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Video Communication Technology Promotes Participation In Community Activities By An Adolescent With Autism: Case Study

Tara O’Neill1, Janice Light1, David McNaughton1

1The Pennsylvania State University 

INTRODUCTION

Individuals with autism who experience significant limitations in communication functioning often benefit from augmentative and alternative communication (AAC), such as communication boards, speech generating devices, and or mobile technologies with AAC apps. Research indicates that AAC interventions are effective to improve communication outcomes for individuals with autism who experience complex communication needs [1, 2]. For these individuals, it is critical that AAC supports communication and participation in real-world community and vocational tasks [3]. However, much of the AAC research to date has examined AAC use and participation in segregated settings [3, 4].

The limited research available investigating participation in real-world settings may reflect limitations in the design of existing technologies. Visual scene displays (VSDs) are one type of AAC display that depict meaningful events from an individual’s life in a photograph, with vocabulary embedded as hotspots (i.e., a part of the display that can be activated to result in voice output). VSDs lessen cognitive and linguistic demands of use by preserving the context within meaningful events [5]. However, VSDs are static, while real-world activities contain dynamic routines that require communication. Light, McNaughton, and Jakobs [6] proposed the use of videos with integrated VSDs, suggesting that videos would preserve the spatial and temporal contexts of activities and preserve the dynamic relationships found in real-world interactions. 

Previous research indicates that Individuals with autism benefit from video modeling to improve participation in community and vocational tasks [7, 8]. However, current video modeling apps do not include communication supports, and many community and vocational activities require communication by employees [9]. Therefore, the use of videos with integrated VSDs (i.e., video VSDs) should capitalize on the positive effects of both video modeling and VSDs.  

The purpose of this pilot case study was to evaluate the effectiveness of videos with integrated VSDs on a tablet-based app (EasyVSD by InvoTek Inc.) on the percent of steps completed (including communication steps) during vocational and community activities by a teenager with autism and complex communication needs. 

METHODS

Design

A case study was used to evaluate the effects of video VSDs on participation. The independent variable was the video VSD app and a least-to-most prompting hierarchy to encourage use of the app. The dependent variable was the percent of steps (including communication steps) completed independently in each activity. Due to time constraints, the introduction of the independent variable was not systematically staggered across contexts. Accordingly, the study did not establish experimental control, and the results should be interpreted with caution. This study served as a pilot to examine the efficacy and feasibly of utilizing video VSDs to promote communication and participation in real-world activities. Given the current lack of research in this area, pilot work is critical.

Participant

One participant with autism (Lena, pseudonym used here) participated. She experienced limitations in expressive communication and was highly prompt dependent during community and vocational activities.

Settings and tasks

Three intervention tasks were chosen, based on a pre-established set of criteria. The three tasks were: working at the print shop, riding the public bus, and doing a shredding job. Task analyses were used to identify the required steps for each activity, including steps related to task completion and steps related to communication. Each task had between 11-22 steps and at least 2 communication steps.

Materials

Tablet and app

Figure 1 depicts a video VSD app screenshot from the bus riding activity. The left side of the screen contains 4 programming buttons, including: capture a photo, capture a video, make a hotspot, and draw. It also contains the play button that is used to play videos. Below the programming icons, there is a menu that contains thumbnails of videoVSDs within the bus riding activity. The video that is currently playing is highlighted with a pink border. To the right of the programming icons and navigation menu, the right part of the screen contains the video VSD. This particular video VSD depicts the participant handing her ticket to the bus driver. There is a hotspot, which is depicted as blue circle, over the action of handing the ticket. The hotspot contained the embedded message “hello” used to greet the bus driver. At the bottom of the video VSD screen, there is a short text caption that describes the step. It reads: Give your ticket to the bus driver and say hello.
Figure 1. Video VSD app screenshot from the bus riding activity; it demonstrates a VSD with an embedded hotspot (“hello”). It includes a short text caption that describes the step.
A 12-inch tablet containing the EasyVSD app was used. Figure 1 provides a screenshot of the EasyVSD app from the bus riding task. The app contains a primary display containing video VSDs, as well as programming icons positioned to the left vertically that were used to capture videos and make hotspots. The menu also contained thumbnails that were used to navigate between video segments. The following steps were required to use the app: (1) press play, (2) watch the video segment depicting one step from the task analysis, (3) perform the step depicted, (4) select the thumbnail of the next video, (5) repeat steps 1-4 for each segment until the task is completed.

Videos with integrated VSDs

Videos were captured using a video recorder with Lena serving as a self-model. Videos were collected and edited to eliminate or mute any prompts and divided into segments of about 10 seconds in length corresponding to the steps in the task analysis. Videos were then loaded onto the EasyVSD app and hotspots were added to fulfill the communicative opportunities identified within the task analysis. Wherever a hotspot was programmed, the video automatically paused and the hotspot appeared momentarily to highlight the message. Figure 1 provides an example of a VSD with an embedded hotspot.

Text captions that provided a short description of the step were added for the final two sessions of bus riding and the final session at the print shop. They were added to evaluate if this additional support would promote task completion and communication.

Procedures

The study included baseline and intervention phases. During baseline, data were collected during target tasks as they typically occurred within Lena’s school program, without the use of the video VSDs. During intervention, the participant completed the tasks while using the video VSD app. No separate phase was completed for training. Prior to beginning each activity, Lena reviewed the videos with the first author who modeled the operation of the app. Lena demonstrated independent operation of the app by the third session.

During intervention sessions, after a general verbal prompt (e.g., “Time to work”), Lena operated the app to complete the task. If Lena failed to compete a step after 5 seconds of the natural environmental stimulus, the interventionist used a least-to-most prompting hierarchy to encourage use of the app. It included the following set of prompts: (a) expectant delay (i.e., wait 5 seconds), (b) gestural prompt (i.e., point towards the app), (c) model (i.e., model playing the video or activating the hotspot).

Procedural integrity was calculated for 19% of intervention sessions. It was 93% on average across contexts (range 91-94%).

Measures and data analysis

The percent of steps completed independently was the dependent variable. Steps included both behavioral task steps and communicative opportunities. It was calculated by dividing the number of steps completed by the total number of steps and multiplying by 100.

Data were collected and coded post hoc through review of videos. The data were summarized for each session and graphed separately for each activity in the order in which they were collected. The data were analyzed visually for changes in trend, slope, and variability to explore the effects of the video VSDs on independent communication and task completion [10].

Interobserver agreement between the first author and a graduate research assistant was computed for 23% of sessions by calculating taking the number of agreements divided by the number of disagreements plus agreements and multiplying by 100. Interobserver agreement resulted in an average score of 95% (range 89-100%). 

RESULTS

Figure 2 contains three stacked graphs of the percent of steps independently completed during baseline and intervention sessions across the three activities. The y-axis for each graph is the percent of steps completed independently. The x-axis is the session number. Each graph contains data for both baseline and intervention sessions. The top graph contains data from the print shop activity. She participated in one baseline session in which she competed about 15% of steps independently. She then participated in three intervention sessions. The data for intervention show a steady upward slope. She reached about 75% independent completion by the third and final intervention session. The middle graph contains data from the public transportation activity. The first three sessions are baseline sessions, where the participant completed between 18% to 25% of activities independently. Her performance for the first three intervention sessions increases to 40%. By the 8th and final intervention session, the percent of steps completed independently reaches 100%. The middle graph contains data from the shredding job. During two baseline sessions, the participant the percent of steps completed independently was between 8% and 12%. Upon introduction of the video VSD app in intervention, her performance immediately increased to 70%. By the third and final intervention session, the percent of steps completed independently was 100%.
Figure 2. Percent of steps independently completed during baseline and intervention across three activities.
The data suggested that videos with integrated VSDs improved Lena’s independent task completion and communication within community and vocational tasks. Data for the dependent variable (i.e., the number of steps completed independently within each task) are represented in Figure 2. Changes in the participant’s performance were noted immediately after the app was introduced. Additionally, she required only a few intervention sessions to perform tasks independently even with low performance levels at baseline. In two of the three activities (public transportation and shredding), she reached 100% independence by the final intervention session.

DISCUSSION

This study provides preliminary evidence of the effectiveness of video VSDs to promote independent communication and participation of individuals with autism in authentic community and vocational activities. The participant reached 100% independence by the final session in two out three activities.

Several factors may have contributed to the outcomes in this intervention. The intervention included a number of evidence-based practices for individuals with autism including: VSDs depicting vocabulary in meaningful contexts, video self-modeling, task analysis, videos with automatic pauses to prompt task completion, and a least-to-most cuing hierarchy.

Video VSDs have the potential to improve independence and decrease dependence on prompting from staff, such as job coaches. This has important implications for reducing costs and developing self-determination.

There are several limitations of the study that warrant consideration. It did not use an experimental design; therefore, it cannot be said with certainty that the introduction of the independent variable (video VSD app) produced a change in the dependent variable (percent of steps completed independently. However, given the rapid positive gains, it seems likely that gains are due to the introduction of the video VSD app.  Additionally, the generalization of results is limited due to the study only including one participant. Finally, maintenance and generalization were not collected. Future research should include greater numbers of participants, with various diagnoses, and evaluate outcomes in the context of maintenance and generalization.

CONCLUSION

It is critical that, moving forward, research in AAC target communication and participation of individuals with complex communication needs within real world tasks. This study suggests that video VSDs may support meaningful, independent participation of learners with autism in real-world activities. This could allow individuals who use AAC to have greater access to employment and meaningful participation in society.

REFERENCES

[1] Ganz, J. B., Earles-Vollrath, T. L., Heath, A. K., Parker, R. I., Rispoli, M. J., & Duran, J. B. (2012). A meta-analysis of single case research studies on aided augmentative and alternative communication systems with individuals with autism spectrum disorders. Journal of autism and developmental disorders, 42, 60-74

[2] Holyfield, C., Drager, K. D., Kremkow, J. M., & Light, J. (2017). Systematic review of AAC intervention research for adolescents and adults with autism spectrum disorder. Augmentative and Alternative Communication, 33, 201-212

[3] Light, J., & McNaughton, D. (2015). Designing AAC research and intervention to improve outcomes for individuals with complex communication needs. Augmentative and Alternative Communication, 31. 85-96.

[4] Wehmeyer, M. L., Palmer, S. B., Smith, S. J., Davies, D. K., & Stock, S. (2008). The efficacy of technology use by people with intellectual disability: A single-subject design meta-analysis. Journal of Special Education Technology, 23, 21-30.

[5] Light, J., & McNaughton, D. (2012). Supporting the communication, language, and literacy development of children with complex communication needs: State of the science and future research priorities. Assistive Technology, 24, 34-44.

[6] Light, J., McNaughton, D., & Jakobs, T. (2014). Developing AAC technology to support interactive video visual scene displays. RERC on AAC: Rehabilitation Engineering Research Center on Augmentative and Alternative Communication. Retrieved from https://rerc-aac.psu.edu/development/d2-developing-aac-technology-to-support-interactive-video-visual-scene-displays/

[7] Bereznak, S., Ayres, K. M., Mechling, L. C., & Alexander, J. L. (2012). Video self-prompting and mobile technology to increase daily living and vocational independence for students with autism spectrum disorders. Journal of Developmental and Physical Disabilities, 24, 269-285.

[8] van Laarhoven, T., Winiarski, L., Blood, E., & Chan, J. M. (2012). Maintaining vocational skills of individuals with autism and developmental disabilities through video modeling. Education and Training in Autism and Developmental Disabilities, 447-461.

[9] Bryen, D. N., Potts, B. B., & Carey, A. C. (2007). So you want to work? What employers say about job skills, recruitment and hiring employees who rely on AAC. Augmentative and Alternative Communication, 23, 126-139.

[10] Kazdin, A. E. (2010). Single-case research designs: Methods for clinical and applied settings (2nd ed.). New   York, NY: Oxford University Press.

ACKNOWLEDGEMENTS

This project was supported, in part, by funding from the (a) Penn State AAC Leadership Project, a doctoral training grant funded by U.S. Department of Education grant #H325D110008 and (b) Rehabilitation Engineering Research Center on Augmentative and Alternative Communication (The RERC on AAC), funded by grant #90RE5017 from the National Institute on Disability, Independent Living, and Rehabilitation (NIDILRR) within the Administration for Community Living (ACL) of the U.S. Department of Health and Human Services (HHS).