Supporting leisure and functional activity engagement in people with multiple disabilities via a technology-aided program

Abstract

BACKGROUND:

Technology-aided programs have typically been used to support either leisure or functional activity engagement. Yet, supporting both types of engagement would be highly relevant within applied contexts.

OBJECTIVE:

This study was aimed at assessing two versions of a technology-aided program designed to support combinations of leisure and functional activity engagement with seven participants with intellectual disability and sensory or sensory-motor impairment.

METHODS:

The first version was assessed with four participants and included a computer system presenting leisure categories (e.g., music and family slides), a microswitch whereby the participants could choose among those categories and related stimuli, and a tablet device with pictorial activity instructions. The second version was assessed with three participants, who possessed only basic choice and activity skills, and presented the leisure stimuli individually and did not include the tablet.

RESULTS:

Participants learned to use the respective program versions and their independent leisure and activity engagement times increased from zero during baseline to means of 9-13 min and 8-15 min per session, respectively, with the program. Mean session lengths varied between 24 and 31 min.

CONCLUSIONS:

The program versions seem suited to support combinations of leisure and functional activity engagement in persons with multiple disabilities.

Keywords

Technology-aided program microswitch multiple disabilities leisure activity

1. Introduction

Persons with multiple (i.e., intellectual and sensory or sensory-motor) disabilities can have major difficulties accessing leisure/recreational events and performing functional activities independent of staff assistance [1, 2, 3, 4, 5]. Indeed, their condition may seriously interfere with their possibility of operating standard devices, such as computers, for selecting leisure stimuli (e.g., music and videos). Their condition may also prevent them from taking the initiative to start and correctly perform functional activities (i.e., useful daily tasks such as setting the table or simple occupational tasks such as sorting objects) [6, 7, 8, 9, 10]. Given their condition, those persons tend to remain passive during daily periods, in which staff assistance is not available. Aiming to minimize those periods and the negative implications they may have (e.g., persons’ withdrawal and reduced sensory/stimulation input) through increased staff assistance may not be feasible or desirable [11, 12, 13, 14, 15, 16]. In fact, staff resources may be insufficient to guarantee regular assistance in most education, rehabilitation and care contexts. Moreover, the use of extensive staff assistance would emphasize the persons’ dependence and preclude their self-determination.

In light of the above, one may argue that a more reasonable approach to help those persons circumvent the aforementioned condition is to provide them with technology-aided programs designed to support their constructive engagement independent of staff assistance [17, 18, 19, 20, 21, 22]. Recent studies have explored the possibility of following such an approach. For example, Lancioni et al. [23] investigated a program, which was aimed at helping three adults with multiple disabilities to independently start and carry out functional activities at the appropriate times of the day. The technology used within the program included (a) a mini smartphone for delivering timely reminders about the activities that were to be carried out and (b) a tablet device for presenting pictorial instructions concerning the steps of those activities. Data showed that the program was effective with all three participants.

Lancioni et al. [7] assessed a program aimed at enabling nine adults with multiple disabilities to access different leisure options/categories (e.g., music and videos) and possibly make phone calls. The program, which was based on an experimental computer-aided system adapted to the characteristics of the participants, presented the leisure categories available for them visually and verbally. The participants were provided with a microswitch (which they could operate with simple responses) for choosing among those categories and the stimuli they included. For example, a participant could choose the music category and then one of the different songs included in that category. The results showed that all participants succeeded in making choices and activating preferred stimuli independently.

While the results of previous studies were encouraging, the programs reported were set up to support either the performance of functional activities or leisure engagement (with or without phone-call opportunities). More practical (comprehensive) programs would certainly be desirable for use inside rehabilitation and care contexts. For example, programs supporting combinations of leisure and functional activity engagement could be considered more practical than the programs so far available because they would enable the participants to alternate the two forms of engagement (rather than persisting with one of them) within the technology-assisted sessions. Such an alternation would also ensure that the performance of functional activities is always followed by access to preferred stimulation (i.e., leisure events) with potentially positive effects on the participants’ performance motivation [24, 25].

Table 1
Participants’ age, levels of intellectual disability, and sensory or sensory-motor impairments

Participants	Age	Intellectual	Sensory/Sensory-Motor
	(years)	disability	impairments
Bert	37	Moderate	Severe visual impairment
Yvonne	41	Moderate	Severe visual impairment and diplegia
Susan	42	Moderate	Severe visual impairment
Oliver	17	Moderate	Severe visual impairment
1-4[2pt/3pt] Max	27	Severe/profound	Total blindness
Peter	50	Severe	Severe visual impairment and spasticity
Margret	30	Severe	Total blindness

Note. The dotted line separates the participants of Group 1 and Group 2.

In line with the above, the present study was aimed at assessing two basic versions of a technology-aided program designed to support combinations of both types of engagement for participants with intellectual disability and sensory or sensory-motor impairment. The first version was assessed with four participants with moderate levels of intellectual disability, and involved a computer system showing leisure stimulus categories, a microswitch for choosing among those categories and accessing the stimuli included, and a tablet device with the pictorial instructions for relevant daily tasks (e.g., setting the table). The second version was assessed with three participants with severe or severe/profound intellectual disability, who possessed only basic choice and activity skills. This version relied on computer presentation of (a) brief samples of leisure stimuli that the participants could choose and access with a microswitch and (b) reminders/encouragements for the performance of simple occupational tasks such as putting objects away.

Establishing independent leisure and functional activity engagement with both groups of participants could represent a relevant achievement in spite of the small size of the groups. In essence, it would stress (a) the effectiveness of the two versions of the program in promoting participants’ self-determination, personal accomplishment, and choice, and (b) the potential of those versions for use within rehabilitation and care contexts.

2. Method

2.1 Participants

Table 1 reports the ages, levels of intellectual disability, and sensory or sensory-motor impairment of the seven participants, who represented a convenience sample [26]. The first four participants (Bert, Yvonne, Susan, and Oliver), who used the first version of the program, were between 17 and 42 years of age. Psychological records indicated that their intellectual disability was in the low moderate range, but no IQ scores were available. The same psychological records reported Vineland age equivalences [27] ranging between about 4 years (Oliver) and 6 years (Susan) for communication, and between about 4 and a half years (Oliver) and over 6 years (Susan) for daily living skills. The participants’ sensory condition was characterized by severely reduced visual acuity and visual field, which did not, however, prevent them from effectively using pictorial instructions or enjoying preferred visual stimuli (e.g., family slides) on computer or tablet screens. Yvonne also presented with a moderate level of leg diplegia and some alteration of her walking.

The last three participants (Max, Peter, and Margret), who used the second version of the program, were between 27 and 50 years of age and were diagnosed with severe or severe/profound intellectual disability combined with total blindness or severe visual impairment and spasticity (see Table 1). Their Vineland age equivalences ranged between slightly above 2 years (Max and Peter) and over 3 years (Margret) on communication and around 3 years on daily living skills.

The participants attended rehabilitation and care centers for persons with multiple disabilities and were reported to be unable to independently access leisure stimuli and start and carry out activities. Staff and families had expressed their interest in a technology-aided program to support the participants’ independent leisure and functional activity engagement during periods of the day, in which staff assistance was not available. Given the participants’ inability to sign a consent form for the study, their legal representatives had done so for them. The study complied with the 1964 Helsinki declaration and its later amendments and was approved by a relevant Ethics Committee.

2.2 Setting, sessions, and data recording

Familiar areas of the centers that the participants attended served as the setting for the study. The sessions were conducted on an individual basis and were scheduled to last about 30 min for the first four participants (Group 1) and about 25 min for the last three participants (Group 2). Data recording concerned the (a) leisure stimuli independently chosen/activated, (b) leisure engagement time, (c) functional activities independently started, (d) activity engagement time, and (e) session duration. The percentage of correct activity steps (Group 1) and the frequency of activity-related objects used (Group 2) were also recorded. Leisure and activity engagement times were the sum of the independently started leisure and functional activity periods of the session. Inter-rater agreement was checked in 20% of the participants’ sessions with a reliability observer joining the research assistant in charge of the sessions. Agreement consisted of the research assistant and reliability observer reporting the activation of the same leisure stimuli, the performance of the same activities, leisure and activity engagement times, and session lengths within a margin of 1.5 min, and percentages of correct steps or frequencies of objects used within margins of 10 or 4 points. Agreement was recorded in more than 90% of the sessions checked.

2.3 Leisure categories, leisure stimuli, and activities

The leisure stimulus categories used for Group 1 included: music, nature and sport videos, family and friends’ slides, television programs, and comedy sketches. The categories and related stimuli were deemed preferred by the participants, based on staff recommendation and preference screening. During screening, those stimuli had been presented 10–20 nonconsecutive times and retained only if the participants responded positively (e.g., with smiles) in over 60% of the times. The specific leisure stimuli presented to Group 2 consisted of various songs, videos or recorded voices of family members or friends talking to them, pieces of instrumental/dance music, and comedy sketches. These stimuli also had been selected via preference screening. The activities used for Group 1 consisted of functional tasks (e.g., packing the bag for swimming, storing away grocery items, setting the table, and cleaning specific areas), which were valued within their context and involved between 17 and 27 steps [23]. The activities used for Group 2 were simple occupational tasks, such as sorting objects and assembling two-piece objects.

2.4 Technology for Group 1

The technology used during the intervention and post-intervention phases included a laptop computer with sound amplifier, pressure microswitch, and basic software, and a tablet device. At the start of the sessions, the computer screen showed three leisure categories, such as music, television programs, and comedy sketches (see Fig. 1), and illuminated and verbally presented each category in succession. When the participant selected one of the categories (e.g., music) by activating the microswitch within 4 s from its verbal presentation, the computer showed a new screen with four stimuli related to that category (e.g., specific singers or groups; see Fig. 2). Several stimuli were rotated during the study to ensure participants’ interest. Selecting a singer/group led the computer to play a related song for about 2 min. At the end of the song, the computer reset to the first page for a new leisure choice sequence, or showed the tablet with a daily activity.

Figure 1.

Computer screen showing three leisure categories, that is, music, television programs, and comedy sketches.

Figure 2.

Computer screen showing four different stimuli (singer alternatives) related to the choice of the “music” category.

In the latter case, the participant was to (a) take the tablet whose screen remained constantly “on”, (b) move to the activity area, (c) touch the activity image, (d) respond to the first-step instruction appearing immediately after his or her touch, and (e) respond to each of the subsequent step instructions that were presented automatically by the tablet. The instructions involved photos of the object(s) required for the single steps of the activity. Each instruction was shown on the tablet screen for a specific time (e.g., between 10 and 30 s) programmed by the research assistant, and then was replaced automatically by the next one in the sequence [23]. Longer times were programmed for instructions related to more demanding steps, and vice-versa. The times could be readjusted in line with the participant’s progress. Every change of instruction on the screen (occurring at the end of the scheduled time interval) was signaled by a voice cue, which was to alert the participant and direct his or her attention. Seven or eight activities were available for each participant.

2.5 Technology for Group 2

The technology used during the intervention and post-intervention phases included a laptop computer with sound amplifier, pressure microswitch, and basic software, and an optic sensor. At the start of a session, the computer presented brief samples of the single leisure stimuli (e.g., 5 s of a specific music piece and 5 s of a comedy sketch) separated by intervals of about 6 s. The participant could directly choose and access any of the stimuli for about 2 min by activating the microswitch in relation to the sample. At the end of a leisure stimulus, the computer could present new stimulus samples as above (i.e., for a new leisure opportunity) or encouraged the participant to go and carry out an activity. Five or six activities were available for the participants. Encouragements consisted of two-word verbal messages emitted at intervals of about 8 s until the optic sensor was triggered (i.e., the participant had reached the activity located at a distance of over 2 m from the computer desk). After about 2 min from reaching the activity, the computer started to present samples of leisure stimuli. The participant was expected to return to the computer and use the microswitch to choose/access a leisure stimulus as before.

2.6 Experimental conditions and data analysis

A non-concurrent multiple baseline design across participants [28] was used for each group of participants. Within each group, the number of baseline sessions varied across participants. The baseline was followed by an activity performance check, an intervention and a post-intervention phase. Four research assistants experienced in using technology-aided programs for persons with disabilities, and specifically prepared to implement the experimental conditions characterizing the phases of this study, were in charge of the sessions and recorded the data. The Kolmogorov-Smirnov test was used to analyze individual differences between pre-intervention (i.e., baseline or activity check) and post-intervention data [29] except in cases with pre-intervention values of zero and post-intervention values well above zero. In those cases, the statistical significance of the difference was directly implied.

2.6.1 Baseline

The baseline included four to seven sessions carried out over about a week, which served to ascertain whether the participants could access leisure stimuli or start and perform functional activities independently of the program versions used during intervention and post-intervention phases. Group 1 had the computer with the leisure categories on the screen and a mouse to access them. Group 2 had the computer presenting a 5-s stimulus sample every 30 s and a mouse to activate any sample and receive the related stimulation. Activity material was on display. If the participants were inactive for about 15 min, the research assistant activated a leisure stimulus for them and ended the session once the stimulus was over.

2.6.2 Activity check

The check included four or five sessions carried out over a week or less. At each session, the research assistant asked the participant to perform three or four of the activities available. For Group 1, the research assistant (a) verbalized the request while showing the pictorial representation of the activity, (b) corrected an error if this interfered with the continuation of the activity, and (c) ended the activity if the participant failed to perform any correct step for 1–2 min. For Group 2, the research assistant provided verbal encouragements to carry out the activities, allowing the participant 2 min for each activity. At the end of the activities, the participants were provided with praise.

2.6.3 Intervention

Ten or 12 intervention sessions were carried out for each participant over 1 or 2 weeks. During those sessions, the participant was provided with the technol-ogy-aided program version scheduled for him or her. The research assistant (a) gave the participants the guidance they needed to successfully use the technology (i.e., activate leisure stimuli and perform activities), and then (b) faded the guidance out so that the participants would reach independence.

2.6.4 Post-intervention

This phase included 93–132 sessions carried out over periods of about 4 to 6 months. Participants used the technology-aided program versions scheduled for them. The research assistant provided guidance only if the participants (a) did not take the tablet for an activity within about 1 min from its appearance on the computer screen, (b) made step errors that interfered with the continuation of the activity, or (c) did not respond to six or seven successive encouragements.

3. Results

Table 2 reports the participants’ (a) number of sessions during the baseline and the post-intervention phase, (b) mean leisure and activity engagement times per session (i.e., related to independently activated stimuli and independently started activities), and (c) mean session length. During the baseline, the participants did not independently activate leisure stimuli or perform activities, thus their mean leisure and activity engagement times per session were reported as zero. Sessions were typically ended after 17 or 18 min (i.e., after the participants had been exposed to a leisure stimulus activated for them by the research assistant). During the activity check, the participants’ mean percentages of correct activity steps (Group 1) or mean frequencies of objects used (Group 2) per session were between 9 and 19, and 16 and 23, respectively.

Table 2
Participants’ numbers (No) of baseline and post-intervention sessions, with mean ( $M)$ leisure and activity times per session and mean session length (in minutes)

Participants	Baseline				Post-intervention
	No	M	M	M	No	M	M	M
	Sess.	Leisure	Activity	Sess. Length	Sess.	Leisure	Activity	Sess. Length
Bert	6	0	0	17	101	9	12	30
Yvonne	4	0	0	18	111	9	15	31
Susan	7	0	0	18	106	10	12	30
Oliver	6	0	0	18	124	13	10	29
1-10[2pt/3pt] Max	5	0	0	17	132	11	8	26
Peter	6	0	0	18	93	10	8	24
Margret	4	0	0	18	104	11	8	25

Note. The dotted line separates the participants of Group 1 and Group 2. Decimal points are rounded to the nearest full value.

During the post-intervention phase, the participants’ mean leisure and activity engagement times per session were between about 9 and 13 min, and 8 and 15 min, respectively (i.e., clearly/significantly different from the zero baseline values). The mean session lengths were between about 24 and 31 min. The discrepancy between the sum of leisure plus activity times and the session lengths was the time the participants needed for selecting the leisure stimuli and moving to and from the activity areas. The use of shorter sessions for the last three participants was based on their lower activity skills (and presumably lower ability to remain engaged).

The post-intervention mean percentages of activity steps carried out correctly by Group 1 exceeded 90. The Kolmogorov-Smirnov test indicated that the post-intervention session values of each participant were significantly higher than his or her session values during the activity check ( $p<$ 0.01). The post-intervention mean frequencies of activity-related objects used by Group 2 were between 15 and 27 per session. The differences between the participants’ post-intervention and activity-check session values were not statistically significant. In practice, the participants of Group 1 had a drastic improvement of their activity performance with the program (i.e., with the tablet instructions). The participants of Group 2 maintained during the program the same level of performance that they had during the activity check (i.e., when a research assistant directly encouraged them to carry out the activities).

4. Discussion

The results suggest that it is possible to set up a program for supporting independent leisure and functional activity engagement in persons affected by moderate to severe/profound intellectual disability and sensory or sensory-motor impairments. These results extend the evidence available about the usability and scope of technology-aided programs for persons with multiple disabilities and portray the present program versions as useful additions [7, 8, 20, 22, 23, 30]. In light of the above, a number of considerations might be in order.

First, previous technology-aided programs in this area had basically been aimed at supporting either functional activity or leisure engagement [7, 22, 20, 23, 30, 31, 32, 33]. Yet, supporting combinations of functional activity and leisure engagement (i.e., as in this study) may be considered quite advantageous in situations, in which the participants are expected to be positively engaged for lengthy periods of time with minimal supervision. Activity engagement would give the participants a constructive role and promote their self-determination, confidence, and social image. Leisure engagement opportunities would be critical to foster the participants’ choice as well as their motivation and performance continuity within the sessions [12, 34, 35, 36].

Second, the use of a computer with a microswitch and a tablet for implementing the first program version was decided on the basis of practical reasons. In fact, the computer was located in a specific corner of the participant’s setting (i.e., a corner where the participant could enjoy leisure engagement without disturbing others). The tablet was viewed as a small and convenient device to transport to the activity areas and use for receiving visual instructions related to the activity steps. It is obvious that alternative technology solutions should be investigated to extend the range of options available. Also, the use of activity step instructions could be simplified over time (e.g., the instructions could be presented in clusters of two or three rather than individually) [37].

Third, the participants’ consistent engagement th-roughout the post-intervention phase may be taken to indicate that the program versions were largely suitable to the characteristics of the participants and that the participants were motivated to be constructively busy. With regard to the latter aspect, it is noteworthy that the leisure material available (selected through preference screening) was likely to produce satisfying/reinforcing effects. Those effects could have been instrumental to maintain the participants’ positive responding in relation to the activities (all of which were followed by leisure engagement periods) [24, 25]. It might also be that activity engagement, albeit not strictly reinforcing per se, was preferable to inactivity and sedentariness for the participants and thus benefited their session performance [38, 39, 40].

Fourth, some limitations of the study need to be reviewed here. One limitation is the small number of participants involved. Additional participants should definitely be exposed to each program version in order to determine the robustness of the present data and the feasibility of recommending the program’s use on a wider scale [41, 42]. A second limitation is the absence of any data on the participants’ satisfaction with the sessions [40, 43]. Given the sessions’ content, the assumption was that the participants found them enjoyable. Yet, future studies should investigate this point [44, 45]. A third limitation is the absence of a social validation assessment of the program versions (e.g., absence of staff interviews about the benefits and applicability of those versions) [46, 47]. Positive social validation data might be viewed as a predictor of program acceptance and use within daily contexts [48, 49, 50]. Another apparent limitation of the study is the lack of reliability checks on the research assistants’ performance [51]. In essence, the study relied on the experience and specific, preliminary preparation of the research assistants as a way to ensure their performance fidelity. It should also be noted that their role during the baseline and post-intervention phases was minimal. Notwithstanding these points, reliability checks may still be a requirement [52].

In conclusion, the study provides encouraging evidence on the suitability and effectiveness of the technology-aided program versions tested for promoting leisure and functional activity engagement in persons with multiple disabilities. New research needs to verify the strength of these findings with additional participants and address each of the aforementioned limitations of the present study. Research would also need to investigate ways of upgrading the technology solutions adopted in the study in order to improve their usability and overall acceptability [15, 22, 53, 54, 55, 56, 57].

Footnotes

Conflict of interest

The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the article.

Ethical approval

Appropriate institutional board approval was obtained for the study. All procedures performed were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards.

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Supporting leisure and functional activity engagement in people with multiple disabilities via a technology-aided program

Abstract

BACKGROUND:

OBJECTIVE:

METHODS:

RESULTS:

CONCLUSIONS:

Keywords

1. Introduction

Table 1 Participants’ age, levels of intellectual disability, and sensory or sensory-motor impairments

2.1 Participants

2.2 Setting, sessions, and data recording

2.3 Leisure categories, leisure stimuli, and activities

2.4 Technology for Group 1

2.6 Experimental conditions and data analysis

2.6.1 Baseline

2.6.2 Activity check

2.6.3 Intervention

2.6.4 Post-intervention

3. Results

Table 2 Participants’ numbers (No) of baseline and post-intervention sessions, with mean ( M ) leisure and activity times per session and mean session length (in minutes)

Footnotes

Conflict of interest

Ethical approval

References

Table 1
Participants’ age, levels of intellectual disability, and sensory or sensory-motor impairments

Table 2
Participants’ numbers (No) of baseline and post-intervention sessions, with mean ( $M)$ leisure and activity times per session and mean session length (in minutes)