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Persons with profound intellectual disability (PID) are mostly not able to use assistive technology (AT) independently. Caregivers play an important mediating role in implementing AT in the daily life of persons with PID. Both first-order barriers, extrinsic to caregivers, and second-order barriers, intrinsic to caregivers, influence the attitudes and behaviors of caregivers with regard to AT-use. It could be asked if increased knowledge on and experience with AT may impact the effect of first- and second-order barriers. This study investigated how knowledge and experience influence the professional caregivers' beliefs about which factors may impact the AT use in persons with PID and their intentions to use AT for persons with PID. A questionnaire on the experienced limitations and successes in using AT was developed. The questionnaire was send to professionals working with or responsible for persons with PID in various countries in Europe. In total the answers of 195 respondents were included in this study. This study's results demonstrate that AT is used for various reasons in persons with PID, mostly to support communication and interaction or for fun or relaxation. Based on the answers of the respondents can be concluded that both experience and knowledge of caregivers seem to influence first- and second-order barriers. Besides, a possibility to overcome the second-order barriers is to provide professionals with possibilities to increase their knowledge and experience. AT for persons with PID is mostly used for communication and interaction or for fun and relaxation. Professional caregivers belief that AT-use may positively influence various aspects in the life of persons with PID, especially communication and interaction, active engagement and participation in activities, and self-esteem of the person. Caregivers need to have sufficient experience in order to rate the barriers of AT-use as less limited in the group of persons with PID. In order to overcome the barriers experienced in implementing AT in persons with PID, knowledge of caregivers is essential. [ABSTRACT FROM AUTHOR]

Background: Within the context of the Special Interest Research Group (SIRG) on Persons with Profound Intellectual and Multiple Disabilities (PIMD), researchers often discuss the methodological problems and challenges they are confronted with. The aim of the current article was to give an overview of these challenges. Methods: The challenges are centred on six topics. These reflect the main components of a study's design: (a) participant demarcation, (b) participant recruitment, (c) data collection and instruments, (d) data analysis, (e) ethics/including the "voice" of persons with PIMD and (f) theoretical models. Results: Next, to describing the specific challenges, possible solutions and pathways to address them are discussed. These are illustrated by recent studies by the authors and other researchers in the field. Conclusions: The current contribution wants to stimulate further discussion and exchange of ideas, and the development of creative research techniques. [ABSTRACT FROM AUTHOR]

While children with developmental language disorder or Williams syndrome appear to use hand gestures to compensate for specific cognitive and communicative difficulties, they have different cognitive strength-weakness profiles. Their semantic and visuospatial skills potentially affect gesture quality such as iconicity. The present study focuses on untangling the unique contribution of these skills in the quality of gestures. An explicit gesture elicitation task was presented to 25 participants with developmental language disorder between 7 and 10 years of age, 25 age-matched peers with typical development, and 14 participants with Williams Syndrome (8−23 years). They gestured pictures of objects without using speech (pantomime). The iconicity, semantic richness, and representation technique of the pantomimes were coded. Participants' semantic association and visuospatial skills were formally assessed. Iconicity was slightly lower in individuals with Williams syndrome, which seems related to their visuospatial deficit. While semantic saliency was similar across participant groups, small differences in representation technique were found. Partial correlations showed that visuospatial skills and semantic skills were instrumental in producing clear pantomimes. These findings indicate that clinicians aiming to enhance individuals' natural iconic gestures should consider achieved iconicity, particularly in individuals with low visuospatial skills. [ABSTRACT FROM AUTHOR]

Background In typical development, primarily contextual factors at the family level are clearly associated with child developmental outcomes. In contrast, knowledge about the contextual factors influencing the developmental characteristics of children (0-12 years) with severe to profound intellectual disability is scarce.Method Through computerised searches of 4 bibliographic databases, 54 studies were identified.Results The included studies were characterised by the use of small study populations and nonvalidated research instruments, as well as by strong research designs and detailed reporting of individual results. The majority of the studies evaluated procedures based on behaviourist learning theory, mostly aimed at reducing nonadaptive behaviour or stimulating choice behaviour. The studied factors proved to be generally effective.Conclusions Family and parenting factors are one of the most striking gaps in the current literature about the development of children with intellectual disability. Also, further research on long-term developmental changes and bidirectional influences is necessary. [ABSTRACT FROM AUTHOR]

The aim of the present study was to examine the relationship between the use of key word signing (KWS) by support staff and by adults with intellectual disabilities (clients) who had experience with using KWS. Specifically, we explored whether these clients were more inclined to use KWS when sup- port staff used KWS or imitated signs. One-to-one conversations between 24 clients and their support staff were filmed and transcribed. Partner turns were coded for communication mode (spoken or signed) and KWS response type (i.e., imitation, repetition, or new), while client turns were coded for communication mode and novelty (novel or non-novel). Using Cramer's V, strength of association was measured between each partner and subsequent client turn. Results indicated a moderate to strong association between partners' and clients' communication mode. In addition, partner turns containing newly introduced signs were associated with non-novel signed client turns, whereas sign imitations and repetitions by partners were more often followed by novel than non-novel signed client turns. These findings suggest that a balanced KWS input that includes new signed lexical items and sign imitations/repetitions may help to facilitate clients' KWS production and maintenance. This study was exploratory, and further research is needed to validate these results. [ABSTRACT FROM AUTHOR]

Purpose: In services for adults with intellectual disabilities, various staff members may have different key word signing (KWS) skills and conversational style. Little is known about how these clients use KWS with different staff members. Therefore, we observed staff–client conversations and examined how clients’ KWS usage was shaped by staff members’ KWS usage and conversational style. Method: Three 10-min dyadic conversations between an adult with moderate or severe intellectual disabilities (N = 15) and three familiar staff members were filmed and transcribed. The KWS usage and conversational responsivity in the transcriptions was analyzed at group (using generalized estimating equations), subgroup, and individual levels. Results: Clients appeared to produce significantly more KWS as partners imitated more signs and as partners were more responsive. There was a negative interaction between these two factors. Subgroup analyses showed that spontaneity of clients’ KWS usage was a continuum. Conclusion: Findings suggest that staff can encourage clients’ KWS usage by imitating manual signs but that clients’ response efficiency should also be taken into account. [ABSTRACT FROM AUTHOR]

Even though use of aided augmentative and alternative communication (AAC) by staff has been extensively researched, few studies relate to unaided AAC strategies such as key word signing (KWS). We explored the KWS views of two groups: direct support staff in group residential homes and teachers from special education secondary schools. We examined transcripts from individual semi-structured interviews with five direct support staff and five teachers using thematic analysis. Participants discussed consistency of KWS use and reasons for implementing KWS. Compared to direct support staff, teachers described more use of KWS throughout the day with more individuals with intellectual disability. Teachers discussed use of KWS to facilitate students’ present and future interactions, while direct support staff primarily discussed immediate effects. Participants experienced KWS implementation as a learning process and aimed to turn the use of manual signs into a routine habit. This required considerable self-monitoring, and the effort that this continuous self-feedback required, combined with environmental factors, could hinder KWS implementation. These preliminary findings suggest that preservice KWS training and on-site KWS assistance may need to be enhanced. [ABSTRACT FROM PUBLISHER]

BackgroundResearch findings suggest that direct support staff use augmentative and alternative communication (AAC) inconsistently. Various staff-related factors have been identified, and researchers agree that these factors somehow interrelate. Therefore, we approached AAC use as a behavioural process and examined the synergy between staff-related factors. MethodFifteen direct support staff and 10 speech-language/occupational therapists who work with adults who have an intellectual disability and use AAC were individually interviewed. Transcripts were studied using thematic analysis. ResultsThree main themes were discerned: consistent versus inconsistent AAC usage in direct support staff; time as a real and virtual barrier; friction in the peer–expert relationship. ConclusionsDirect support staff primarily used AAC when there was an acute need for communication support. In contrast, both direct support staff and speech-language therapists felt that direct support staff should consistently provide augmented input. This discrepancy was driven by team dynamics as well as actual and perceived lack of time. [ABSTRACT FROM AUTHOR]

Background In spite of the profound cognitive and physical problems, people with profound intellectual and multiple disabilities ( PIMD) are able to develop joint attention behaviours ( JAB) and benefit from positive interactions. Aims To investigate which context factors influence the JAB of people with PIMD. Method Based on video recordings of 45 participants, JAB and context factors were analysed. Results An unstructured interaction situation produced the most responses of a person with PIMD, whereas a structured interaction situation produced the most initiatives. Furthermore, the familiarity of the partner and the familiarity of objects used in the interaction had no influence on the JAB. The sensitivity of the interaction partner was positively related to the presence of JAB. Conclusions Interaction partners of people with PIMD should be aware of both the ability of people with PIMD to use JAB and the influence of different context factors on these JAB. [ABSTRACT FROM AUTHOR]

Background: Support staff may diverge in their use of augmentative and alternative communication (AAC) and key word signing (KWS). AAC use is determined by multiple personal and environmental factors. In this study, the relation between KWS attitudes and usage was examined in support staff.Method: Twelve adults with an intellectual disability who use KWS were each filmed during a dyadic interaction with two professionals from their service: one had received first-hand (1HT) and the other second-hand KWS training (2HT). Each communication partner participated with only one client. The professionals' sign usage was coded, and their attitude towards KWS was measured using a survey and single-category Implicit Association Test (IAT).Results: 1HT produced more signed utterances and distinct signs than 2HT, and this increase had a positive, linear relation to IAT scores. Explicit attitude did not correlate with KWS usage, but did significantly correlate with the discrepancy between intention and KWS usage.Conclusion: The train-the-trainer system may not reach its full potential as 2HT knew fewer distinct signs and consequently produced fewer signed utterances than 1HT. In contrast to implicit attitude, no relation was found between explicit attitude and KWS usage. Though the survey may provide valuable information, it may not fully capture the complex influences that shape AAC usage. [ABSTRACT FROM AUTHOR]

Purpose: The goal of this study was to evaluate a key word signing (KWS) program in which adults with mild to severe intellectual disability (ID) were taught manual signs through their support staff. Our hypothesis was that spontaneous manual sign production of participants would increase significantly after 12 months of implementation of the KWS program. Method: A KWS immersion program was implemented in a facility for adults with ID. First, 8 support workers received 8 hr of training. These KWS ambassadors then taught 2 manual signs per week to their colleagues, who modeled the use of the signs throughout the day in natural interactions with their clients. KWS use in 15 adults with ID and 15 of their support staff was evaluated before the start of the program and at a 12-month follow-up using a narrative task and during spontaneous conversation. Results: Manual sign production of support workers and adults with ID had increased significantly 12 months after the start of the program. The adults with ID were able to express significantly more communicative functions in their narrative language after the intervention and when using KWS. Conclusion: The KWS program was successful and can be applied in similar clinical settings. [ABSTRACT FROM AUTHOR]

Key word signing (KWS) is a means of augmentative and alternative communication frequently used with adults with intellectual disabilities (ID). Their acquisition of KWS has been described in the literature; however, little is known about the everyday KWS use among adults with ID and their support staff. This study aimed to give an account of the prevalence of KWS and the sign knowledge of adults with ID and their support staff in Flemish residential programs (RPs) and day care programs (DCPs). Communication specialists in all RPs and DCPs for adults with ID in Flanders, the Dutch-speaking part of Belgium, were contacted by phone and were asked whether they used KWS, and if so, whether they were willing to fill out a questionnaire about the KWS use of support staff and clients. Findings show that of 347 RPs and DCPs in Flanders, 85% met the inclusion criteria. Half (51.2%) of these programs used KWS. Of these 152 programs, 93 (61.2%) completed our questionnaire. A quarter (26.6%) of their adult clients with ID used KWS.Most of them knew 10-50 signs, whereas most support staff knew fewer than 10 signs. The presence of a speech and language therapist as well as sign knowledge and attitude of support staff were significantly related to the sign knowledge of their clients.Motivational problems for staff to use KWS were quite common. KWS support should be more widespread and more easily accessible. [ABSTRACT FROM AUTHOR]

The evaluation of language and communication skills in adults who use augmentative and alternative communication (AAC) in general and key word signing (KWS) in particular, can be an elaborate task. Besides being time-consuming and not very similar to natural communication, standard language tests often do not take AAC or KWS into account. Therefore, we developed a narrative task specifically for adults with intellectual disability (ID) who use KWS. The task was evaluated in a group of 40 adult KWS users. Outcome measures on the narrative task correlated significantly with measures of standard language and communication tests for verbal language, but not for use of manual signs. All narrative measures, for both verbal language and manual signing, correlated highly with similar measures from a conversation sample. The developed narrative task proved useful and valid to evaluate the language and communication skills of adults with ID taking into account both their verbal language and manual sign use. [ABSTRACT FROM AUTHOR]

Purpose: The purpose of this study was to investigate the influence of sign characteristics in a key word signing (KWS) system on the functional use of those signs by adults with intellectual disability (ID). Method: All 507 signs from a Flemish KWS system were characterized in terms of phonological, iconic, and referential characteristics. Phonological and referential characteristics were assigned to the signs by speech-language pathologists. The iconicity (i.e., transparency, guessing the meaning of the sign; and translucency, rating on a 6-point scale) of the signs were tested in 467 students. Sign functionality was studied in 119 adults with ID (mean mental age of 50.54 months) by means of a questionnaire, filled out by a support worker. Results: A generalized linear model with a negative binomial distribution (with log-link) showed that semantic category was the factor with the strongest influence on sign functionality, with grammatical class, referential concreteness, and translucency also playing a part. No sign phonological characteristics were found to be of significant influence on sign use. Conclusion: The meaning of a sign is the most important factor regarding its functionality (i.e., whether a sign is used in everyday communication). Phonological characteristics seem only of minor importance. [ABSTRACT FROM AUTHOR]

Purpose: The purpose of this study was to investigate the influence of sign characteristics in a key word signing (KWS) system on the functional use of those signs by adults with intellectual disability (ID). Method: All 507 signs from a Flemish KWS system were characterized in terms of phonological, iconic, and referential characteristics. Phonological and referential characteristics were assigned to the signs by speech-language pathologists. The iconicity (i.e., transparency, guessing the meaning of the sign; and translucency, rating on a 6-point scale) of the signs were tested in 467 students. Sign functionality was studied in 119 adults with ID (mean mental age of 50.54 months) by means of a questionnaire, filled out by a support worker. Results: A generalized linear model with a negative binomial distribution (with log-link) showed that semantic category was the factor with the strongest influence on sign functionality, with grammatical class, referential concreteness, and translucency also playing a part. No sign phonological characteristics were found to be of significant influence on sign use. Conclusion: The meaning of a sign is the most important factor regarding its functionality (i.e., whether a sign is used in everyday communication). Phonological characteristics seem only of minor importance. [ABSTRACT FROM AUTHOR]

Background The aim of this descriptive single case study was to describe a unique interaction with a person with profound intellectual and multiple disabilities (PIMD) in a holistic way-focusing on the client, the staff member, and the interacting dyad-and to include the experiential knowledge of the interaction partner. Method A videotaped interaction of the staff-client dyad was analysed by triangulating data from video analysis, documents, observational rating scales, and an interview with the staff member. Results The interactional pattern revealed in this study is that of a staff member who offers an activity that is considered to be stimulating for the client, by using a variety of initiatives and structuring strategies, and a client who is alert and responsive, but has limited chances to take own initiatives. Rather low scores were obtained on observations from a dialogical perspective. Conclusions This study highlights the value of video analysis for practitioners, demonstrates the usefulness of describing an interaction episode supported by an integrative theoretical framework, and confirms the importance of combining observations by an independent researcher with experiential staff knowledge. [ABSTRACT FROM AUTHOR]

The aim of this study was to test whether the effect of the pile-up of demands associated with a disability on quality of life, was mediated by resilience, quantity and quality of social support for adolescents with a disability and their parents. One hundred and thirty two parents, 90 mothers and 42 fathers and 111 adolescents, aged between 16 and 24 years completed measures of the pile-up of demands, social support, resilience and quality of life. Structural equation modeling with the bootstrap resampling method showed that the impact of the disability of their son/daughter on the quality of life of the parents was fully mediated through the parents' resilience and the quantity of social support and that resilience, however only partly, mediates the effect of adaptive skills on the quality of life of the adolescents with a disability. Limitations of the study and clinical implications are discussed. [ABSTRACT FROM AUTHOR]

Being confident as attachment figures is not self-evident for parents of children with severe or profound intellectual disabilities (SPID) given the children’s limited clear communicative responses. The current study drew upon the Attachment Strengths and Needs Interview to get an overview of factors that parents identify as influencing their parent-child attachment relationships. Inductive semantic thematic analysis was conducted on 23 semi-structured interviews (including responses of 35 parents). These were the parents of children (1–9 years) with a severe or profound intellectual (or multiple) disability. The results showed that parents mentioned a large number of inhibiting and facilitating factors related to developing attachment relationships with their children. Adopting an ecological systems perspective, these influences were organised in a micro-, meso-, macro-, exo- and chrono-level. This implies that not only factors related to the child (and his/her disability) were mentioned, but also factors related to (amongst others) the parents, the parent-child and family interactions, the broader environment and policy. Concluding, from parents’ perspectives, it seemed that the factors influencing the (development of) attachment relationships can be positive and negative, are versatile, layered in different levels, interconnected and not necessarily linked to their children’s disability. Both generic factors across parents and specific factors, related to individual families, should be taken into account to provide tailored support. [ABSTRACT FROM AUTHOR]

Background: Individuals with developmental language disorder or Williams syndrome are reported to use more gestures than individuals with typical development. However, these two groups differ considerably in visuospatial and language skills, two skills that are hypothesized to shape gesture rate. Aims: We first examined whether children with both developmental language disorder and children Williams syndrome do indeed use more gestures. Our second aim was to disentangle the role of vocabulary and visuospatial skills in the use of supplementary gestures (i.e., containing unique information). To account for participant heterogeneity, analyses included both group comparisons and vocabulary and visuospatial skills at an individual level. As a third aim, the role of visuospatial skills was further examined in relation to gestures containing spatial content. Methods & Procedures: In a cross‐sectional group design, three participant groups watched and then retold a cartoon: children with typical development (n = 25), children with developmental language disorder (n = 25) and children/young people with Williams syndrome (n = 14). Their narrations were transcribed and hand gestures were coded based on gesture–speech integration (redundant, adds information to particular lexical items, gives information that is entirely absent from speech) and spatial content. Participants' expressive vocabulary and visuospatial skills were measured. Outcomes & Results: Between‐group comparisons showed that individuals with developmental language disorder or Williams syndrome did indeed use more gestures. Poisson loglinear modelling demonstrated that a relative higher use of supplementary gestures was determined by lower expressive vocabulary skills. Neither the group distinction nor visuospatial skills shaped the supplementary gesture rate nor spatial gesture rate. Conclusions & Implications: Regardless of neurodevelopmental condition or typical development, a higher use of supplementary gestures was influenced by expressive vocabulary skills. Children with lower vocabulary skills spontaneously capitalized on the multimodality of communication to express constituents that were not present in their verbal speech. This finding is a promising starting point for future gesture intervention studies examining whether implicit modelling of gesture use can encourage gestures even more in these children and if this allows them to achieve higher linguistic complexity. On a methodological note, the observed intra‐group skill variability demonstrates that group comparisons need to be complemented with correlational measures accounting for skills at an individual level. What this paper adds: What is already known on the subject: Children with developmental language disorder and children with Williams syndrome are more inclined to use gestures than typically developing children. Research conducted in adults with typical development points towards the role of lexical and visuospatial skills in gesture use, but it is unclear how these skills shape gesture use in children with atypical development. What this paper adds to existing knowledge: This study compares the rate of gestures that convey meaning that is not expressed in speech between the three aforementioned populations. Novel is the inclusion of the group distinction, individual lexical skills, and visuospatial skills in one encompassing statistical model. What are the potential or actual clinical implications of this work?: The inclination to use gestures that replace speech is related to lexical skills. Visuospatial skills do not seem to play a role and should not be considered as a factor when thinking about gesture intervention. Understanding how gestures relate to specific skills is a first step to understanding how gesture interventions can bolster language production. [ABSTRACT FROM AUTHOR]

Background: Over the past decades the links between gesture and language have become intensively studied. For example, the emergence of requesting and commenting gestures has been found to signal the onset of intentional communication. Furthermore, in typically developing children, gestures play a transitional role in the acquisition of early lexical and syntactic milestones. Previous research has demonstrated that, particularly supplementary, gesture-word combinations not only precede, but also reliably predict the onset of two-word speech. However, the gestural correlates of two-word speech have rarely been studied in children with intellectual disabilities. Aims: The primary aim was to investigate developmental changes in speech and gesture use as well as to relate the use of gesture-word combinations to the onset of two-word speech in children with intellectual disabilities. A supplementary aim was to investigate differences in speech and gesture use between requests and comments in children with intellectual disabilities. Methods & Procedures: Participants in this study were 16 children with intellectual disabilities (eight girls, eight boys). Chronological ages at the start of the study were between 3;1 and 5;7 years; mental ages were between 1;5 and 3;3 years. Every 4 months within a 2-year period children's requests and comments were sampled during structured interactions. All gestures and words used communicatively to request and comment were transcribed. Outcomes & Results: Although children's use of spoken words as well as the diversity in their spoken vocabularies increased over time, gestures were used with a constant rate over time. Temporal tendencies similar to those described in typically developing children were observed: gesture-word combinations typically preceded, rather than followed, two-word speech. Furthermore, gestures (deictic gestures in particular) were more often used to request than to comment. Conclusions & Implications: Overall, gestures were used as a transitional tool towards children's first two-word utterances. This result highlights gesture use as a robust phenomenon during the early stages of syntactic development across populations. The observed differences in gesture use between requests and comments might be explained by differences in interactional as well as in procedural context. [ABSTRACT FROM AUTHOR]

Background The aim of this study was to examine the degree to which children with intellectual disability ((ID)) depend on manual signs during their expressive vocabulary acquisition, in relation to child and social-environmental characteristics. Method Expressive vocabulary acquisition in speech and manual signs was monitored over a 2-year period in 23 children with ID using parent report. The children's cognitive, communicative, and vocabulary comprehension skills were measured at baseline. Speech-language pathologists' and parents' use of and attitudes towards manual signs were measured using self-report. Results Four distinct profiles of vocabulary acquisition were evident. Those children who initially demonstrated the most significant cognitive, communicative, and comprehension delays acquired the smallest expressive vocabularies during follow-up, yet these variables were not related to the children's degree of dependence on manual signs. Conclusions Specific cognitive, communicative, and comprehension skills relate to vocabulary acquisition. The same skills that allow for speech development seem to be fundamental to the acquisition of manual signs. [ABSTRACT FROM AUTHOR]

Purpose: This study's objectives were to describe expressive vocabulary acquisition in children with intellectual disabilities (ID) and to examine specific pre- and early linguistic behaviors used to request and comment, chronological age, cognitive skills, and vocabulary comprehension as predictors of expressive vocabulary. Method: This study included 36 children with ID, age 3;00 (years;months) to 6;05, with an average initial expressive vocabulary of 67 words. Expressive vocabulary acquisition was longitudinally followed over a 2-year period based on 4-monthly administrations of the Dutch version of the MacArthur Communicative Development Inventory/Words and Gestures (I. Zink & M. Lejaegere, 2002). Specific pre- and early linguistic behaviors used to request and comment as well as cognitive skills and vocabulary comprehension were measured at baseline. Results: Individual growth modeling indicated that vocabulary comprehension was the only unique predictor of initial expressive vocabulary. Subsequent vocabulary growth was uniquely predicted by proportion of bimodal gesture + vocalization comments, chronological age, and cognitive skills. Conclusions: The results of this study underscore the great heterogeneity in expressive vocabulary skills in children with ID. The importance of prelinguistic communication, chronological age, cognitive skills, and vocabulary comprehension for explaining differences in expressive vocabulary skills is discussed. [ABSTRACT FROM AUTHOR]

Background Although high-structured elicitation tasks have been shown to be efficient means to sample communication in children with intellectual disabilities, their validity and reliability remain to be evaluated. The aims of this study were threefold: (i) to evaluate the eliciting potential, (ii) to examine the utterance forms of proto-imperative and proto-declarative intentions, and (iii) to evaluate the reliability of two high-structured elicitation tasks. Methods Twenty-eight children with intellectual disabilities participated in a standard assessment battery, consisting of a formal language assessment, a parent questionnaire, an elicitation task for proto-imperatives, and an elicitation task for proto-declaratives. Results The elicitation tasks elicited significantly more proto-imperatives than proto-declaratives; with proto-imperatives being predominantly expressed with gestures and proto-declaratives predominantly with vocalizations. Furthermore, medium to large correlations were found between the elicitation tasks and the other communication and language instruments. Conclusions Several factors need to be considered to account for the observed differences in frequency and utterance forms of the elicited proto-imperatives versus proto-declaratives. Nevertheless, the results overall suggest that the elicitation tasks for proto-imperatives and proto-declaratives can be reliably used in children with intellectual disabilities. [ABSTRACT FROM AUTHOR]

Background High quality interactions are of crucial importance for quality of life of persons with profound intellectual and multiple disabilities (PIMD). This literature review describes and synthesises studies addressing the interaction between persons with PIMD and their partners. Method A computerised literature search using defined inclusion criteria yielded 15 articles. Results The literature analysis revealed four components important in interactions: sensitive responsiveness, joint attention, co-regulation, and an emotional component. The abilities and disabilities, interactive behaviours, and personality of persons with PIMD influence these interactions. Additional influences are the partners' interactive strategies, knowledge, and perceptions and the context of the interaction. Conclusions An overview model integrates the results and forms a vehicle to facilitate our understanding of interactions with persons with high support needs. Methodological analyses of the studies show lacunae in current research. This review offers a starting point to guide future research and intervention. [ABSTRACT FROM AUTHOR]

Abstract: The present study focused on the objective components of quality of life (QOL) of people with profound multiple disabilities (PMD). More specific, we aimed at evaluating different dimensions of QOL of people with PMD and investigating the association between their QOL and several personal (age, gender, intellectual capabilities, motor limitations, sensory limitations, physical and mental health status) as well as setting characteristics (location of the setting, type of setting, size of the setting, group size, group composition, staffing level and staff turnover). As a measure of the QOL of people with PMD we used the QOL-PMD, a questionnaire that we specifically developed for this purpose. To measure the personal and setting characteristics we also used a self-developed questionnaire. Forty-nine people with PMD were selected. For each of these people three informants were chosen who each filled out the QOL-PMD. To account for the clustered nature of the data, data were analysed by means of mixed models. Characteristics regarding the medical condition of the person with PMD turned out to be most strongly associated with the QOL-PMD scores. Other personal characteristics such as age, gender, motor limitations and sensory limitations did not have a significant effect on the QOL-PMD scores. With regard to the setting characteristics, location of the setting and staffing level turned out to have a significant effect on the QOL-PMD scores. [Copyright &y& Elsevier]

Abstract: Because of a shortage of valid instruments to measure the QOL of people with profound multiple disabilities (PMD), the QOL-PMD was developed. In the present study, possibilities for item reduction as well as the psychometric properties of the questionnaire were examined. One hundred and forty-seven informants of people with PMD participated in the study. Fifty items were removed from the questionnaire on the basis of preset criteria. Internal consistency was good for the total questionnaire as well as for the subscales. Evidence of the construct validity of the questionnaire was found. Correspondence between the groups of informants was moderate. The results of this preliminary analysis of the psychometric properties of the QOL-PMD are encouraging, but further validation of the measure is warranted. [Copyright &y& Elsevier]

Abstract: The main goal of this study was to investigate whether staff members vary in their frequency reports on challenging behaviour concerning the same client. Because staff''s approaches of challenging behaviour are affected by a range of staff characteristics, we hypothesised that these staff characteristics could explain this variability between staff members. We used questionnaires to investigate the influence of staff''s age, gender, experience in working with people with intellectual disabilities, working hours, professional qualifications, sort of education, and their emotional reactions and beliefs regarding the challenging behaviour. This study involved 152 staff members and 51 clients with severe or profound intellectual disabilities who displayed self-injurious behaviour, stereotyped behaviour, and/or aggressive/destructive behaviour. A part of the variability between staff''s reports on the frequency of challenging behaviour was indeed explained by differences between the staff members. Working hours, internal attribution, gender, and experience in working with people with severe or profound intellectual disabilities turned out to be influencing variables. Summarising, staff members differ in their reports on the frequency of challenging behaviour. To get an accurate picture of a client''s challenging behaviour, perceptions of several staff members are needed. [Copyright &y& Elsevier]

Background This study evaluates the effects of reminiscence group work on the subjective well-being of ageing people with intellectual disabilities. Methods The content of the successive group work sessions was manipulated as follows: a control-phase with three ‘current topics’ sessions, an experimental phase with six ‘reminiscence’ sessions and finally three ‘current topics’ sessions. Life satisfaction, perceived self-competence and mood were measured by questionnaires, filled in by the participants and direct support workers. Results A quasi-experimental pre-test–post-test design ( n = 41) did not detect any changes in life satisfaction and perceived self-competence. For mood, a quasi-experimental ABA-design ( n = 41) did not yield an experimental treatment effect, but a significant increase in scores was observed over time. Personality characteristics ‘extraversion’ and ‘emotional stability’, but not memory specificity were found to be significant covariates for the mood scores. Conclusion Although the study’s design did not allow us to confirm the effect of reminiscence group work, the analysis nonetheless revealed some useful indications for further research. Also, interviews conducted before and after the programme resulted in positive appraisals of the programme as a worthwhile and meaningful activity for ageing people with intellectual disability. [ABSTRACT FROM AUTHOR]

The authors attempted to find out to what extent and in which ways, in Belgium, have Flemish services for people with intellectual disability adapted to the specific needs of aging people. A study was undertaken and a questionnaire was developed to address the following research topics: (1) accommodations and personnel, (2) staff working methods, and (3) staff views and attitudes. The questionnaire was completed by 66 coordinating staff members in as many facilities. At the time of our study, these services supported 310 (27%) persons with Down syndrome age 40 years and older and 833 (73%) persons with intellectual disability (other than Down syndrome) age 55 years and older. Adaptations in accommodation and personnel management were obvious in the majority of the participating services. The working methods reflected a person-centered philosophy, regardless of the age-factor. An exploratory factor analysis revealed three different staff approaches: an activating/socializing, disengaging, and methodical. Participation in activities and involvement in social relations have a prominent place in the staff's views. In general, the authors found that about two-thirds of the services have started to modify their accommodation and personnel to the needs of aging people with intellectual disability. The authors note also that the results suggest there is still a lot of work to do in improving staff training, introducing specific working methods, and in altering stereotypical staff attitudes to assure a good “aging in place.” [ABSTRACT FROM AUTHOR]

The present article reviews reminiscence research with regard to people with intellectual disabilities. Although the term "reminiscence" is not often used in intellectual disability research, the concept offers a useful framework for charting the different approaches in literature, thanks to its multidisciplinary character and eclectic theoretical background. Three main perspectives are identified: a critical approach, in which reminiscence is stimulated to let people with intellectual disabilities become critically aware of their past; a person-centred approach, in which reminiscence serves informational and social purposes; and a clinical approach, in which reminiscence is presented as an alternative diagnostic instrument and/or a "low-threshold" narrative counselling method for people with intellectual disabilities. The three approaches differ in language use, aims, and backgrounds, but there is congruency amongst the approaches in that reminiscence work can strengthen the identity of people with intellectual disabilities, raise self-esteem, and enhance social contacts. The review concludes that a more balanced view of reminiscence, better methodological procedures, and more evaluation studies on the effect and process of reminiscence work are needed in future research. [ABSTRACT FROM AUTHOR]

Background This study provides an overview of empirical research on the effectiveness of quality-enhancing interventions for people with profound intellectual and multiple disabilities (PIMD). Method Through computerised searches of the PsycINFO and ERIC databases, and using several search criteria specifically relating to the target group and to the subject of this review, 16 studies were identified. Results The interventions described are targeted at the physical and material well-being, emotional well-being, social interactions, choices, and personal development of individuals with PIMD, but do not address community participation and rights. The majority of the studies report positive effects of the interventions on staff and/or client behaviour. However these effects should be interpreted with caution because of methodological and other considerations. Conclusions Current research gives only limited insight into the effectiveness of quality-enhancing interventions for people with PIMD. To foster evidence-based practice, further studies of larger groups and with more robust designs are warranted. The potential differential effects associated with client characteristics and the context of the implementation should also be considered. [ABSTRACT FROM AUTHOR]

The authors examined which support characteristics are associated with the quality of life (QOL) of people with profound intellectual and multiple disabilities (PIMD). The authors invited parents and direct support staff of people with PIMD to adopt the perspective of their child or the person with PIMD for whom they care. Some 76 parents and direct support staff of people with PIMD were interviewed, and to obtain data, transcripts were analyzed in-depth. The respondents mentioned: (1) characteristics with regard to the structure of the setting (physical environment, staff ratio, staff turnover, group size, and group composition); (2) characteristics with regard to the internal organization of the support (partnership, teamwork, interdisciplinarity, and support planning); and (3) characteristics with regard to the support staff (experience, sensitive responsiveness, commitment and motivation, physical strength, knowledge and skills, and self-reflection). The respondents considered structural as well as operating features of the support setting to be important for the QOL of people with PIMD. The authors conclude that their main emphasis, however, was on the central role of direct support staff in supporting people with PIMD. [ABSTRACT FROM AUTHOR]

Background The goal of this study was to adapt a narrative reminiscence program for the special needs of ageing people with mild/moderate intellectual disabilities. Research has shown that stimulating reminiscence in the elderly can be a meaningful activity, and holds promise for positive effects on well‐being. Method In the first stage (10 weeks), the program was developed with 1 group. Evaluation and adjustments to the program were made based on video recordings, the researcher's log, and feedback from participants and support workers. Formative evaluation was performed by means of a within‐group analysis. In the second stage (3 weeks), the program was introduced to 6 other groups. Interviews with professional support workers were subjected to a cross‐case analysis. Results The final program consists of 13 sessions covering different reminiscence themes. The success of reminiscence group work relies on (a) well‐prepared and structured sessions, (b) adequate use of visual triggers, and (c) facilitating, coaching and moderating. Conclusion The program was perceived as a valuable and meaningful activity by all participants. Although reminiscence group work is not therapeutic in nature, it may have therapeutic use for ageing people with intellectual disabilities, and in this sense is worth evaluating. [ABSTRACT FROM AUTHOR]

Background The aim of this study was to explore a procedure for drafting individualised profiles of how people with profound multiple disabilities express pleasure and displeasure. Method There were 6 participants with profound multiple disabilities. The procedure involved an observational analysis of videotaped critical incidents by a researcher and a questionnaire for parents and support workers. Results The procedure is useful for making an individualised profile of the ways a person with profound multiple disabilities expresses his/her pleasure and displeasure. Despite the significant correlation between parents, support workers and the researcher, each has a complementary contribution to make in identifying affective expressions. People with profound multiple disabilities especially use sounds and facial expressions to express pleasure and displeasure and positive or negative moods. Conclusions The procedure may be useful in services or schools for learning more about the affective communication of these individuals, to determine their specific interests, and to evaluate the effects of living and support characteristics on their wellbeing. [ABSTRACT FROM AUTHOR]

This study considered the general validity of the basic domains of quality of life that appear in theoretical models, in relation to people with profound multiple disabilities. The authors examined how parents and direct support staff operationalized these basic domains for people with profound multiple disabilities. They investigated the effect of the support setting and age of people with profound multiple disabilities on this operationalization.A number (n = 76) of parents and direct support staff of people with profound multiple disabilities were interviewed. Transcripts were analysed in depth.Results showed that the five basic domains as described within the model of Felce&Perry [Research in Developmental Disabilities (1995) vol. 16, pp. 51–74;Quality of Life in Health Promotion and Rehabilitation Conceptual Approaches, Issues and Applications(1996a) Sage Publications;Quality of Life.Vol. I:Conceptualization and Measurement(1996b) American Association on Mental Retardation] were identified spontaneously by more than half of the respondents as being salient for the quality of life of people with profound multiple disabilities. When asked explicitly, this value rose to between 88.2 and 100%. The operationalization of these basic domains by parents and direct support staff differed in several aspects from operationalizations for other target groups. Neither age nor support setting turned out to have a significant effect on the operationalization.The results supported the multidimensionality of quality of life and the validity of the basic domains for people with profound multiple disabilities. The content of the domains of quality of life differed, however, to a considerable extent for people with profound multiple disabilities. Furthermore, these people are extremely dependent on others for the gratification of their needs and therefore for their quality of life. [ABSTRACT FROM AUTHOR]

Parent-reported problem behaviors of 94 children with visual and auditory disabilities, attending elementary regular schools, were compared with problems reported in a general population sample of nondisabled children. Both samples were matched by means of a pairwise matching procedure, taking into account age and sex. Problem behavior was measured by Achenbach’s (1991) CBCL (Achenbach, T. M. (1991).Manual for the Child Behavior Checklist/4-18 and 1991 Profile, University of Vermont, Department of Psychiatry, Burlington, VT). No significant main effects of type, degree, and nature of disability were found on the CBCL Total Problems scale, nor on the syndrome scales. In general, children with sensory disabilities attending elementary regular schools did not show more problems in comparison to nondisabled children. Merely on the Social Problems scale there was a significant difference between both samples, the children with sensory disabilities getting higher scores than their nondisabled peers. Further, children with sensory disabilities ran considerable risks of developing deviant scores on the Social Problems and the Thought Problems syndromes, the odds being respectively 3.2 and 5.2 times higher than in the general population sample. To optimize the benefits from placement in integrated classrooms for children with sensory disabilities, school counselors and teachers should not only focus on the academic achievements of these children, but also on their social skills and peer sociometric status. [ABSTRACT FROM AUTHOR]

Research on special needs education is often very complex and puts specific demands on the methodology used. Data-triangulation, at the very least, is required. In most of our recent research projects on the development of special needs education in Flanders (the Dutch speaking part of Belgium), we have made use of qualitative case studies to describe and understand the complex reality of the innovations taking place in our schools. In this article we discuss some methodological aspects of qualitative case study designs, illustrated with a study on the implementation of inclusive education in Flemish primary schools. [ABSTRACT FROM AUTHOR]

Background: Evidence shows that neurotypical individuals who stutter use fewer gestures than those who do not stutter. Presently, no research exists about the interaction of stuttering and gestures in individuals with Down syndrome. Method: Twenty‐nine individuals with Down syndrome (7–19 years) of whom 16 stuttered and 13 spoke fluently and 20 neurotypical children (3–10 years) of whom 8 stuttered and 12 spoke fluently participated in this study. In spontaneous speech transcriptions, stuttering events and gestures were coded. Results: Comparisons of gesture frequency during stuttered and fluent speech inside the Down syndrome and neurotypical group show that the Down syndrome group uses significantly more gestures during stuttered than during fluent speech while no significant difference is seen in the neurotypical group. Conclusions: There is some preliminary evidence that individuals with Down syndrome try to compensate for their stuttering events, however, analyses on word level are necessary to confirm a successful compensation. [ABSTRACT FROM AUTHOR]

Background: It is generally acknowledged that parent social support is an important target for intervention. To explore the specific needs of parents of young children with a significant cognitive and motor developmental delay (SDD), we aim to chart the sources and perceived sufficiency of the social support they receive. Method: Within the context of a broader project, 42 parents of a young child with SDD filled out a questionnaire on contextual factors, including information on social support. Results: The majority of parents reported to receive (more than) sufficient support. Insufficiency is primarily reported with regard to practical support. Apart from the partner, grandparents of the child were the most common source of support. Conclusions: This study confirms the importance of professional support and work‐life balance within this specific target group. Specific attention for practical support needs seems warranted considering the high basic care needs of these children. [ABSTRACT FROM AUTHOR]

Background: Professionals play an important role in supporting the social relations of persons with a disability. This study looks at professional practices supporting or strengthening social relations of persons in independent supported living, by integrating the perspectives of adults with a disability, network members and professionals. Method: Fifty-one semi-structured interviews were carried out. Results: Identified practices were: facilitating social situations, connecting with current and new network members, getting to know the person with a disability really well, delivering person-directed work, being a sounding board, being a safety net, working with an empowering attitude, seeing and exploiting opportunities. Influencing factors were related to the person with a disability, the professional, the network members and the broader environment. Conclusion: Identified practices were small actions rather than structured or programmatic interventions. An unique combination and complex interplay of factors was found within each case, where negative factors could be counterbalanced by positive factors. [ABSTRACT FROM AUTHOR]

• Taking care for children with severe disabilities puts high demands on parents. • Outsourcing care to residential care facilities is emotionally complex for parents. • The decision to outsource is a process, marked by fields of tension and uncertainty. • Parents fear to be replaced as attachment figures, while also cherishing hope and trust. • Support to parents should be sensitive to and normalize these complex emotions. Caring for children with severe to profound intellectual disabilities (SPID) can be an overwhelming burden for parents, leading them to consider outsourcing some of the care to residential care facilities. However, this decision is complex and emotionally challenging for both the parents and the child. This Interpretative Phenomenological Analysis study aimed to explore the emotional experiences of parents when making the decision to outsource care for their children with SPID to residential care facilities. In-depth interviews were conducted with seven mothers of children aged between 8 and 18 who were actively considering a transition to residential care. The study revealed that this decision is a complex and ambiguous process, accompanied by layers of insecurities and fields of tension, against a backdrop of high care burden and (fragile) resilience. It requires parents to balance their child's and their own needs, rational and emotional arguments, and complex emotions, with the ultimate goal of finding a sustainable care solution in the long term while still fulfilling their role as attachment figures. The findings of this study are critical in supporting families who are facing such an important and emotional transition in their lives. [ABSTRACT FROM AUTHOR]

Purpose: Key word signing (KWS) entails using manual signs to support the natural speech of individuals with normal hearing and who have communication difficulties. While manual signs from the local sign language may be used for this purpose, some KWS systems have opted for a distinct KWS lexicon. Distinct KWS lexicon typically aims for higher sign iconicity or recognizability to make the lexicon more accessible for individuals with intellectual disabilities. We sought to determine if, in the Belgian Dutch context, signs from such a distinct KWS lexicon (Spreken Met Ondersteuning van Gebaren [Speaking With Support of Signs; SMOG]) were indeed more iconic than their Flemish Sign Language (FSL) counterparts. Method: Participants were 224 adults with typical development who had no signing experience. They rated the resemblance between a FSL sign and its meaning. Raw data on the iconicity of SMOG from a previous study were used. Translucency was statistically and qualitatively compared between the SMOG lexicon and their FSL counterparts. Results: SMOG had an overall higher translucency than FSL and contained a higher number of iconic signs. Conclusion: This finding may support the value of a separate sign lexicon over using sign language signs. Nevertheless, other aspects, such as wide availability and inclusion, need to be considered. [ABSTRACT FROM AUTHOR]

Despite the high prevalence of visual impairments in persons with severe or profound intellectual disability (ID), often a formal diagnosis is unavailable. Direct support workers and staff members have access to the information of the visual functioning through the personal files and build knowledge based on their own experiences. In order to provide individualized and high quality support in daily life, the accuracy and availability of this information of the visual functioning is essential. This study investigates the knowledge of direct support workers and staff members on the visual functioning of their clients and the written information available in the personal files. It is investigated to what extent they do agree on their knowledge and how certain direct support workers and staff members are about their knowledge on the visual functioning. Additionally is investigated to what extent the information available in support files is based on formal assessment. For 104 clients with severe or profound ID a direct support worker and a staff member filled in a questionnaire about their visual functioning. Next, the personal files were analyzed. Direct support workers and staff members respond significantly differently on the questions on the impaired visual functions. Direct support workers rate the certainty level of their knowledge on their clients' visual functions higher than staff members. The personal files lack information on the visual functioning. If information is available, it is mostly based on subjective impressions. The knowledge of direct support workers and staff members and the information available in the personal files provide no comprehensive picture of the visual functioning of the persons with severe or profound ID. [ABSTRACT FROM AUTHOR]

Current literature mainly focuses on adaptive profiles from a categorical perspective but yields inconclusive results. The present study puts a transdiagnostic approach next to a "classical" categorical approach. In this study, 222 children (5–18 years old) with autism and/or intellectual disability participated. Variance analyses, based on standard scores from ABAS-3 at group-level, were conducted in order to compare adaptive domains within categories. A K-Means cluster analysis was used to delineate empirically derived clusters with a similar profile of difference scores at an individual level. Chi-square tests and variance analyses were used to investigate the distribution of variables across clusters. From a categorical perspective, results were in line with current literature. A transdiagnostic perspective revealed three adaptive profiles (Homogeneous, Social, and Practical). No perfect match was found between specific adaptive profiles and diagnostic categories. A transdiagnostic perspective sheds light on the heterogeneity within and the overlap across diagnostic categories. [ABSTRACT FROM AUTHOR]

Parents of children with severe disabilities have differing attachmentrelated support needs. An online vignette study with 25 experts, working in academia and/or clinical practice, was conducted to reflect upon the task of matching intervention components to families, based on their attachment strengths and needs. In two online rounds, the experts first completed an inventory of intervention (n = 25) components and second, they prioritised three components for particular families (n = 22). In addition, they reflected upon their argumentations for selecting these intervention components on different levels, either closely or more remotely connected to the children with disabilities themselves. The most common intervention choice across experts was to converse with parents to increase their understanding in the child's behaviours and communication. Experts justified their choices at various levels (child, parent, family unit, broader environment and professional). In that way, the current study provided an overview of the large number of elements that professionals and policy need to take into account when providing tailored intervention trajectories to these families. Systematically reflecting upon parents' attachment-related perceptions, strengths and (support) needs can furthermore stimulate professionals to prioritise their actions. It should, however, be embedded in a broader (diagnostic and contextual) intake procedure. [ABSTRACT FROM AUTHOR]

Background: Everyday activities are an important setting for stimulating child functioning, but are understudied in young children with a significant cognitive and motor developmental delay. Therefore, we aim to characterize their family activities in terms of diversity, frequency, child engagement and family member's presence, compared to typically developing children. Methods: By asking a parent to fill out an adapted version of the Child Participation in Family Activities questionnaire, the activity pattern of 49 children within the study group and 45 children within the control group were assessed and compared. Results: Children in the study group generally experience less diverse activities (with an additional lower frequency of out‐of‐home activities) and show lower engagement levels compared to typically developing children. Conclusions: Incorporating high levels of personal interaction, highly stimulating activities and adapted leisure activities into the daily activity pattern of children with multiple disabilities might be a pathway to increased engagement levels. [ABSTRACT FROM AUTHOR]

Background: The increased life expectancy of people with intellectual disability intensifies the need for age‐specific support. Research on effects of support strategies on quality of life (QoL) of these people remains scattered. Methods: A systematic search of peer‐reviewed publications since 1995 was performed, with participants having intellectual disability and being aged ≥50 years. Studies include experimental, observational and exploratory designs, analysing links between support strategies and QoL outcomes. The present authors adopted a narrative approach. Results: The present authors found 73 articles, assessed their quality, thematically categorized interventions into 12 themes, and listed them with their stated relationships to QoL. Conclusions: The studies indicated the importance of funding, provision and organization of services/personnel, education, and cooperation among different support systems. The provision of good housing or activities, support when these provisions change, provision of (mental) health care, dementia care and end‐of‐life care, life story work, future planning and support for (I)ADLs are crucial. [ABSTRACT FROM AUTHOR]

Abstract: Persons with profound intellectual and multiple disabilities (PIMD) present limited peer‐directed behaviors toward their peers with PIMD. It is not clear how staff can facilitate and promote the mutual peer‐directed behaviors between persons with PIMD. In this study, we explored if peer‐directed behaviors among persons with PIMD can be increased by an intervention that is focused on training the staff in providing social scaffolding behaviors toward their clients. An A‐B‐B′‐C design was used in this study. A baseline condition was followed by two intervention conditions and a follow‐up. Four staff members participated in a training in which they were informed about peer interactions in persons with PIMD and learned how to promote these interactions. They developed a peer interaction supportive activity. This activity was provided to two persons with PIMD for 10 weeks. Social scaffolding behaviors of staff as well as peer‐directed behaviors of persons with PIMD were coded during videotaped observations. A significant increase of social scaffolding behaviors of staff members was observed during the intervention with a significant decrease at follow‐up. Significantly, more singular and fewer multiple peer‐directed behaviors of persons with PIMD were observed during the intervention. Both singular and multiple peer‐directed behaviors decreased again at follow‐up. A short training of staff members already positively affects their social scaffolding behaviors and increases the amount of peer‐directed behaviors of persons with PIMD. However, the amount of both behaviors decreased again at follow‐up. This argues to broadly apply this training in services and schools for persons with PIMD and to complement it with continuing staff coaching on this topic. [ABSTRACT FROM AUTHOR]

Background: A digital micro-intervention offering attachment psychoeducational videos was explored regarding its feasibility in parents of children with severe disabilities. Method: A mixed-methods study (including daily diaries and one-time questionnaires) with 16 parents (75.0% female) of children with severe disabilities (up to 10 years of age) was done during a three-week intervention. Results: Parents were positive about the video series and almost no drop-out occurred. The videos stimulated their learning and thinking and offered parents some personal meaning. Preliminary efficacy tests showed no major changes in parents' parenting self-efficacy (PSE) or perceptions of statements on parent–child attachment. Conclusions: The study showed promising results regarding the micro-interventions' acceptability and implementation. The limited efficacy testing did not show major changes in parents' PSE. Further research is needed to investigate the differential relevance of the micro-intervention, based on parents' needs, as well as its optimal embeddedness in a broader intervention trajectory. [ABSTRACT FROM AUTHOR]