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Sep 24, 2014 - of Visual Instructions to Support Activity Performance in Persons ... related pictorial cues presented via computer systems (Furniss et al. 2001 ...
J Dev Phys Disabil (2015) 27:79–91 DOI 10.1007/s10882-014-9402-4 O R I G I N A L A RT I C L E

A Computer-aided Program Regulating the Presentation of Visual Instructions to Support Activity Performance in Persons with Multiple Disabilities Giulio E. Lancioni & Nirbhay Singh & Mark O′Reilly & Jeff Sigafoos & Gloria Alberti & Adele Boccasini & Viviana Perilli & Russell Lang

Published online: 24 September 2014 # Springer Science+Business Media New York 2014

Abstract This study assessed whether a computer-aided program presenting static pictorial instructions or video prompts according to prearranged time intervals would be suitable for teaching six persons with multiple (i.e., intellectual, sensory, and social) disabilities to perform simple daily activities. The program was applied with each G. E. Lancioni (*) Department of Neuroscience and Sense Organs, University of Bari, Via Quintino Sella 268, 70100 Bari, Italy e-mail: [email protected] N. Singh Medical College of Georgia, Georgia Regents University, Augusta, USA e-mail: [email protected] M. O′Reilly University of Texas at Austin, Texas, TX, USA e-mail: [email protected] J. Sigafoos Victoria University of Wellington, Wellington, New Zealand e-mail: [email protected] G. Alberti : A. Boccasini : V. Perilli Lega F. D’Oro Research Center, Osimo, Italy G. Alberti e-mail: [email protected] A. Boccasini e-mail: [email protected] V. Perilli e-mail: [email protected] R. Lang Texas State University, San Marcos, TX, USA e-mail: [email protected]

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participant according to a multiple probe across activities design. The results showed that all participants (i.e., the five using pictorial instructions and the one using video prompts) had a fairly rapid performance improvement with the introduction of the program. A post-intervention probe carried out to verify whether the participants had eventually become capable of performing the activities independent of the instructions showed clear declines in performance. Such declines underlined the enduring relevance of the instructions. These results (a) extend previous evidence on the use of visual instructions and computer-aided programs for supporting their presentation and (b) have clear practical implications for daily contexts. Keywords Computer-aided programs . Visual instructions . Pictorial instructions . Video prompts . Multiple disabilities

Introduction Ensuring independent activity engagement is a critical objective of any intervention program directed at persons with moderate/severe intellectual or multiple disabilities (Axelsson et al. 2013; Duttlinger et al. 2013; Lin et al. 2013; Ramdoss et al. 2012; Sabielny and Cannella-Malone 2014; Taylor and Hodapp 2012). Indeed, the performance of simple daily activities can (a) serve as a main source of functional occupation within the participants’ context, (b) provide the participants an active role and promote their attention and motor involvement, and (c) help the participants improve their social image/status and, in turn, encourage a better attitude toward them from families, staff and service providers (Ayres et al. 2013; Cannella-Malone et al. 2013; Harr et al. 2011; Lancioni et al. 2013a, 2014; Ramdoss et al. 2012). Promoting activity engagement has been a main objective of research with these persons and a variety of instruction strategies have been assessed to achieve such an objective (Cannella-Malone et al. 2006, 2011; Furniss et al. 2001; Johnson et al. 2013; Lancioni et al. 1999, 2000; Mechling and Gustafson 2009; Sigafoos et al. 2007). Early studies assessed pictorial cues as instructions for the activity steps (Copeland and Hughes 2000; Lancioni and O′Reilly 2001; Steed and Lutzker 1997). Those instructions were generally presented on cards arranged in booklets (Lancioni et al. 1995; Singh et al. 1995; Steed and Lutzker 1997). A variety of studies also used steprelated pictorial cues presented via computer systems (Furniss et al. 2001; Lancioni et al. 1999, 2000). Irrespective of the presentation means, those instructions were simple, static images of the objects involved in the single activity steps. Other forms of visual instructions have involved video modeling and video prompting (Bidwell and Rehfeldt 2004; Cannella-Malone et al. 2011; Graves et al. 2005; Payne et al. 2012; Sigafoos et al. 2005). Video modeling consists of presenting a video/film of the entire activity and then asking the person to carry out the same activity (i.e., immediately after watching the video and eventually independent of it). Video prompting consists of (a) presenting one video clip/prompt showing the execution of an activity step (i.e., dynamic visual instruction), at a time, and (b) asking the person to perform the step immediately after the presentation of the clip. Verbal instructions have been reported as another plausible approach in this context. These instructions are designed to occur individually, one per step (i.e., the same way as the pictorial instructions and video prompts) (Briggs et al. 1990; Lancioni et al. 2011; Steed and Lutzker 1999).

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An overall analysis of the literature suggests that each of the aforementioned approaches might produce positive outcomes. Comparison studies, however, seem to indicate that computer-aided pictorial programs may be more effective than card-based pictorial programs (Lancioni et al. 2000). Similarly, programs involving video prompting may be more effective than programs based on video modeling or static pictorial instructions (Cannella-Malone et al. 2006, 2011; Mechling and Gustafson 2009). The fact that the computer-aided pictorial programs do not require handling of card materials may give them an advantage over card programs involving the use of booklets (Lancioni and O′Reilly 2001). Similarly, the fact that video prompting programs presents dynamic representations of (instructions for) each step of the activity may give them an advantage over (a) video modeling (that does not provide the instructions on a step by step basis) and (b) pictorial programs (that rely on static, less clearly illustrative instructions) (Cannella-Malone et al. 2013; Mechling and Gustafson 2009; Perilli et al. 2013). In light of the above, one might argue that computer-aided programs with pictorial instructions or video prompts can be the more promising options for a variety of persons (Lancioni et al. 2013a; Mechling and Gustafson 2009). The way the instructions (pictures or video prompts) are made available to the persons within those program options, however, may be a point of debate. For example, asking the participants to perform a specific response to access each new instruction (e.g., touching the computer screen or a sensor/key) extends the behavioral sequence required. This might pose difficulties whenever the participants are not accurate in their response (e.g., can touch a screen repeatedly) or are not consistent in performing such response prior to each step. The use of microswitches to automatically monitor the participants’ performance and regulate the presentation of instructions on the screen might represent a very effective strategy, but it requires an extension of the technology used and thus a disadvantage in terms of its practicality and general usability (Lancioni et al. 2011, 2012). Arranging the presentation of the instructions according to preset time intervals (i.e., varying for different individuals and steps based on the time deemed necessary for their execution of those steps) might be a plausible strategy, free from the drawbacks of the other approaches. Such a strategy would be easy to set up (i.e., using standard software such as Pinnacle video editing or Microsoft PowerPoint; see Lancioni et al. 2013b, 2014) and quite practical. To counter the risk that participants would not regularly keep up with automatically presented (time-based) instructions, one could use the precaution of breaking the activity in fairly small steps. In that case, missing a step instruction might not cause the participants to lose track of the activity and arrest their progress through it. The aim of this study was to assess whether a computer-aided program presenting static pictorial instructions or video prompts according to prearranged time intervals would be suitable for teaching six persons with multiple (i.e., intellectual, sensory, and social) disabilities to perform simple daily activities. A post-intervention probe was also carried out to verify whether the participants’ performance continued to rely on the instructions or had become independent of them.

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Method Participants The six participants (Diane, Tammy, Irene, Ruby, Carl, and Rafael) were between 14 (Rafael) and 54 (Irene) years of age. Psychological reports indicated that their levels of intellectual disability were in the moderate range (i.e., Diane, Irene, Carl, and Rafael) or moderate-to-severe range (i.e., Tammy and Ruby). The participants also presented with visual and/or hearing impairments. The visual impairment ranged from moderate to severe, but did not preclude the discrimination of visual instructions on a computer screen. All participants, except for Rafael, were known to use pictorial material within their daily contexts and thus were expected to be suited for a program based on pictorial instructions. Rafael was reported to have minimal use of pictures (relying more on general gestures and words), and was able to imitate simple actions presented by a research assistant or shown on a computer screen. Table 1 provides a summary of their characteristics. Rafael and Tammy attended regular school contexts while the other four participants attended activity centers within rehabilitation and care contexts for persons with intellectual and multiple disabilities. Staff and families had stressed the importance that the participants learned to engage successfully/independently in daily activities so as to have occasions of meaningful occupational engagement and acquire a positive role and an acceptable social status within their context. The participants had expressed their interest in learning to carry out activities. Their parents or legal representatives had signed an informed consent for this study, which had been approved by a scientific and ethics committee. Setting, Activities, and Data Recording The study was carried out in the activity centers or educational contexts that the participants attended. Three activities were available for each participant. Two of them (i.e., making sandwiches and preparing a fruit salad) were used for all participants. The other activity consisted of preparing a drink for Diane, Irene, and Carl, and preparing a lunch tray for Tammy, Ruby, and Rafael. These activities were similar to those described in previous studies with persons with multiple disabilities or Alzheimer’s disease and included 37 to 43 steps (see Lancioni et al. 2011, 2013b). Table 2 provides the list of steps involved in one of those activities, that is, preparing sandwiches. The Table 1 Participants’ Characteristics Name

Age (years) Intellectual Disability Sensory Condition

Social Condition

Diane

39

Moderate

Visual Impairment

Adequate

Tammy

15

Moderate- Severe

Visual Impairment, Hearing loss

Autistic-like behavior

Irene

54

Moderate

Hearing loss

Adequate

Ruby

47

Moderate- Severe

Visual impairment

Rare behavioral tantrums

Carl

34

Moderate

Visual Impairment

Adequate

Rafael

14

Moderate

Hearing loss

Adequate

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Table 2 Steps for Preparing Sandwiches

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1. Take the tray. 2. Put the tray on the table. 3. Take a small plastic container 4. Put the container on the tray. 5. Take a slice of bread. 6. Put the bread in the container. 7. Take some lettuce/tomato. 8.Put the lettuce/tomato on the bread. 9.Take a portion of ham. 10.Put the ham of the lettuce/tomato. 11.Take a slice of bread. 12.Put the bread on the ham. 13.Take the container’s top. 14.Place the top on the container with sandwich. 15.Take a new container. 16.Put the new container on the tray. 17. Take a slice of bread. 18. Put the bread in the new container. 19. Take some lettuce/tomato. 20. Put the lettuce/tomato on the bread. 21. Take a portion of ham. 22. Put the ham of the lettuce/tomato. 23. Take a slice of bread 24. Put the bread on the ham. 25.Take a container’s top. 26. Place the top on the new container with sandwich 27. Take a third container. 28. Put this new container on the tray 29. Take a slice of bread. 30. Put the bread in the new container. 31. Take some lettuce/tomato 32. Put the lettuce/tomato on the bread. 33. Take a portion of ham. 34. Put the ham of the lettuce/tomato. 35. Take a slice of bread 36. Put the bread on the ham. 37. Take a container’s top. 38. Place the top on the new container with sandwich. 39. Take napkins. 40. Place the napkins beside the tray. 41. Take soft drink bottles. 42. Place the bottles beside the tray.

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participants had two tables separated by a cart with the computer and a loudspeaker or stroboscopic lights. One of the tables contained the activity items. The other table served for carrying out the activity (i.e., using the items taken from the first table). Data recording concerned the participants’ performance of the activity steps throughout all activity trials of the study. A step was considered correct if it fitted the task analysis and occurred independent of guidance from the research assistant (see below). Interrater agreement (assessed in about 20 % of the activity trials, by dividing the number of steps in which the raters’ scoring coincided by the total number of steps and multiplying by 100) was within the 80-100 % range, with means of about 95 %. Computer-aided Pictorial Instructions Pictorial instructions were used for all participants except Rafael (see Participants). The technology used for the intervention program included a portable computer equipped with Pinnacle Studio software that allowed the research assistant to build files with object photos serving as instructions for activity steps. The photos were shown on the computer screen for specific times (e.g., between 5 and 25 s), which were programmed by the research assistant, based on observations of the participant’s performance of the related steps (see Cohen-Mansfield et al. 2006; Lancioni et al. 2013b). Longer exposure times were programmed for the instructions of more laborious (time-demanding) steps, and vice-versa. The times could be regularly readjusted in line with the participant’s progress. At every change of instruction on the screen (occurring at the end of the preprogrammed time interval), the participant was alerted by a 2-s sound signal, a call of his or her name, a one-word encouragement, or flashing stroboscopic lights. Computer-aided Video Prompts Video-prompt instructions were used for Rafael. Conditions matched those described for Computer-aided Pictorial Instructions except that each pictorial instruction was substituted with a video clip of 3–5 s, which illustrated the action involved in the activity step being represented. The clips were filmed from the performer’s perspective (i.e., the perspective of the person who had to carry out the activity). The last frame of the clip remained on the screen until the next video clip was presented (Perilli et al. 2013). Experimental Conditions A multiple probe design across activities (Barlow et al. 2009) was used for each participant. Baseline trials were initially carried out on the three activities available. Then intervention started on the first activity. When a clear improvement had occurred on this activity (i.e., the percentage of correct steps was above 85 for a number of trials that varied across participants; see the Results section), new baseline and intervention occurred on the second activity. During the intervention on the second activity, occasional trials on the first were maintained. When the performance of the second activity showed clear improvement, new baseline and intervention occurred on the third activity. During the intervention proper on this activity, trials on the first two activities were only occasional. Thereafter, trials on the three activities were regularly distributed.

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Following the end of the intervention, a post-intervention probe was conducted without instructions to determine whether the participants continued to rely on the instructions or had become independent of them. Verbal and physical guidance from the research assistant occurred if the participant (a) asked for help or failed to carry out any step for 20–30 s (baseline) or (b) failed to carry out a step correctly in relation to the matching instruction or parallel to the performance of the next two steps (intervention). At the end of each baseline and intervention trial, the research assistant praised the participant and embraced him or her (i.e., provided him or her with a motivating/reinforcing consequence) (see Lancioni et al. 2013b). Baseline During each baseline trial, the participant was asked to carry out the activity scheduled but no instructions were available. A trial ended if the participant carried out all the steps or failed to proceed in spite of three to five instances of guidance by the research assistant (see Lancioni et al. 2014). Intervention with pictorial instructions or video prompts The intervention on each of the activities was typically preceded by two practice trials during which the research assistant used guidance to ensure that the participant followed the instructions and performed the activity steps without errors. These trials were followed by regular intervention trials involving pictorial instructions or video clips and guidance by the research assistant, as described above. Post-intervention probe Conditions matched those in place during the baseline.

Results Figures 1, 2, 3, 4, 5, and 6 summarize the data for Diane, Tammy, Irene, Ruby, Carl, and Rafael, respectively. The white bars refer to the first activity exposed to intervention (i.e., making sandwiches for all participants). The gray bars refer to the second activity exposed to intervention (i.e., preparing fruit salad for Diane, Irene, and Carl; and preparing a lunch tray for the others). The black bars refer to the third activity exposed to intervention (i.e., preparing a drink for Diane, Irene, and Carl; and preparing a fruit salad for the others). The bars represent mean percentages of correct steps per INTERV.

INTERV.

INTERV.

INTERV.

100

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BASELINE

Mean Percentages

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50 25

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0

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8 9 10 Blocks of Trials [ DIANE ]

11

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Fig. 1 Diane’s data. The white, gray, and black bars refer to the first, second, and third activity exposed to intervention. The bars represent mean percentages of correct steps per activity trial computed over blocks of activity trials. The number of trials included in each block is indicated by the numeral above it

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J Dev Phys Disabil (2015) 27:79–91 INTERV.

INTERV.

INTERV.

INTERV.

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Mean Percentages

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Blocks of Trials [ TAMMY ]

Fig. 2 Tammy’s data plotted as in Fig. 1

activity trial computed over blocks of activity trials. The number of trials included in each block is indicated by the numeral above it. The initial two to five baseline trials carried out on each of the activities showed mean percentages of correct steps below 25 for all participants (see the first section of the figures). The intervention on the first activity (with pictorial instructions for the first five participants and video prompts for Rafael) involved 14–28 trials. The differences in number of trials were mainly due to participants’ availability and prevailing practical conditions. In fact, all participants showed fairly rapid and reliable increases in the percentages of correct steps. The two new baseline trials on the second activity showed no performance changes (see the third section of the figures). Intervention on this activity involved 10–29 trials. The final two baseline trials and the 10–18 intervention trials on the third activity showed data comparable with those obtained with the previous two activities (see the fifth and sixth section of the figures). Occasional trials on the first two activities occurring parallel to this intervention phase (not reported in the figures) continued to show satisfactory performance. During the subsequent 30-84 trials concerning all three activities (see the seventh section of the figures), the participants’ percentages of correct steps were usually above 90. The post-intervention probe included 9–18 trials distributed on the three activities. During those trials, in which the instructions were not available, the participants’ mean percentages of correct steps across activities ranged from clearly below 30 (Ruby) to about 60 (Irene). The percentage declines (compared to the intervention values) indicate that the participants were still relying on the instructions for their performance.

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Blocks of Trials [ IRENE ]

Fig. 3 Irene’s data plotted as in Fig. 1

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Blocks of Trials [ RUBY ]

Fig. 4 Ruby’s data plotted as in Fig. 1

Discussion The results of the study show that a relatively simple computer-aided program, regulating the presentation of pictorial instructions or video prompts according to preset time intervals, was helpful in fostering correct activity engagement for all six participants. All participants (irrespective of the instructions used) continued to rely on those instructions after the end of the intervention period proper, as indicated by the postintervention probe. These findings (a) extend previous evidence on the use of visual instructions and computer-aided programs for supporting their presentation and (b) have clear practical implications for daily contexts (Cannella-Malone et al. 2011, 2013; Lancioni et al. 1995, 2013b). First, the effectiveness of the intervention phase may need to be explained in relation to the activities adopted and the steps identified, the instructions used, and the instruction presentation procedure. With regard to the activities, one could argue that they did not involve difficult requirements that would be challenging for the participants’ abilities. The steps were quite small on purpose. The reasoning was that missing a step instruction would not be likely to block the progress if the participant could recover the small information lost through the instruction(s) related to the next one or two steps. This was considered a form of precaution because a presentation system based on preset time intervals could not be considered totally reliable in ensuring that the participant would keep up regularly with the instruction presented (Lancioni et al. 2013b). A clear advantage of the automatic instruction presentation was that the participant was not required the extra response of seeking the instructions on his or her own (i.e., was spared from the potential problems linked with it) (Lancioni et al. 2011). INTERV.

INTERV.

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Mean Percentages

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Blocks of Trials [ CARL ]

Fig. 5 Carl’s data plotted as in Fig. 1

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Fig. 6 Rafael’s data plotted as in Fig. 1

Second, static pictorial instructions seemed largely clear and effective for five of the participants. The sixth participant, who was known to be rather unaccustomed to such instructional material, seemed totally comfortable with the use of video clips illustrating the step actions. Indeed, the use of video clips increased his percentage of correct performance very rapidly and across all three activities. While these observations emphasize the strength of video prompting in contrast with the apparent (reported) unsuitability of static pictorial material, no specific statement can be made on the presumed advantages of the former over the latter. Such a statement would be possible only after a direct comparison of the two instruction strategies through alternating treatments procedures (Cihak et al. 2006; Mechling and Gustafson 2009; Perilli et al. 2013; Van Laarhoven et al. 2010). Third, the participants’ data during the post-intervention probe unequivocally indicate that they still relied (at least partially) on the use of the instructions for their performance of the activities. This finding seems to underline that the goal of abandoning the instructions and bringing the participants to be totally independent may not be necessarily realistic when a number of rather complex activities are involved and the level of the participants ranges from moderate to moderate-severe intellectual and multiple disabilities (Duttlinger et al. 2013; Lancioni et al. 1995, 2000, 2011; Sigafoos et al. 2007). This evidence places extra emphasis on the program conditions available. Indeed, long-term reliance on instructions can be more easily manageable and acceptable if simple and inexpensive/affordable technology is applied for regulating their presentation (Lancioni et al. 2013a, b; Näslund and Gardelli 2013; Ripat and Woodgate 2011; Scherer et al. 2011; Tanis et al. 2012; Wehmeyer et al. 2012). The computer-aided program used in this study may be viewed as an example of such simplicity and affordability. In conclusion, the results of this study indicate that (a) a simple computer-aided program ensuring the automatic presentation of visual instructions may be a valuable resource within daily contexts providing education and care to persons with moderate to severe intellectual and multiple disabilities, and (b) the use of instructions might not be a short-term requirement particularly when a variety of rather complex activities are targeted for persons presenting with the range of disabilities indicated above (Lancioni et al. 1995, 2000, 2011; Sigafoos et al. 2007). The reliability of the aforementioned statements would need to be assessed with new research efforts involving additional participants and activities (Barlow et al. 2009; Kennedy 2005). The technical solutions at the basis of the intervention program would also need to be reassessed and updated in light of the continuous developments in the technology area (Borg et al. 2011; Foley

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and Ferri 2012; Lancioni et al. 2014; Luckasson and Schalock 2012; Näslund and Gardelli 2013). One final issue for new research could concern social validation checks in which families, staff, and service providers are asked to evaluate the present program and make suggestions for new ones (Callahan et al. 2008; Lancioni et al. 2006; Luiselli et al. 2010; Ripat and Woodgate 2011; Scherer et al. 2011).

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