Community-based public transportation training with the integration of assistive technology: A pilot program for young adults with intellectual disability

Abstract

BACKGROUND:

Young adults with an intellectual disability require transportation to participate in work and leisure, however reports on specific public transportation training programs, use of assistive technology supports, and outcomes are limited.

OBJECTIVE:

This pilot study was designed to explore if a transportation training program which utilized technology aids decreased the amount travel assistance required. A secondary objective was to observe and describe the specific assistive technology utilized while traveling within the community.

METHODS:

Eight individualized training sessions were administered within the community with the integration of technology aids and travel skill training through a facilitated learning model. The Pre & Post Travel Training Test was administered pre-test and post-test.

RESULTS:

The paired $t$ test ( $n=$ 10) revealed a significant increase in scores upon post-test ( $p=$ 0.00011), indicating a decrease in assistance required for travel. The most preferred technology aid was individualized, printed Google Maps directions (60%) followed by smartphone Apps (40%) and visual social stories (40%).

CONCLUSIONS:

All participants increased independence in public transportation travel skills. Ample opportunity to trial low to high technology aids should be considered. Through this initial pilot, possible greater availability of access to work and community opportunities may result after community-based transportation training.

Keywords

Travel instruction community mobility intellectual disability public transportation assistive technology

1. Introduction

Community mobility, categorized as an Instrumental Activity of Daily Living (IADL), is defined as “planning and moving around in the community and using public or private transportation, such as driving, walking, bicycling, or accessing and riding in buses, taxi cabs, or other transportation systems” [1]. For those with intellectual disabilities, the skills required to travel within the community may be limited, which include motor skills, processing skills, safety awareness, and appropriate social interaction skills. For individuals with disabilities, the difficulties of navigating and accessing transportation is the number one reported problem of their disability, and in addition is a frequently citedÂ reason as to why a person with a disability is discouraged from seeking employment [2, 3]. Community mobility or the ability to use fixed route services is an identified predictor of community employment for transitioning youth, with many youths indicating the desire to also use fixed-route transit services as opposed to paratransit services [4, 5]. In the United States (US), the Americans with Disabilities Act (ADA) (1990) is a mandate that requires public transportation authorities to provide reasonable accommodations to fixed route services (i.e. established bus routes) and to provide paratransit services for those unable to safely and independently access fixed-route services, with paratransit services acting as a “safety net” on the same basis as fixed route services [6]. For individuals with psychological or intellectual disabilities, the language used to describe the “reasonable accommodation” is more vague than for physical disabilities and is largely mandated by the specific public transportation agency. As a result, individuals with mild intellectual disability may not always qualify for paratransit services based on the eligibility criteria. In addition, reliance on paratransit services decreases spontaneity and independence. Scheduling paratransit service requires a one-to-three day advance notice and is costly and time consuming for both the rider and service provider [2]. Increasing opportunities to use public transportation through training may enable greater opportunities for independent navigation, employability, and community engagement [7]. Organizational, community partnerships with public transportation agencies focusing on public transportation training is an appropriate avenue of opportunity to increase independence in accessing community services for this population while also helping to reduce paratransit operating costs for the public transportation agency [8].

At this time, there is no commonly accepted transportation training protocol or program for individuals with intellectual disabilities in the US [9]. The Easter Seals’ Project ACTION (ESPA) “Introduction to Travel Training Guide” and The Kennedy Center’s “Chance to Ride” program are two curricula that address accessing public transportation. These curricula begin with an assessment of baseline travel skills, then provide education in a series of predominantly didactic-based skill building with some community-based learning, and conclude with a final assessment of learned skills [10]. Transportation training literature has progressed over the years to include studies examining classroom-based instruction, pedestrian skills training, and community-based immersion training, however the specifics of the programming designs are limited [11, 12, 13, 14, 15, 16, 17]. Several studies discuss classroom skill-based travel instruction for those with intellectual disability, which may include teaching practical social safety [16], identifying landmarks in the community, and signaling for the driver when to stop at the appropriate time [15]. These studies explore the benefits of video-based instruction and modelling techniques during simulated travel practice to facilitate attention and sequencing skills required to identify landmarks along a travel route in addition to recognizing and removing one’s self from dangerous situations in various social scenarios during travel. Benefits from this method included instant feedback from the virtual environment and providing a safe and controlled environment, with the aim to generalize skills from the classroom to the community [18]. These publications attribute limitations with classroom-based travel simulations and lacking the in-vivo experience of fixed route trip exposure using public transportation in the community.

Accessing and navigating public transportation is a dynamic process and as a result, individuals would benefit from greater opportunities of in-vivo feedback from the environment beyond didactic teaching methods when learning and practicing the skills [11, 13, 14, 15, 16, 17, 19]. Community-based public transportation training programs allow for more practical experience to adjust to unforeseen events (i.e. no available seat on the bus). Specifically using a purposeful trip, for example from home to school, is integral for identifying what tools and strategies would be most appropriate and highlights the value of a social-ecological approach to public transportation training [13]. Another approach is a prompting protocol, for example when teaching the skill of pedestrian safety when crossing the street in various contexts [11]. During this program, instructors provided systematic feedback, known as errorless learning or most-to-least prompting. This involved beginning with physical prompting (i.e. holding the participant’s arm to guide them across the street) and fading the frequency and intensity of intrusion over time, which yielded positive results to generalize pedestrian safety skills more independently in community traffic. Other literature has compared classroom-based travel instruction, simulated travel instruction on facility grounds, and community-based travel instruction, and determined that the use of community-based instruction was more successful in completing the training program compared to those who received classroom-based instruction [14]. With the understanding of community-based travel and the benefits of learning new skills within functional contexts that exist when working with individuals with intellectual disability, a community-based approach was deemed as most appropriate to train travel skills during the planned program of study, through a facilitator-initiated to learner-initiated prompting system integrating the Four-Quadrant Model of Facilitated Learning (4QM) [20].

4QM is an acquisition skill model which focuses on the intrinsic process of learning. As a participant acquires skills through each of the four defined quadrants, the level of facilitation from the instructor decreases. Quadrant 1, Task specification, is the most intrusive facilitator-to-learner interaction, which involves explicit instruction, modeling, physical cueing or prompting (such as physically manipulating a participant’s hand to demonstrate the motion required to swipe a transit pass), and asking lower order questions of the participant, such as “what does this pull cord do?” As the participant progresses to Quadrant 2, Decision-making, the facilitator may begin to ask higher order questions, such as “how” (i.e. “How would you inform the driver if you need help?”), provide feedback to the learner, fade prompting to less intrusive contact such as a facial expression or nodding, and facilitate think-aloud modeling from the participant. Within Quadrant 3, Recall, the participant practices travel training steps using verbal rehearsal and the facilitator begins to fade cueing to include only visual cues, such as pointing to cue the use of the visual display of the assistive technology device. The last quadrant, Quadrant 4, Autonomy, involves indirect learner-initiated strategies, such as mental imagery, problem-solving, and self-questioning to achieve his or her personal goals. Throughout this process, the facilitator applies both remediation and compensatory strategies through the use of assistive devices as appropriate, fades the amount and types of prompts required, and orients the client to progress through challenges [20]. With regard to clinical utility of this framework, 4QM is considered a theoretical scaffold to better facilitate skill acquisition in a structured manner [21]. Similar frameworks were described using fading cues, errorless learning, and most-to-least prompting to when teaching travel skills in both classroom and community-based travel settings [11, 12, 13, 14, 15, 16, 17].

Considering that individuals with intellectual disability may demonstrate difficulty with generalization of learning required of the Quadrant 4 Autonomy stage and may continue to require some form of prompting, the use of adaptations and compensatory approaches may be needed [13]. For example, participants with an intellectual disability were more successful at completing a bus route when using a GPS-based visual and auditory prompting assistive technology device, as compared to a control group [19]. Assistive technology (AT) is any tool or device that supports adaptation to promote participation, and in this case, community mobility. AT devices may be arranged in a hierarchy of low or no technology used (i.e. redesign the activity so the participant will memorize only one navigation route without bus transfers) to mid and high technology, such as using a smartphone [22]. Following this hierarchy, the individual may not require a sophisticated, electronic-based device if a lower technology is sufficient. One example of a commonly used low-tech tool is the use of a social story. A meta-analysis of the use of social stories was noted to improve the social skills in interactions of individuals with ASD and other developmental disabilities [23]. The primary focus of AT transportation training usage should be identifying the most appropriate device to meet the individual’s needs. For young adults who are “digital natives,” off-the-shelf technology may already be utilized in socialization or leisure aspects of the individual’s everyday personal lives, as well as using visual and auditory cueing devices for job performance tasks to improve employment outcomes [24]. The use of a mobile phone is important during emergency situation travel instruction [17]. Although gaming to teach transportation skills involving a system that is both educational and engaging for learners is in development [18], the use of specific off-the-shelf AT devices to support transportation independence, as chosen by the user, is limited in reports in the literature.

This pilot study was designed to explore if a public transportation training program integrating the 4QM model decreased the amount travel assistance required, after eight sessions of training. Individuals with intellectual disability participated in in-vivo community mobility, utilizing a one group, pre-test post-test (i.e. repeated methods) design. A secondary objective was to observe and describe the specific AT utilized while traveling within the community. This study sought to address the following research question: Does assistance required when using public transportation decrease after eight sessions of a community-based transportation training program with the integration of technology aids for individuals over the age of 21 with an intellectual disability?

2. Method

2.1 Participants

Inclusion criteria involved individuals ages 21 and over with intellectual disabilities, with the individual having personal goals for public transportation training using fixed route services. The first author interviewed all potential participants. The first author read the consent forms aloud, which was written to a 6.9 grade reading level, to the potential study participants at each respective community program. Participants were required to provide informed self-consent if they correctly answered at least three out of four comprehension and memory questions regarding the study protocol. Exclusion criteria included if the potential participant incorrectly answered two or more questions of the comprehension and memory questions. The study protocol was approved by the local university’s Institutional Review Board, who agreed to oversee the ethical treatment of the participants.

Through convenience sampling, all participants in this study were recruited from five local adult day programs, located on the East Coast of the US in an urban setting, with similar missions to serve individuals with intellectual, developmental, and physical disabilities over the age of 21. The day program facilitators, such as case managers and social workers, identified and referred potential participants they deemed as appropriate to participate and may meet the inclusion criteria prior to the initial interview and self-consent process. As a community-based setting for the study, the local transportation authority does not function under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), therefore the researchers did not have access to demographic information regarding participant diagnosis or concurrent services. At the time of the interview, the first author asked each participant and the adult program liaison a series of profile-generating questions regarding prior experience using public transportation and current transportation methods, personal goals for public transportation training, and potential barriers such as sensory sensitivities, anxiety, and assistive technology or mobility devices used in the community.

2.2 Instruments

Following consent, the pre-test was administered. The Pre & Post Travel Training Test was chosen to measure travel skills over time through observing the type of prompting that was required from the instructor for the participant to complete each skill successfully [10]. The Pre & Post Travel Training Test is in alignment with the 4QM model of this study, which requires the identification of the components of the skills required for completion of a task. The test includes 28 transportation skills observed within the community to determine independence with community travel using public transportation at baseline and post-training. Scores range from 0–84, with higher scores indicating less prompting required (i.e. higher scores are more favorable). To the authors’ knowledge, there are no published studies reporting psychometric properties of the Pre & Post Travel Training Test. However, the test was chosen as the researchers concluded that the instrument models the 4QM framework of the study to best capture the intended outcomes measuring both the assistance required and the skills acquired. The authors received permission from Kennedy Center representatives to use the assessment for this program.

To administer the Pre & Post Travel Training Test, the evaluators completed training through one researcher (the first author) to ensure consistency of the documentation of the prompting provided to the participant. Evaluators were two occupational therapists and one fourth year entry-level occupational therapy doctoral student. To ensure uniformity of understanding, during training the evaluators discussed each item to determine the various skills addressed in a functional context, as some items required clarification. For example, the item “Travels to and from the transit stop using the route that is both safe and most convenient” [10][p. 11] was mutually agreed to reflect the skill of wayfinding or orientation within the physical context or environment, and adhering to any safety concerns for navigating within that space. Whereas, the item “Reads the transit vehicle’s schedules and/or finds routes” [10][p. 11] was determined to reflect the skill of trip planning and time management involved with various route schedules and locations. Prior to administration of the tool, the evaluators reviewed each item for feasibility within a typical travel session. During administration, evaluators assigned scores to each item to capture the amount of input or type of prompting assistance provided by the evaluator to the participant in order to complete the skill correctly and within the 4QM. A score of “3” indicated that the participant completed the test item without assistance from the evaluator, or is within the 4QM Quadrant 4 Autonomy; “2” indicated that the participant completed the item by his or herself, however did not confidently complete the item as demonstrating Quadrant 3 Recall; “1” indicated that the evaluator guided completion of various travel tasks within each test item by providing verbal cues and is within the Quadrant 2 Decision-making; “0” indicated that the participant required extensive assistance to complete the test item, including but not limited to physical assistance, or no response from the participant, which is consistent with Quadrant 1 Task specification. To reduce the risk of bias, the evaluator of the participant was not the same person who administered the eight public transportation training sessions (i.e. the evaluator was blinded to the participant’s transportation skill performance within the training sessions). To address interrater reliability, the same evaluator completed the pre-test and post-test, and to minimize observer bias, evaluators were blinded to the participant’s pre-test scoring, upon post-test.

Each pre-test consisted of a novel “simple trip,” which the researchers defined as a short trip within the community (approximately 15–20 minutes each way), traveling by bus, without having to transfer to another vehicle to reach the destination. While on the trip, participants were provided with printed Google Maps directions, which included the following information: the number and direction of the bus route, walking directions to the bus stop, time of anticipated bus departure and arrival, all bus stops along the route, and walking directions to the destination.

2.3 Procedure

The participants then completed eight individualized transportation training sessions, in-vivo within the community, on public transportation fixed route services, including buses, subways, regional rail trains, and trolleys, with introductions to various AT during each session. Participants traveled to meaningful places as identified as a goal destination from their generated profile, such as their homes, workplaces, a relative’s home, preferred leisure spaces, to and from the day program, or other community facilities. Each trip was facilitated one-on-one by an occupational therapy student instructor, with one to two consistent instructors over the course of eight sessions. Transit passes were provided at no cost to participants during the training sessions. During the training, the participants completed many activities appropriate for individualized travel skill training. Some of these skills included: crossing the street, following directions, “stranger danger,” using a bus pass, and sequencing Google Maps directions. Participants walked in their neighborhoods to locate bus stops and solved commonly encountered travel problems such as asking for help if they were lost. Various strategies, inclusive of both remediation of skills and adaptation strategies, were used among travel instructors. For example, role play is a problem-solving remediation activity, in which the instructor and participants would practice scenarios such as rehearsing a scripted call to customer service to increase comfort when asking for help, consistent with the 4QM Quadrant 2 stage of Decision-making and asking higher-order questions. After practice, the participant would then complete a live call during the functional scenario, within Quadrant 3 Recall. Another remediation technique used among instructors was errorless learning, in which the instructor would provide as much input necessary for the participant to complete the skill successfully. For example, physical assistance may be provided on the first session so that the participant could swipe a bus pass correctly, within the Quadrant 1 stage using physical patterning. The goal of this technique was to fade the amount of input overtime so that the participant develops an understanding of how to complete each sequential task correctly. Another commonly used remediation technique was allowing for “safe failures” within the Quadrant 3 stage of Recall. This involved allowing participants to “get lost” within the community, under the supervision and guidance of the travel instructor, as a result of signaling for his or her stop at the wrong time. The participant would then recall the problem-solving strategies with the travel instructor to way-find back to the desired location and discuss possible adaptation strategies to avoid repeating the mistake to achieve the Quadrant 4 of Autonomy.

For adaptation strategies, various low AT to high AT and devices were trialed to facilitate independence with travel instruction, including the following: printed Google Maps directions, visual social stories, task lists, Google Maps application (App) on a smart device, the official public transportation authority’s App on a smart mobile device, digital schedule boards within major transportation stations, or printed route schedules. Problem solving strategies and navigation aids ranging from low technology (e.g. printed maps) to high technology (e.g. Google Maps App) were used at the discretion of the instructor using the least intrusive methods possible to promote maximal independence within the Quadrant 4 Autonomy.

For post-test procedures after the final completion of the eight training sessions, the same evaluator from pre-test assessed the participant using the Pre & Post Travel Training Test. Each participant repeated the same simple trip that was completed at pre-test. The evaluators instructed the participants that they may self-initiate use of any technology aid or navigation technique previously used during their public transportation training sessions to aid while completing the post-test trip.

Table 1
Detailed participant information ( $n=$ 10)

Code	Age (years)	Sex (M/F)	Transportation methods at pre-test	Reported sensory sensitivities and/or anxiety at pre-test	Living situation	Technology owned at pre-test	Preferred technology use at post-test	Change of score from pre-test to post-test
1	27	F	Driven by parent for vocational, social, medical and leisure pursuits	Anxiety related to novel situations or unknown expectations	Lives in parents’ home with parent support	Smart phone; Smart Watch	Printed Google Map	$+$ 6
2	25	M	Takes paratransit to work; Driven by parent for social, medical, and leisure pursuits	None reported	Lives in parents’ home with parent support	Smart phone	Printed Google Map; Google App	$+$ 21
3	30	M	Takes bus to work; Driven by parent for social, medical, and leisure pursuits	Anxiety related to unmet expectations (i.e. bus is late)	Lives in parents’ home with parent support	Smart phone	Printed Google Map; Visual Social Story; Transit App	$+$ 28
4	33	F	Takes paratransit to work independently; Driven by parent for social, medical, and leisure pursuits	Sensory sensitivities of aversions to loud noises, flashing lights, and rapid change in vestibular input	Lives in parents’ home with parent support	Smart phone	Visual Social Story; Google App	$+$ 13
5	35	M	Takes bus to work with staff support; driven by support staff for social, medical, and leisure pursuits	None reported	Lives in group home with staff support	None reported	Printed Google Map	$+$ 18
6	21	M	Driven by parent for vocational, social, medical and leisure pursuits	Anxiety related to novel situations or places; Sensory sensitivities of aversions to strong smells and loud noises	Lives in parents’ home with parent support	Smart phone	Printed Google Map	$+$ 11
7	32	M	Takes subway to work; driven by guardian for medical and leisure pursuits	None reported	Lives in guardian’s home with social coordinator support	Smart phone; limited by data access	Printed Google Map	$+$ 12
8	28	F	Takes paratransit to day program; driven by parent for social, medical, and leisure pursuits	None reported	Lives in parents’ home with parent support	Smart phone; limited by data access	Printed Google Map	$+$ 17
9	33	M	Takes paratransit to work; driven by parent for social, medical, and leisure pursuits	Sensory sensitivity reported as prone to heat-induced seizures	Lives in parents’ home with parent support	None reported	Visual Social Story	$+$ 15
10	22	F	Driven by parent for all vocational, social, medical and leisure pursuits	None reported	Lives in parents’ home with parent support	Smart phone	Visual Social Story	$+$ 4

2.4 Data analysis

Pretest characteristics were examined with the use of descriptive statistics and on a case-by-case basis to identify trends in demographics, reports of living situation and possible barriers within the profiles, gains in travel skills acquired, and AT utilized. Paired $t$ tests were utilized to analyze the significance of the Pre & Post Travel Training Test mean changes with SPSS software (Version 24.0; IBM Corp.; Armonk, NY). Significance level was set at 0.05. Cohen’s $d$ was used to calculate effect size [25]. Descriptive analysis was completed on the AT used by the participants upon post-test.

3. Results

3.1 Sample characteristics

Fourteen potential participants were screened for inclusion, with two of the potential participants not meeting inclusion criteria, due to incorrect responses to study comprehension questions (a requirement to self-consent). Of the remaining twelve participants who signed the consent and agreed to participate, two participants were not able to complete the entirety of the transportation training procedures secondary to personal scheduling conflicts. A total of ten participants completed the eight public transportation training sessions and the pre and post outcome measurements, and were therefore included in the final analysis. The detailed profiles obtained from each participant are included in Table 1, with summarizations of demographic characteristics in Table 2. The average age of the participants was 28.60 ( $\pm$ 4.84), 60% of the participants were male, and one participant utilized an assistive device for mobility (indicative that the sampled participants from the day programs were individuals with intellectual disability and not primarily individuals with physical disability).

Table 2
Summarized participant information

Baseline characteristics ( $n=$ 10)
	$n$ (%) or M (SD)
Age	28.60 (4.84)
Sex
Male	6 (60%)
Female	4 (40%)
Uses ambulation or mobility aid	1 (10%)

Note. M $=$ mean; SD $=$ standard deviation.

Table 3

Pre-test to post-test changes on the Pre & Post Travel Training Test ( $n=$ 10)

	Pre M (SD)	Post M (SD)	$t$	df	$p$	Effect size (cohen’s $d$ )	95% CI lower	95% CI upper
Pre & Post Travel Training Test	38.20 (7.10)	52.70 (9.79)	6.51	9	0.00011 ${}^{*}$	2.06	9.46	19.54
(x/84)	Range: 27 to 49	Range: 45 to 65

Note. M $=$ mean; SD $=$ standard deviation; CI $=$ confidence interval; Effect size interpretation $<$ 0.2 $=$ trivial effect; 0.2–0.5 $=$ small effect; 0.5–0.8 $=$ moderate effect; $>$ 0.8 $=$ large effect. ${}^{*}$ Statistical significance at $p<$ 0.05.

Table 4

Assistive technology (AT) self-initiated by the participant upon post-test

Assistive technology utilized on post-test ( $n=$ 10)
	$n$ (%)
Transportation authority-issued guide or map	0 (0%)
Visual social story	4 (40%)
Individualized, printed Google Map	6 (60%)
Smartphone navigation App	4 (40%)
Google Maps App	3 (30%)
Transportation authority App	1 (10%)

Note. Results are not mutually exclusive (Participant Codes #2, #3, and #4 used more than one type of AT during post-test).

The paired $t$ test revealed that post-test scores (mean $=$ 52.70) were significantly higher than pre-test scores (mean $=$ 38.20) ( $p=$ 0.00011, $d=$ 2.06, confidence interval $=$ [9.46, 19.54]), which is described in Table 3. When examining each participant’s progress throughout the program, all participants improved in travel skills, with ranges of increases in scoring being 4 points to 28 points from pre-test to post-test. All participants lived in a home setting with support and it does not appear that home support from parents, a guardian, or a within a group setting is consistent with the amount of improvement upon post-test, as well as no trends identified by age, sex, or reported sensory sensitivities or anxiety. The technology owned at pre-test does not appear to be consistent with the technology used upon post-test, as Codes 2, 3, and 4 owned a smart phone and utilized an app upon post-test, while Codes 1, 6, 7, 8, and 10 also owned a smart phone but chose to use a lower-technology aid option upon post-test, such as the printed Google Map or the Visual Social Story. For those that utilized the paratransit services, bus, or subway transportation to work, those participants all improved in their scores at post-test by 12 or more points. For the participants whose parent primarily drove the participant for all transportation needs, those participants all improved in scores less than 12 points of improvement.

Additionally, descriptive analysis was completed on the types of AT utilized by the participants during the post-test (Table 4). Note that these data are not mutually exclusive, as some participants chose to use more than one type of AT upon post-test. 100% of the participants used some form of AT upon post-test. The information in the rows progresses from low AT to high AT devices. Printed Google Maps were utilized most frequently by the participants (60%), followed by navigation Apps on smartphones (40%) and visual social stories (40%).

4. Discussion

The primary objective of this study was to examine if the implementation of a travel instruction program modeled after 4QM for young adults ages 21 or older with intellectual disability will decrease the amount of facilitation required to complete a functional trip using public transportation, as measured by the Pre & Post Travel Training Test [10]. Within the 4QM, which was used to structure the teaching-and-learning facilitation, it is important to note that not all participants progressed to Quadrant 4 Autonomy for each skill level. However, this study supports that providing a one-on-one travel instruction program decreased the amount of input required from an instructor, as all participants required less assistance from their trainer at post-test. Evidence from this program indicates that the use of appropriate remediation within the matched Quadrant for each participant, such as errorless learning within Quadrant 1, role playing various solutions to common travel problems within Quadrant 2, and providing opportunities for “safe failures” in a community-based setting within Quadrant 3, or the use of compensatory strategies such as providing various levels of assistive technology to facilitate navigation may be beneficial for this population to learn how to use public transportation safely. Additionally, this program took place in the community for its entirety, inclusive of the pre-test, post-test, and all eight training sessions. The researchers felt that this was a setting essential to the design of the program, as it was a commonly identified concern for future research throughout the literature review [11, 13, 14, 15, 16, 19]. Additionally, the researchers considered the in-vivo community feedback to be crucial when teaching travel skills to capture an authentic understanding of each participant’s ability to react to their environment and adjust to the nuances of community travel. Furthermore, this program suggests an opportunity for an alternative to paratransit at an organizational level for those deemed functionally eligible to ride fixed route services but may require further training [2, 8].

In regards to the benefit of paratransit services, a trend of previous public transit experience of the primary transportation method is seeming to emerge within the amount of change of score from pre-test to post-test. Upon review of the interview profiles, four participants utilized paratransit services upon pre-test. Three additional participants previously utilized transit services for work transportation, totaling seven participants who had previous exposure to routine public transit service usage, all of which improved their post-scoring by at least 12 points with one participant improving by 28 points. Of the three participants who were primarily driven in a vehicle by their parents and did not have routine exposure to public transportation services, these participants improved by less than 12 points upon post-test. Although with this small sample size, these results should be interpreted with caution, the use of paratransit or other public transit services may act as a primer for an individual with intellectual disability to gain exposure and confidence with the public transit services. Priming is a technique within the Quadrant 3 of the 4QM, which allows for preparation for performance of the tasks. Although as previously mentioned in this manuscript, the barriers to utilizing paratransit services are many to both the rider and the transportation authority, transportation authorities should not fully discount the value of paratransit programming and the possibility to utilize the programming as a primer in preparation for fixed route services trainings. Future studies may explore predictions of participant success in transportation trainings if paratransit services are utilized prior to trainings, and given the increasing popularity of ride share services, if this method also may act as a primer to increase exposure and confidence in preparation for trainings.

This pilot study provided support of using most-to-least prompting by fading the amount and intrusion of cues over time, also known as errorless learning with the use of physical patterning within Quadrant 1. Mechling & O’Brien utilize similar errorless learning techniques to facilitate learning of travel skills [15]. Consistency across all sessions involved instructor training for prompting methods using most-to-least cueing. This involved fading of frequency and level of intrusion when cuing as appropriate. This methodology for facilitating independence with travel is supported by the literature as an effective strategy to support individuals with developmental disorders [11, 26]. The Kennedy Center’s “A Chance to Ride” curriculum also encourages this methodology of fading of supports over time by beginning with more visual supports such as using social stories as a guide, then fading to less intrusive cues such as verbal review of various steps required during the trip, indicative of Quadrant 4 Autonomy [10].

A common travel goal for participants who took part in this pilot study involved abstract judgment for signaling to the driver to stop. As similarly implemented in Mechling & O’Brien’s study [15], the participants of this program learned this skill by following a list of serial landmarks while en route as an antecedent to signaling for a stop. However, no video instruction was used to practice this skill during our public transportation training program. Some participants in our study required more intrusive antecedents to signal for a stop; in which case, instructors provided visual social stories that depicted a series of images of various landmarks from the vantage point of a vehicle on the road. These photos were taken from Google Maps street view to best simulate what the participant would see while on a transit vehicle.

The use of AT, both high and low technology, were fundamental for this program. Not all participants had access to a smartphone due to financial constraints, whereas others had inconsistent access to a smartphone due to personal limitations, such as data use limits each month, low battery, or forgotten phone at home. Additionally, not all participants had access to a printer, thus the instructors provided the printed Google Maps directions for these participants. Notably, the customized or individualized AT were more frequently used. The mass-printed guides and maps provided by the transit authority did not present enough information specific to the needs of the participant and were not utilized as preferential to the participant (0%). Visual social stories (40%) and printed, customized maps (60%) are a lower technology option. However, if the participant has access to a smartphone, both may be better integrated as a higher technology option, such as use of the Social Stories Creator App or the Google Maps App. Use of AT may require quite a bit of trial and error and the key is choosing AT that matches the participant’s performance skills in a collaborative effort with the participant [22]. It is important to note that limited access to both high and low technologies may affect success with programming, and future studies should include equal opportunity and training of a continuum of low to high technology devices when training this population to use public transportation. In the review of the characteristics of the small sample size of the participants, there are no trends present based on age, sex, or previous exposure to higher technology devices when examining the outcomes of each participant’s trainings and the choice of AT upon pretest, which further justifies the need of equal opportunity to trial and error multiple AT devices.

The recruitment procedures for this program were implemented in collaboration with adult day program facilitators. Community program facilitators recommended the appropriate participants for this study. Although program facilitators were informed of the inclusion and exclusion criteria, there was potential for recruitment bias, as there was no distinction of methodology used to select the recommended participants. In addition, there was limited access to demographic information such as diagnosis and other medical or therapeutic treatments being provided concurrently, as this community-based program administered through the local transit agency did not allow for access to medical records. However, future researchers should consider acquiring access to participants’ medical histories such as comorbid diagnoses, severity of intellectual disability (IQ), and concurrent support services such as occupational therapy, physical therapy, or Orientation & Mobility training, prior to conducting research. Understanding the severity of disability for the participants (i.e. mild, moderate, or severe) in future studies may better guide the amount of input required from an instructor for the most successful engagement of navigating public transportation.

Future researchers should consider various barriers to implementation of a community-based public transportation training program. During implementation of this eight-week training program, there were several physical and architectural barriers that existed within the fixed-route system. Architectural barriers included fixed-route regional rail and subway stations, or vehicles that were inaccessible for participants using mobility devices or with balance deficits. Additionally, one day program required a paraprofessional staff member to accompany the participant during sessions. Future recommendations include education to day program site staff to enhance carryover and the continuation of public transit usage and communication on the understanding of transportation training programs.

4.1 Limitations

This study had several limitations. The sample size was limited to ten participants, as the exclusion criteria of the study disqualified those with an inability to self-consent. Retention was a challenge due to participants’ inability to attend the required number of training sessions for varying reasons, including inconsistent participant personal schedules, a match with instructor availability, and limited paraprofessional support staff within the day programs. The chosen research methodology is a considerable limitation. This research design was limited to quantitative measures which did not capture the feasibility or perceptions of a public transportation training program from the perspectives of individuals with intellectual disability, the trainers, the family, and the support and referral staff. Mixed methodology may have been better suited for this exploratory research in order to achieve the triangulation of multiple data sources and increase the credibility and validity of the results. In addition, the assessment tool, the Pre & Post Travel Training Test [10], has not been validated for psychometric properties, and thus the Minimal Clinically Important Difference (MCID), or the indication of the smallest change in an outcome that the participant identifies as important, is unknown. The content validity should be determined for this assessment tool given future opportunity for more rigorous testing methodologies, specifically a more systematic methodology for sampling procedures to yield a larger yet more targeted randomized sample. Additionally, ecological validity should be investigated to determine the generalizability of data yielded when using this assessment tool with the vast population of individuals with disabilities.

Further restrictions with the Pre & Post Travel Training Test included limited sensitivity for each item. For example, if a participant remains alert for 10 minutes throughout the trip during session three; however, increases his or her ability to remain alert for 25 minutes at session seven, this is not reflected in the outcome measurement, as the item measuring this skill states “remains alert throughout the trip.” Future studies would benefit from multi-modal measurement tools sensitive to motor skills, processing skills, and social skills involved with community mobility using public transportation. Future development of assessment tools that may arise to measure the travel skills of individuals with intellectual disability using public transportation should be valid and reliable. Other valid and reliable measures of travel skills such as the Functional Assessment of Common Transit Skills (FACTS) could be considered for future studies. The FACTS was developed by orientation and mobility (O & M) specialists and is commonly used by public transportation authorities to determine a person’s eligibility for paratransit services, as results from this assessment tool can reflect if a person is functionally able to use fixed route services such as a standard bus or train. According to the developers of this tool in collaboration with Easter Seals Project ACTION through a cooperative agreement with the U.S. Department of Transportation, Federal Transit Administration, 85% of those who completed the FACTS were correctly classified in the appropriate eligibility classification for paratransit service (i.e. eligible, conditional, or ineligible) [27]. However, the assessment setting is within a testing center to determine the performance of underlying skills needed for a real trip. For the specific research design of our pilot program, the researchers sought an assessment to measure the actual performance taking place in the community during the in-vivo trip.

Furthermore, this exploratory pilot study was limited to data from one sample of participants in the community-based travel program. It should be noted that there may be a testing effect of the learning acquired during the pre-test trip, although a substantial amount of time passed before repeating the same simple trip upon the post-test. Future research designs would be strengthened by including a comparison (i.e. control) group to account for the learning effect of the measurement and to control for extraneous variables. The researchers suggest comparing an experimental group of individuals who complete a community-based public transportation training program to a control group of equal sessions of video-based instruction. As previous reports have suggested the benefits of static virtual-based curricula [15, 16], further understanding is necessary to determine comparison effects of in-vivo, instructor-facilitated public transportation training when learning how to complete a functional trip. Changes at the organizational level should be considered to address the discrepancy of individuals who do not qualify for paratransit services but would require training to navigate public transportation independently [8], as our data further justifies that three participants previously took a bus or subway to work, however these participants further benefited from the trainings. The development of travel instruction programs on a larger scale should be explored to better enable this population to travel more independently. The ADA states transit should be accessible to and usable by individuals with disabilities. With regard to transportation, the predominant policy in the U.S. addresses the needs of individuals with physical impairments in the ADA [6]. The Federal Transit Administration (FTA) has since developed and addressed this disparity in supports. A program called “FTA Section 5310 Enhanced Mobility of Seniors and Individuals with Disabilities” is a federal funding program specifically for seniors and individuals with disabilities whose public transportation needs are not met under the ADA [28]. This funding is allocated to states based on the census of older adults or individuals with disabilities and the grant is subsequently provided to major service agencies, including state authorities or public transportation authorities. Examples of activities funded by the FTA Section 5310 include, but are not limited to, public transportation training and improving signage or wayfinding technology [28, 29]. Encouraging policy makers and public transportation authorities to include travel training in budget expenditures may increase supports for individuals with intellectual disabilities. Transportation training may facilitate the ease of use of transit systems for individuals with disabilities by providing instruction, adaptations, reasonable accommodations, and rights. Reasonable accommodations are largely defined by the individual transit agency and not specifically defined by the ADA. Public transportation authorities considering the implementation of training programs for individuals with intellectual disabilities must consider the most up-to-date literature and published transportation instruction curriculum. In addition, transit authorities should understand the level of intellectual disability (i.e. mild, moderate, severe) to best accommodate the needs of the individuals and the facilitation of the most appropriate level of instruction through a teaching-learning model, such as the 4QM.

5. Conclusion

In conclusion, by the end of the 8 week program, data revealed that 100% of the study participants required less assistance from an instructor to complete a functional trip upon post-test ( $p=$ 0.000110), suggesting an increase of travel skills learned with the integration of preferred, individualized AT. The results suggest that the implementation of individualized public transportation instruction over the course of eight training sessions facilitated by an instructor and given a combination of remediation and compensatory strategies within an appropriate model of facilitated learning, in addition to a continuum of AT training, can positively influence individuals with intellectual disabilities ability to access and navigate public transportation. Data revealed that the most preferred navigation aid among the participants was printed Google Maps directions. These data suggest a possible greater availability of access to work and community opportunities for those who participate in community-based transportation training.

Author contributions

CONCEPTION: Alora McDonnell, Sara Benham, Catherine Fleming and Amy Raphael

PERFORMANCE OF WORK: Alora McDonnell, Catherine Fleming and Amy Raphael

INTERPRETATION OR ANALYSIS OF DATA: Alora McDonnell and Sara Benham

PREPARATION OF THE MANUSCRIPT: Alora McDonnell, Sara Benham, Catherine Fleming and Amy Raphael

REVISION FOR IMPORTANT INTELLECTUAL CONTENT: Alora McDonnell and Sara Benham

SUPERVISION: Sara Benham

Ethical considerations

This research was approved by the University of the Sciences in Philadelphia Institutional Review Board (IRB), on 2/12/2018, IRBnetID: 1157708-4. Informed consent was obtained for all study participants.

Footnotes

Acknowledgments

Thank you to the Southeastern Pennsylvania Trans- portation Authority (SEPTA) Program Eligibility Regulatory Compliance (PERC) Department for providing transit passes for the participants and the researchers. Thank you to Abigail Herron, Forest Miller, Jadyn Sharber, Margaret Folkes, and Erin Weymer, occupational therapy graduate students at the time of the study from the University of the Sciences in Philadelphia, Salus University, and Temple University, for their assistance with the training sessions, as well as to Cara Crawford from Moravian College for her editing assistance. The authors thank the occupational therapy practitioners at the SEPTA Accessible Travel Center (ATC), all of the participants who took part in the program, the participants’ families, and the participants’ caregivers. This study was completed in partial fulfillment of the requirements for the degree of Doctor of Occupational Therapy, University of the Sciences in Philadelphia, for the first author. The second author’s affiliation was with the University of the Sciences in Philadelphia at the time of the study.

Conflict of interest

The authors have no conflicts of interest to report.

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Community-based public transportation training with the integration of assistive technology: A pilot program for young adults with intellectual disability

Abstract

BACKGROUND:

OBJECTIVE:

METHODS:

RESULTS:

CONCLUSIONS:

Keywords

1. Introduction

2. Method

2.1 Participants

2.2 Instruments

2.3 Procedure

Table 1 Detailed participant information ( n = 10)

3. Results

3.1 Sample characteristics

Table 2 Summarized participant information

4.1 Limitations

5. Conclusion

Author contributions

Ethical considerations

Footnotes

Acknowledgments

Conflict of interest

References

Table 1
Detailed participant information ( $n=$ 10)

Table 2
Summarized participant information