involved in self-help activities (e.g., personal care), domestic daily activities (e.g., food preparation), as well as social and leisure events (e.g., recreational activities inside and outside the center). She had a diagnosis of congenital encephalopathy with optic atrophy and consequent low vision, and spasticity with limited manual dexterity. Her intellectual disability was described as moderate, but no IQ score was available. She also presented speech articulation problems that caused her to show some slurring and stuttering. These problems did not seem to affect the comprehension of her utterances by her regular social partners (i.e., family members, friends, and staff). She showed the ability to participate in simple conversations, and enjoyed them when in direct contact with partners or on the telephone with them. Given her limited vision and motor disabilities, she did not make phone calls on her own. However, she was very interested in doing so with the help of technology. Her legal representative had signed a formal consent for this study, which had been approved by a scientific and ethics committee. Setting, Sessions, and Data Collection The study was carried out in a quiet room of the center that Frances attended. Sessions occurred once or twice a day and lasted 10 min. (or until Frances had completed a call started before the 10-min. limit). This length was considered appropriate for her and suitable for her context. Within each session, a research assistant recorded the (a) total number of
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telephone calls made and whether they were made independently (i.e., by the participant without guidance from the research assistant; see below), and (b) number of telephone calls which were answered by the persons called. Interrater reliability was assessed in over 30% of the sessions, with two research assistants recording the measures during those sessions. The percentages of agreement on the single measures (computed over groups of two or three sessions by dividing the total number of agreements by the total number of agreements and disagreements and multiplying by 100) exceeded 90. Computer-aided Program and Response The modified computer-aided program used for Frances worked as follows. First, the initial microswitch activation led the computer to present the names of the persons available for a call (and skip the list of groups, thus making the process more direct). Twelve names/persons were available. Second, the presentation of each name was followed by a sentence such as “if you want to call him/her, press the green button” (i.e., the microswitch). A similar sentence (response reminder) had been used successfully with two post-coma participants during a program on text messaging (see Lancioni, Singh, O'Reilly, Sigafoos, Signorino, Oliva, et al., 2010). Third, the computer was set to start a new call sequence (i.e., with the presentation of the names available) at the first microswitch activation after the end of the previous call or if an interval of 15–25 sec. had elapsed from it. Experimental Conditions The study was carried out according to an ABAB design, in which A and B represented baseline and intervention phases with the computeraided program, respectively (Barlow, Nock, & Hersen, 2009). Four weeks after the second B phase, a post-intervention check was carried out. Baseline phases.—Each baseline phase included only two sessions, as Frances was not deemed capable of making telephone calls through the mobile or the desk telephone devices available to her during those sessions (see Participant). After 3–5 min. of inactivity, the research assistant (a) asked her whether she wanted to call somebody and then (b) called for her the person she had indicated. Intervention phases.—The first intervention phase was introduced by seven practice sessions aimed at familiarizing Frances with the use of the technology. The research assistant guided her to activate the microswitch in relation to at least three persons (considered most preferred) per session so as to let her experience microswitch responses followed by telephone calls. The practice sessions were followed by 29 regular intervention sessions, during which the research assistant provided guidance only if Fran-
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ces did not provide a microswitch response for more than five consecutive persons presented by the computer. The second intervention phase included 28 intervention sessions corresponding to those of the first intervention phase. Post-intervention check.—Frances continued to receive sessions such as those available in the second intervention phase. Eight of those sessions, carried out four weeks after the end of the phase, served as the post-intervention check. RESULTS Frances' data during the baseline and intervention phases and the post-intervention check are summarized in Fig. 1 (upper graph). The bars represent mean frequencies of telephone calls made independently per session, over blocks of sessions. The number of sessions involved in each block/bar is indicated by the numeral above it. The black squares represent mean frequencies of telephone calls answered per session within those blocks of sessions. During the two baseline phases Frances did not make any independent calls; thus, the figure shows zero frequencies for telephone calls made and telephone calls answered. During the first inter-
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FIG. 1. Upper graph: Frances' data. Lower graph: Martin's data. The bars represent mean frequencies of phone calls made independently per session, over blocks of sessions. The number of sessions involved in each block/bar is indicated by the numeral above it. The black squares represent mean frequencies of phone calls answered per session within the aforementioned blocks of sessions. The zero values during the baseline phases indicate absence of independent calls and answers.
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vention phase, Frances made a mean frequency of about six calls per session (i.e., with the independent selection of as many persons). About four calls per session were answered, on average. Guidance from the research assistant (see above) was used only once. During the second intervention phase and the post-intervention check Frances continued to be successfully independent, and the data matched those of the first intervention phase. Study 2 METHOD Participant The participant (Martin) was 39 yr. old and attended a center for persons with multiple disabilities, in which he was involved, like Frances, in a variety of functional daily activities as well as social and leisure events. He was diagnosed with congenital encephalopathy, due to complications during pregnancy and severely premature birth. He had total blindness and poor manual coordination. His intellectual disability was considered to be mild to moderate, but no IQ score was available. He liked to make telephone calls to family members and friends, but required help to do that. He had expressed great interest in learning to make those calls independently and was eager to use any technology/device for that purpose. His legal representative had signed a formal consent for this study, which had been approved by a scientific and ethics committee. Setting, Sessions, and Data Collection The study was carried out in a quiet room of the center that Martin attended. Sessions occurred once or twice a day and lasted 10 min., as in Study 1. Data collection and reliability matched those described in Study 1. Telephone Device and Responses The telephone device used for Martin was a Galaxy S3 with the Svoice module. The names and telephone numbers of the 14 persons selected for his telephone calls had been recorded in the device's database. Specifically, Martin had been guided to record those 14 names. Given the clarity of his speech, the device easily recognized (and correctly matched) his new utterances of those names. The procedure for the first telephone call of each session required that Martin use a greeting word to enter the device and then use the word “Call,” followed by the name of a person to start the call to him or her. To end a call (at its completion or if there was no answer from the person called), Martin was simply to utter the word “Stop.” For any new call within the session, he was to utter the word “call” followed by the name of the next person he wanted to call.
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Experimental Conditions The study was carried out according to an ABAB design, in which A and B represented baseline and intervention phases, respectively (Barlow, et al., 2009). Four weeks after the second B phase, a post-intervention check was carried out. Baseline phases.—Each baseline included two sessions matching those used in Study 1. Intervention phases.—The first intervention phase was introduced by five practice sessions aimed at familiarizing Martin with the use of the Galaxy S3 device (see Study 1). The practice sessions were followed by 20 regular intervention sessions, during which the research assistant provided guidance only if Martin failed to make any call for an interval of about 3 min. The second intervention phase included 24 intervention sessions corresponding to those of the first intervention phase. Post-intervention check.—Conditions were as in Study 1. RESULTS Martin's data during the baseline and intervention phases and the post-intervention check are summarized in Fig. 1 (lower graph). During the two baseline phases, Martin did not make any independent calls; thus, the figure shows zero frequencies for telephone calls made and telephone calls answered. During the first intervention phase, Martin made a mean frequency of about five independent calls per session. A mean frequency of about three and a half calls was met with an answer. Guidance from the research assistant (see above) was never needed. During the second intervention phase and the post-intervention check, Martin continued to be successfully independent with fairly stable data. GENERAL DISCUSSION Data showed that the computer-aided program used in Study 1 and the commercial device used in Study 2 were effective in enabling these participants with multiple disabilities to make telephone calls independently. These data provide (a) an extension of the evidence so far available about the technology options applicable to help those participants, and (b) a basis to assess additional technology options to reach a wider range of participants and help their communication (Nguyen, Garrett, Downing, Walker, & Hobbs, 2007; DePompei, Gillette, Goetz, Xenopoulos-Oddsson, Bryen, & Dowds, 2008; Kim, Huo, & Ghovanloo, 2010; Burgstahler, Comden, Lee, Arnold, & Brown, 2011; Lancioni, O’Reilly, Singh, & Oliva, 2011). Such communication may be useful to enhance their social/emotional relations and reduce their isolation and social impoverishment (Tomasik, 2007; Nguyen, Garrett, Downing, Walker, & Hobbs, 2008; Stock, Davies, Wehmeyer, & Palmer, 2008; Solish, Perry, & Minnes, 2010; Lancioni, O’Reilly, Singh, & Oliva, 2011).
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The program used in Study 1 was somewhat more complex than the program used with previous participants with multiple disabilities (e.g., Lancioni, O’Reilly, Singh, & Oliva, 2011). A particular feature of the new program was the response reminders following the names of the persons listed as candidates for a call. The assumption was that the reminders would help the participant avoid response delays or failures interfering with her possibility to make phone calls. Such an assumption was based on previous, successful use of a similar strategy in a study concerning text messaging (see Lancioni, et al., 2010). Although no formal evaluation of the effect of this strategy was carried out, two aspects of the data suggest that its role was positive. First, Frances did not show long periods of no responding (i.e., bypassing long series of persons in the list presented). Second, Frances was reported to show preferences among the persons called, choosing some of them in about 60% or more of the presentations and others in less than 15% of the presentations (thus indicating that her choices were independent of response reminders). A commercial device, such as that used in Study 2, can be considered advantageous because it is readily accessible and improves (normalizes) the appearance of the person using it (Ripat & Woodgate, 2011; Shih, Shih, & Luo, 2011; Foley & Ferri, 2012; Shih, 2013). The positive results were due to (a) the pre-recording of the names and telephone numbers of the persons available for calls, and (b) Martin's ability to use the key words and the persons' names in a clearly recognizable manner. While the first of these two conditions can be easily ensured, clear speech might be irregular among participants with multiple disabilities, thus reducing the general usability of the device. Indeed, speech skills such as those shown by Frances would not be sufficient to operate such a device. The outcomes of the two studies must be viewed as preliminary because they are based on single participants. It should be the aim of new studies to extend the evaluation of both technology solutions with additional participants (Kazdin, 2001; Kennedy, 2005). Replications of the present findings are necessary to view those technology solutions as real resources for daily contexts (Kennedy, 2005; Barlow, et al., 2009). Obviously, the decision of these contexts as to whether to use those solutions is likely to be affected by replication data as well as by costs. The costs were valued at approximately 2,000 U.S. dollars for the technology used in Study 1, and about 400 U.S. dollars for the commercial device used in Study 2. Such costs might be considered affordable for a variety of families and rehabilitation centers (Hubbard Winkler, Vogel, Hoenig, Cowper Ripley, Wu, Fitzgerald, et al., 2010; Dahlin & Rydén, 2011; Ripat & Woodgate, 2011; Wallace, 2011; Lancioni, et al., 2012). In conclusion, the present case studies underline the effectiveness of two technology solutions for helping different individuals with multiple
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disabilities. New research needs to assess the generality of these findings with the involvement of additional participants (Barlow, et al., 2009; Kennedy, 2005). New research could also (a) determine the participants' satisfaction in using those technology solutions, and (b) carry out social validation assessments of such solutions to identify the view of staff, families, and rehabilitation experts about their practicality and implications (Callahan, Henson, & Cowan, 2008; Luiselli, Bass, & Whitcomb, 2010; Scherer, Craddock, & Mackeogh, 2011; Tullis, Cannella-Malone, Basbigill, Yeager, Fleming, Payne, et al., 2011; Wehmeyer, Palmer, Shogren, Williams-Diehm, & Soukup, 2013). REFERENCES
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WALLACE, J. (2011) Assistive technology funding in the United States. NeuroRehabilitation, 28, 295-302. WEHMEYER, M. L., PALMER, S. B., SHOGREN, K., WILLIAMS-DIEHM, K., & SOUKUP, J. H. (2013) Establishing a causal relationship between intervention to promote self-determination and enhanced student self-determination. The Journal of Special Education, 46, 195-210. Accepted June 4, 2014.
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CASE STUDIES OF TECHNOLOGY FOR ADULTS WITH MULTIPLE DISABILITIES TO MAKE TELEPHONE CALLS INDEPENDENTLY1 GIULIO E. LANCIONI
NIRBHAY N. SINGH
University of Bari, Italy
Medical College of Georgia Georgia Regents University
MARK F. O'REILLY
JEFF SIGAFOOS
University of Texas at Austin, USA
Victoria University of Wellington, New Zealand
ADELE BOCCASINI AND MARIA L. LA MARTIRE
RUSSELL LANG
Lega F. D’Oro Research Center, Osimo and Molfetta, Italy
Texas State University San Marcos, Texas
Summary.—Recent literature has shown the possibility of enabling individuals with multiple disabilities to make telephone calls independently via computeraided telephone technology. These two case studies assessed a modified version of such technology and a commercial alternative to it for a woman and a man with multiple disabilities, respectively. The modified version used in Study 1 (a) presented the names of the persons available for a call and (b) reminded the participant of the response she needed to perform (i.e., pressing a microswitch) if she wanted to call any of those names/persons. The commercial device used in Study 2 was a Galaxy S3 (Samsung) equipped with the S-voice module, which allowed the participant to activate phone calls by uttering the word “Call” followed by the name of the persons he wanted to call. The results of the studies showed that the participants learned to make phone calls independently using the technology/device available. Implications of the results are discussed.
Intervention programs for persons with multiple (e.g., intellectual and motor or visual) disabilities must deal with many challenges to possibly increase the persons' functional engagement, communication, and social behavior (Van Naarden Braun, Yeargin-Allsopp, & Lollar, 2009; Koyama & Wang, 2011; Hua, Woods-Groves, Kaldenberg, & Scheidecker, 2013; Travis & Sturmey, 2013; Hutchins & Prelock, 2014). The use of technology has become an increasingly important part of those programs, i.e., a condition to enhance their effectiveness and improve the chances of positive outcomes (Borg, Larsson, & Östergren, 2011; Mechling, 2011; De Joode, Van Boxtel, Verhey, & Van Heugten, 2012; Luckasson & Schalock, 2012; Hoppestad, 2013; Lancioni, Sigafoos, O'Reilly, & Singh, 2013; Näslund & Gardelli, 2013). Address correspondence to G. E. Lancioni, Department of Neuroscience and Sense Organs, University of Bari, Via Quintino Sella 268, 70100 Bari, Italy or e-mail (giulio.lancioni@uniba. it). 1
DOI 10.2466/15.PMS.119c14z4
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ISSN 0031-5125
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For example, technology-aided intervention programs have been developed and successfully applied for (a) guiding participants to perform sequences of activity steps through pictorial or verbal instructions (e.g., Lancioni, Singh, O'Reilly, Sigafoos, Oliva, Smaldone, et al., 2011), (b) enabling participants to choose text messages to send to family members or friends and have any messages from these people read out (e.g., Lancioni, O'Reilly, Singh, Green, Oliva, Buonocunto, et al., 2012), and (c) allowing participants to make phone calls without any need to remember, find, or dial the numbers of the persons they want to reach (e.g., Lancioni, O'Reilly, Singh, & Oliva, 2011). The aforementioned technology-aided program for allowing participants to make phone calls independently involved the use of a computer with dedicated software and a microswitch that the participants could activate with a simple hand response or via mouth or head movements (Lancioni, O’Reilly, Singh, & Oliva, 2011; Lancioni, Singh, O'Reilly, Sigafoos, Oliva, & Campodonico, 2013). Each phone call started with the participants' microswitch activation, which led the computer system to (a) acknowledge that they could call and (b) list the groups of persons available for a call (e.g., family and friends). The participants' selection of a group (i.e., by activating their microswitch within a few seconds from the computer listing it) led the computer to present the names of the persons available in that group. Microswitch activation within a few seconds from the utterance of a person's name led the computer to place a call to that person. All six participants with multiple disabilities involved in the assessment of this program learned to make phone calls independently (Lancioni, O’Reilly, Singh, & Oliva, 2011; Lancioni, O'Reilly, Singh, Sigafoos, Oliva, Alberti, et al., 2011; Lancioni, Singh, O’Reilly, Sigafoos, Oliva, et al., 2013). The same program was also effective with persons with traumatic or degenerative brain damage (Lancioni, Singh, O'Reilly, Sigafoos, Buonocunto, Sacco, et al., 2013; Perilli, Lancioni, Laporta, Paparella, Caffò, Singh, et al., 2013). The two single-case studies reported here were conceived as part of the general intervention (education/rehabilitation) efforts required for individuals with multiple disabilities. In particular, they were designed to extend the assessment of technology solutions for helping these individuals make phone calls independently. Study 1 involved a woman with moderate intellectual disability and visual and motor impairments. She was considered unable to use a conventional telephone and was partially unsuited for the aforementioned technology-aided program. One problem with such a program was that she could listen to the presentation of groups/persons but could also fail (i.e., forget) to select the one she wanted to call in time, with the consequence that the presentation was to be repeated or the caregiver had to intervene. Given the situation, the program
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was modified and she received reminders about the microswitch response needed to make a selection and start a call. Study 2 involved a man with mild to moderate intellectual disability and total blindness. Given his clear speech, the study assessed whether he could use a commercial device (i.e., a Galaxy S3 smart phone, by Samsung) equipped with the S-voice module, which responds to verbal input. Indeed, such device can place a call to a person if his or her name is presented in a recognizable manner and matches a name (and a number) already stored in its database. The assumption was that the man could learn to (a) use some personal identification words to enter and instruct the device and (b) present the names of the persons to call in a clear manner so that the device could match them to the names and numbers stored in its database (Ayres, Mechling, & Sansosti, 2013). Study 1 METHOD Participant The participant (Frances) was 38 yr. old and attended a center for persons with multiple disabilities, in which she was involved in self-help activities (e.g., personal care), domestic daily activities (e.g., food preparation), as well as social and leisure events (e.g., recreational activities inside and outside the center). She had a diagnosis of congenital encephalopathy with optic atrophy and consequent low vision, and spasticity with limited manual dexterity. Her intellectual disability was described as moderate, but no IQ score was available. She also presented speech articulation problems that caused her to show some slurring and stuttering. These problems did not seem to affect the comprehension of her utterances by her regular social partners (i.e., family members, friends, and staff). She showed the ability to participate in simple conversations, and enjoyed them when in direct contact with partners or on the telephone with them. Given her limited vision and motor disabilities, she did not make phone calls on her own. However, she was very interested in doing so with the help of technology. Her legal representative had signed a formal consent for this study, which had been approved by a scientific and ethics committee. Setting, Sessions, and Data Collection The study was carried out in a quiet room of the center that Frances attended. Sessions occurred once or twice a day and lasted 10 min. (or until Frances had completed a call started before the 10-min. limit). This length was considered appropriate for her and suitable for her context. Within each session, a research assistant recorded the (a) total number of
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telephone calls made and whether they were made independently (i.e., by the participant without guidance from the research assistant; see below), and (b) number of telephone calls which were answered by the persons called. Interrater reliability was assessed in over 30% of the sessions, with two research assistants recording the measures during those sessions. The percentages of agreement on the single measures (computed over groups of two or three sessions by dividing the total number of agreements by the total number of agreements and disagreements and multiplying by 100) exceeded 90. Computer-aided Program and Response The modified computer-aided program used for Frances worked as follows. First, the initial microswitch activation led the computer to present the names of the persons available for a call (and skip the list of groups, thus making the process more direct). Twelve names/persons were available. Second, the presentation of each name was followed by a sentence such as “if you want to call him/her, press the green button” (i.e., the microswitch). A similar sentence (response reminder) had been used successfully with two post-coma participants during a program on text messaging (see Lancioni, Singh, O'Reilly, Sigafoos, Signorino, Oliva, et al., 2010). Third, the computer was set to start a new call sequence (i.e., with the presentation of the names available) at the first microswitch activation after the end of the previous call or if an interval of 15–25 sec. had elapsed from it. Experimental Conditions The study was carried out according to an ABAB design, in which A and B represented baseline and intervention phases with the computeraided program, respectively (Barlow, Nock, & Hersen, 2009). Four weeks after the second B phase, a post-intervention check was carried out. Baseline phases.—Each baseline phase included only two sessions, as Frances was not deemed capable of making telephone calls through the mobile or the desk telephone devices available to her during those sessions (see Participant). After 3–5 min. of inactivity, the research assistant (a) asked her whether she wanted to call somebody and then (b) called for her the person she had indicated. Intervention phases.—The first intervention phase was introduced by seven practice sessions aimed at familiarizing Frances with the use of the technology. The research assistant guided her to activate the microswitch in relation to at least three persons (considered most preferred) per session so as to let her experience microswitch responses followed by telephone calls. The practice sessions were followed by 29 regular intervention sessions, during which the research assistant provided guidance only if Fran-
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ces did not provide a microswitch response for more than five consecutive persons presented by the computer. The second intervention phase included 28 intervention sessions corresponding to those of the first intervention phase. Post-intervention check.—Frances continued to receive sessions such as those available in the second intervention phase. Eight of those sessions, carried out four weeks after the end of the phase, served as the post-intervention check. RESULTS Frances' data during the baseline and intervention phases and the post-intervention check are summarized in Fig. 1 (upper graph). The bars represent mean frequencies of telephone calls made independently per session, over blocks of sessions. The number of sessions involved in each block/bar is indicated by the numeral above it. The black squares represent mean frequencies of telephone calls answered per session within those blocks of sessions. During the two baseline phases Frances did not make any independent calls; thus, the figure shows zero frequencies for telephone calls made and telephone calls answered. During the first inter-
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FIG. 1. Upper graph: Frances' data. Lower graph: Martin's data. The bars represent mean frequencies of phone calls made independently per session, over blocks of sessions. The number of sessions involved in each block/bar is indicated by the numeral above it. The black squares represent mean frequencies of phone calls answered per session within the aforementioned blocks of sessions. The zero values during the baseline phases indicate absence of independent calls and answers.
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vention phase, Frances made a mean frequency of about six calls per session (i.e., with the independent selection of as many persons). About four calls per session were answered, on average. Guidance from the research assistant (see above) was used only once. During the second intervention phase and the post-intervention check Frances continued to be successfully independent, and the data matched those of the first intervention phase. Study 2 METHOD Participant The participant (Martin) was 39 yr. old and attended a center for persons with multiple disabilities, in which he was involved, like Frances, in a variety of functional daily activities as well as social and leisure events. He was diagnosed with congenital encephalopathy, due to complications during pregnancy and severely premature birth. He had total blindness and poor manual coordination. His intellectual disability was considered to be mild to moderate, but no IQ score was available. He liked to make telephone calls to family members and friends, but required help to do that. He had expressed great interest in learning to make those calls independently and was eager to use any technology/device for that purpose. His legal representative had signed a formal consent for this study, which had been approved by a scientific and ethics committee. Setting, Sessions, and Data Collection The study was carried out in a quiet room of the center that Martin attended. Sessions occurred once or twice a day and lasted 10 min., as in Study 1. Data collection and reliability matched those described in Study 1. Telephone Device and Responses The telephone device used for Martin was a Galaxy S3 with the Svoice module. The names and telephone numbers of the 14 persons selected for his telephone calls had been recorded in the device's database. Specifically, Martin had been guided to record those 14 names. Given the clarity of his speech, the device easily recognized (and correctly matched) his new utterances of those names. The procedure for the first telephone call of each session required that Martin use a greeting word to enter the device and then use the word “Call,” followed by the name of a person to start the call to him or her. To end a call (at its completion or if there was no answer from the person called), Martin was simply to utter the word “Stop.” For any new call within the session, he was to utter the word “call” followed by the name of the next person he wanted to call.
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Experimental Conditions The study was carried out according to an ABAB design, in which A and B represented baseline and intervention phases, respectively (Barlow, et al., 2009). Four weeks after the second B phase, a post-intervention check was carried out. Baseline phases.—Each baseline included two sessions matching those used in Study 1. Intervention phases.—The first intervention phase was introduced by five practice sessions aimed at familiarizing Martin with the use of the Galaxy S3 device (see Study 1). The practice sessions were followed by 20 regular intervention sessions, during which the research assistant provided guidance only if Martin failed to make any call for an interval of about 3 min. The second intervention phase included 24 intervention sessions corresponding to those of the first intervention phase. Post-intervention check.—Conditions were as in Study 1. RESULTS Martin's data during the baseline and intervention phases and the post-intervention check are summarized in Fig. 1 (lower graph). During the two baseline phases, Martin did not make any independent calls; thus, the figure shows zero frequencies for telephone calls made and telephone calls answered. During the first intervention phase, Martin made a mean frequency of about five independent calls per session. A mean frequency of about three and a half calls was met with an answer. Guidance from the research assistant (see above) was never needed. During the second intervention phase and the post-intervention check, Martin continued to be successfully independent with fairly stable data. GENERAL DISCUSSION Data showed that the computer-aided program used in Study 1 and the commercial device used in Study 2 were effective in enabling these participants with multiple disabilities to make telephone calls independently. These data provide (a) an extension of the evidence so far available about the technology options applicable to help those participants, and (b) a basis to assess additional technology options to reach a wider range of participants and help their communication (Nguyen, Garrett, Downing, Walker, & Hobbs, 2007; DePompei, Gillette, Goetz, Xenopoulos-Oddsson, Bryen, & Dowds, 2008; Kim, Huo, & Ghovanloo, 2010; Burgstahler, Comden, Lee, Arnold, & Brown, 2011; Lancioni, O’Reilly, Singh, & Oliva, 2011). Such communication may be useful to enhance their social/emotional relations and reduce their isolation and social impoverishment (Tomasik, 2007; Nguyen, Garrett, Downing, Walker, & Hobbs, 2008; Stock, Davies, Wehmeyer, & Palmer, 2008; Solish, Perry, & Minnes, 2010; Lancioni, O’Reilly, Singh, & Oliva, 2011).
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The program used in Study 1 was somewhat more complex than the program used with previous participants with multiple disabilities (e.g., Lancioni, O’Reilly, Singh, & Oliva, 2011). A particular feature of the new program was the response reminders following the names of the persons listed as candidates for a call. The assumption was that the reminders would help the participant avoid response delays or failures interfering with her possibility to make phone calls. Such an assumption was based on previous, successful use of a similar strategy in a study concerning text messaging (see Lancioni, et al., 2010). Although no formal evaluation of the effect of this strategy was carried out, two aspects of the data suggest that its role was positive. First, Frances did not show long periods of no responding (i.e., bypassing long series of persons in the list presented). Second, Frances was reported to show preferences among the persons called, choosing some of them in about 60% or more of the presentations and others in less than 15% of the presentations (thus indicating that her choices were independent of response reminders). A commercial device, such as that used in Study 2, can be considered advantageous because it is readily accessible and improves (normalizes) the appearance of the person using it (Ripat & Woodgate, 2011; Shih, Shih, & Luo, 2011; Foley & Ferri, 2012; Shih, 2013). The positive results were due to (a) the pre-recording of the names and telephone numbers of the persons available for calls, and (b) Martin's ability to use the key words and the persons' names in a clearly recognizable manner. While the first of these two conditions can be easily ensured, clear speech might be irregular among participants with multiple disabilities, thus reducing the general usability of the device. Indeed, speech skills such as those shown by Frances would not be sufficient to operate such a device. The outcomes of the two studies must be viewed as preliminary because they are based on single participants. It should be the aim of new studies to extend the evaluation of both technology solutions with additional participants (Kazdin, 2001; Kennedy, 2005). Replications of the present findings are necessary to view those technology solutions as real resources for daily contexts (Kennedy, 2005; Barlow, et al., 2009). Obviously, the decision of these contexts as to whether to use those solutions is likely to be affected by replication data as well as by costs. The costs were valued at approximately 2,000 U.S. dollars for the technology used in Study 1, and about 400 U.S. dollars for the commercial device used in Study 2. Such costs might be considered affordable for a variety of families and rehabilitation centers (Hubbard Winkler, Vogel, Hoenig, Cowper Ripley, Wu, Fitzgerald, et al., 2010; Dahlin & Rydén, 2011; Ripat & Woodgate, 2011; Wallace, 2011; Lancioni, et al., 2012). In conclusion, the present case studies underline the effectiveness of two technology solutions for helping different individuals with multiple
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disabilities. New research needs to assess the generality of these findings with the involvement of additional participants (Barlow, et al., 2009; Kennedy, 2005). New research could also (a) determine the participants' satisfaction in using those technology solutions, and (b) carry out social validation assessments of such solutions to identify the view of staff, families, and rehabilitation experts about their practicality and implications (Callahan, Henson, & Cowan, 2008; Luiselli, Bass, & Whitcomb, 2010; Scherer, Craddock, & Mackeogh, 2011; Tullis, Cannella-Malone, Basbigill, Yeager, Fleming, Payne, et al., 2011; Wehmeyer, Palmer, Shogren, Williams-Diehm, & Soukup, 2013). REFERENCES
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