Automated prompting technologies in rehabilitation and at home

Abstract

Purpose
The purpose of this paper is to test the efficacy of an interactive verbal prompting technology (Guide) on supporting the morning routine. Data have already established the efficacy of such prompting during procedural tasks, but the efficacy of such prompting in tasks with procedural and motivational elements remains unexamined. Such tasks, such as getting out of bed in the morning and engaging in personal care, are often the focus of rehabilitation goals.

Design/methodology/approach
A single‐n study with a male (age 61) who had severe cognitive impairment and was having trouble completing the morning routine. An A−B−A′−B′−A″−B″ design was used, with the intervention phase occurring both in an in‐patient unit (B, B′) and in the participant's own home (B″).

Findings
Interactive verbal prompting technology (Guide) significantly reduced support worker prompting and number of errors in the in‐patient setting and in the participant's own home.

Research limitations/implications
The results suggest that interactive verbal prompting can be used to support motivational tasks such as getting out of bed and the morning routine. This study used a single subject experimental design and the results need to be confirmed in a larger sample.

Originality/value
This is the first report of use of interactive verbal prompting technology to support rehabilitation of a motivational task. It is also the first study to evaluate Guide in a domestic context.

Full text

Social Care and Neurodisability
Emerald Article: Automated prompting technologies in rehabilitation and at
home
Brian O'Neill, Catherine Best, Alex Gillespie, Lauren O'Neill
Article information:
To cite this document: Brian O'Neill, Catherine Best, Alex Gillespie, Lauren O'Neill, (2013),"Automated prompting technologies in
rehabilitation and at home", Social Care and Neurodisability, Vol. 4 Iss: 1 pp. 17 - 28
Permanent link to this document:
http://dx.doi.org/10.1108/20420911311302281
Downloaded on: 04-02-2013
References: This document contains references to 20 other documents
To copy this document: permissions@emeraldinsight.com
Access to this document was granted through an Emerald subscription provided by Emerald Author Access
For Authors:
If you would like to write for this, or any other Emerald publication, then please use our Emerald for Authors service.
Information about how to choose which publication to write for and submission guidelines are available for all. Please visit
www.emeraldinsight.com/authors for more information.
About Emerald www.emeraldinsight.com
With over forty years' experience, Emerald Group Publishing is a leading independent publisher of global research with impact in
business, society, public policy and education. In total, Emerald publishes over 275 journals and more than 130 book series, as
well as an extensive range of online products and services. Emerald is both COUNTER 3 and TRANSFER compliant. The organization is
a partner of the Committee on Publication Ethics (COPE) and also works with Portico and the LOCKSS initiative for digital archive
preservation. *Related content and download information correct at time of download.

Automated prompting technologies
in rehabilitation and at home
Brian O’Neill, Catherine Best, Alex Gillespie and Lauren O’Neill
Abstract
Purpose – The purpose of this paper is to test the efficacy of an interactive verbal prompting technology
(Guide) on supporting the morning routine. Data have already established the efficacy of such
prompting during procedural tasks, but the efficacy of such prompting in tasks with procedural and
motivational elements remains unexamined. Such tasks, such as getting out of bed in the morning and
engaging in personal care, are often the focus of rehabilitation goals.
Design/methodology/approach – A single-n study with a male (age 61) who had severe cognitive
impairment and was having trouble completing the morning routine. An A 2B2A02B02A00 2B00
design was used, with the intervention phase occurring both in an in-patient unit (B, B0) and in the
participant’s own home (B00).
Findings – Interactive verbal prompting technology (Guide) significantly reduced support worker
prompting and number of errors in the in-patient setting and in the participant’s own home.
Research limitations/implications – The results suggest that interactive verbal prompting can be
used to support motivational tasks such as getting out of bed and the morning routine. This study used a
single subject experimental design and the results need to be confirmed in a larger sample.
Originality/value – This is the first report of use of interactive verbal prompting technology to support
rehabilitation of a motivational task. It is also the first study to evaluate Guide in a domestic context.
Keywords Aids for the disabled, Rehabilitation, Interactive audio, Automated prompting technology,
Interactive verbal prompting technology, Guide
Paper type Case study
Introduction
Cognitive impairment mediates disability in conditions where brain function is impaired.
According to the international classification of functioning (ICF; World Health Organization
(WHO, 2002)), higher level cognitive functions, or executive functions, underpin goal-oriented
behaviours,such as abstraction, planning, timemanagement, cognitive flexibility, sequencing,
problem solving and judgement. Deficits of higher level cognitive functions are often
catastrophically disabling (Oddy and Worthington, 2009) and thus require costly carer input.
ATC is the use of technology to extend or augment mental functions, with particular
application meeting the needs of people with cognitive impairment. The use of technology to
extend human abilities is universal. Bows extend the ability to launch projectiles; knives
augment the ability to bite and tear. It can be argued that the peculiar facility for the selection
and assimilation of technology defines humanity (Aunger, 2010; Clark, 2003). In recent
times, digital technology has matured to be sufficiently portable and capacious to further
extend human cognitive function. Smart mobile phones support both communication across
distances and prospective memory through reminders and calendar functions. Despite their
ubiquity these tools have not been widely used by the people who have the most to gain,
that is, people with impairment to their cognitive function. The learning and memory burden
involved the use of early digital technologies is changing, with simpler more intuitive
DOI 10.1108/20420911311302281 VOL. 4 NO. 1 2013, pp. 17-28, QEmerald Group Publishing Limited, ISSN 2042-0919
j
SOCIAL CARE AND NEURODISABILITY
j
PAGE 17
Brian O’Neill is based at the
Brain Injury Rehabilitation
Trust, Glasgow, UK.
Catherine Best is based at
the Department of
Psychology, University of
Stirling, Stirling, UK.
Alex Gillespie is based at
the London School of
Economics, London, UK.
Lauren O’Neill is based at
the Brain Injury
Rehabilitation Trust,
Glasgow, UK.
This work was, in part, possible
by Grant CZH/4/598 of the
Chief Scientist Office of Health
Service Directorate of the
Scottish Government which is
funding a randomised control
trial of the technology. This trial
is hosted by the Brain Injury
Rehabilitation Trust and the
authors are grateful to all staff
who have contributed to the
project. The authors are grateful
to Mr M for trialling the system
and to his family in supporting a
trial home installation. Guide is
a prototype system and is not
commercially available.

interfaces being developed. There is currently a burgeoning interest in the field of ATC, as
reviewed in Gillespie et al. (2012). ATC is promising in its development of compensatory
technologies to augment existing or preserved cognitive abilities and has potential to reduce
disability and dependence. The portable or ambient technology can be thought of a
prosthesis or replacement for the specific impaired cognitive function (Cole, 1999).
Gillespie et al. (2012) found that a large proportion of ATC have been used to assist with time
management (33 studies of 91 included studies) and organisation and planning (25 studies
of 91). These domains are highly relevant to activities of daily living.
Time management functions are prospective memory functions that ensure that one
behaviour stops and another begins at a specific time. For example, reminding the user to
leave to go to a doctor’s appointment at a specific time. Time management is the most
common ICF specific mental function targeted by ATC. The largest study in the ATC field is the
Neuropage randomised controlled trial (Wilson et al., 2001), n¼143, which demonstrated the
efficacy of using a paging system to deliver reminders for the performance of everyday tasks
in people with cognitive impairments. The efficacy of pagers to perform this function has also
been demonstrated (Kirsch et al., 2004). Other media have also used text or auditory prompts
to overcome prospective memory difficulties. Voice recorders with a timer function (van den
Broek et al., 2000); text messaging to mobile phones (Pijnenborg et al., 2007); voice
messages to phones (Leirer et al., 1991); smartphone reminders (Svoboda and Richards,
2009) or schedule management software on a palmtop computer (Kim et al., 2000) or PDA
(Davies et al., 2002) also have demonstrated efficacy. We would conclude that proof of
concept is established and that for those with specific prospective memory difficulties,
unidirectional text and recorded prompts to mobile devices are effective interventions.
Difficulty monitoring one’s behaviour can lead to problems performing complex sequences.
Successful sequence performance requires active maintenance of the goal state, most
recent step, correct next step and solutions to problems arising. In contrast with the large
number of studies with the aim of supporting organisation and planning functions, there have
been only a limited number of ATCs developed which provide step-by-step support during
task performance.
Lancioni et al. (2000) developed the VICAID system to be used by people with intellectual
disability to guide them through domestic and vocational tasks. The VICAID system is a palm
top computer with a simplified user interface consisting of a single button, providing visual
and auditory prompts through tasks. Users provide feedback to the system by pressing the
button. VICAID also rewards successful task completion through feedback to the user.
Mihailidis et al. (2008) developed the COACH system to prompt users with dementia through
processes such as hand washing. The latest version of the device uses a camera to capture
visual data on the position of the users’ hands to enable the system to be context aware of
the user’s progress through the task and thus select the appropriate auditory prompt.
The Guide system aims to emulate the verbal support provided by carers (O’Neill and
Gillespie, 2008). Guide provides verbal prompts to orient users to sub-steps, remind users to
perform various checks, and work with users to resolve problems. Users respond to the
prompts using the simple verbal responses of ‘‘yes’’ and ‘‘no.’’ When loaded with a protocol
mapping the action pathway and common problems, Guide is an expert system able to deal
with problems that might arise. The system sequences the task for users in terms of sub-steps,
and for each sub-step, a series of questions are asked. Affirmative responses lead to the next
question or sub-step. Negative responses lead to problem solving sub-routines. Thus,
relatively able users can move quickly through the protocol, while less able users receive more
guidance. The contribution is in the close simulation of carer scaffolding of task performance.
The auditory-verbal interface emulates conversational interaction; does not distract the user’s
visual attention from the task and can resolve commonly arising problems. Guide prevents
errors because it prompts users before each action and thus implements an errorless
learning approach.
O’Neill et al. (2010) examined the use of Guide to aid a complex rehabilitation sequence
(donning a prosthetic limb) in a sample of eight older adults with cognitive impairment of
PAGE 18
j
SOCIAL CARE AND NEURODISABILITY
j
VOL. 4 NO. 1 2013

vascular origin. The system significantly reduced safety critical errors and increased the
accuracy of the rehabilitation relevant sequence. A key outstanding question was the extent
to which Guide generalises to other tasks with different structure. For example, donning a
prosthetic limb is mainly a procedural task, but would Guide also be able to support tasks
which have a larger motivational component? Accordingly, the current study presents data
on the effectiveness of Guide to support the morning routine, a complex sequence with both
procedural and motivational aspects. Guide has previously demonstrated efficacy in an in
patient/hospital setting with persons aiming to learn a rehabilitation task. This study also
examines whether Guide can be an effective support for independence in the less
structured setting of the participants own home post-discharge.
Methodology
Settings
BA neurobehavioural assessment and rehabilitation unit specialised in the care of persons
with complex needs after brain injury.
BService user’s home.
Design
A single participant A 2B2A02B02A00 2B00 design (Table I) was used to assess the
effectiveness of Guide to support the morning routine of a gentleman with one-year history of
severe haemorrhagic brain injury.
Outcome variables were number of errors made in the sequence and number of
interventions required by rehabilitation support workers to ensure sequence performance.
Following discharge his performance with and without Guide was also assessed via ratings
made by a family member. Thus, the usability and effectiveness in a domestic context was
also assessed.
Participant
Mr M is a 61-year-old single retired electrician. He had one adult daughter who was not a
dependent. He was found unconscious at his home after a presumed collapse. Admission
Glasgow Coma Scale was 3/15 and brain imaging revealed a right intracerebral
haemorrhage affecting the territory of the caudate nucleus and extending into the third
and fourth ventricles. Hydrocephalus and midline shift led to the insertion of an extra
ventricular drain. Initial GCS and duration of PTA placed him in an extremely severe category
of brain injury.
Mr M was admitted to a neurorehabilitation centre at ten-weeks post-injury.
Neuropsychological report at 14 weeks indicated that he had severe impairment of
memory, executive function and visual perception. Impairment of verbal recall of information
was associated with judgement difficulties. He lacked capacity to make legal or financial
decisions as a result. He did not exhibit challenging behaviour and his mood was euthymic
for the most part. Some anxiety was apparent if disoriented to place. Anxiety was also
Table I Morning routine performance by phase
Setting Phase
Total no. of
days
Data
points
Mean morning checklist
score (SD)
Days fully
independent (%)
Mean error score
(SD)
In-patient Baseline-A 30 28 4.49 (0.28) 1 (3.57) 1.04 (1.23)
Intervention-B 31 12 4.75 (0.04) 6 (50) 0 (0)
Return to
baseline-A0
4 3 4.58 (0.72) 2 (66.67) 0.33 (0.58)
Intervention-B020 11 4.94 (0.13) 8 (72.7) 0.09 (0.30)
Home Baseline-A00 6 6 4.43 (0.78) 0 (0) 1.67 (1.75)
Intervention-B00 14 11 4.8 (0.19) 2 (18.18) 1.36 (0.67)
VOL. 4 NO. 1 2013
j
SOCIAL CARE AND NEURODISABILITY
j
PAGE 19

thought to have had a negative bearing on his sleep pattern and he required zopiclone to
aid sleep onset. There was no evidence of significantly altered personality or current
mood issues.
Medication remained constant throughout the trial and comprised: amlodipine, ramipril,
ibuprofen, trazodone, co-codamol, lactulose, zopiclone, omeprazole, and eumovate.
Mr M was referred to the current project as he was identified by his occupational therapist
staff as having difficulty performing his morning routine, improved by the verbal prompts of
rehabilitation support workers.
Materials
Dell, Precision M4500 laptop.
Guide software loaded with morning routine protocol (Appendix 1).
Acoustic Magic, Voicetracker2 array microphone.
Creative, Inspire T10 speakers.
Morning checklist (Appendix 2) – rating measure designed to quantify performance of
morning personal care routine.
Procedure
Mr M was assessed by his occupational therapist who noted omissions of parts of the
morning routine in the context of verbal report that he had completed those steps. The
morning checklist (Appendix 2) was then introduced, to be completed by Rehabilitation
Support Workers each morning. The observer rated the steps in the sequence as follows:
completes step independently (five points); completes step after 1 verbal prompt (4);
completes step after 2 verbal prompts (3); completes step after 3 verbal prompts (2);
requires physical intervention/assistance to start, continue or complete step (1); refuses to
complete step (zero points). Only prompts by human carers were scored, prompts by the
assistive technology (Guide) were not.
Following each morning routine performance in both baseline and intervention, the
participant was asked to rate ‘‘how well did that go?’’ along a five-point Likert scale from
5 ‘‘very well’’ to ‘‘1 very poorly’’. This was with the aim of tapping into his perspective on his
own behavioural performance and the support that he received.
Suitability for a trial of Guide was decided by the occupational therapist. The functionally
defined inclusion criteria were that he was able to carry out sequences without errors or
omissions when given verbal prompts by the Rehabilitation Support Workers, but omitted
steps when acting independently.
After a baseline (A) period of six weeks, giving 28 datapoints, Guide was installed in his
bedroom to automatically activate at 8am and continue until morning routine was complete.
The Guide was activated and data was recorded only on week days (Monday to Friday).
The voice used in Guide was female (CB) and familiar to Mr M. There were 12 datapoints in
the intervention period three weeks and some missing datapoints. Rehabilitation Support
Workers continued ratings in the Guide intervention (B) period Guide was in use. They were
asked to prompt if there was a safety critical error or omission of an important sub-step.
The Guide was inadvertently switched off after week 6 of the intervention leading to a de
facto return to baseline inpatient phase of four days (A0– three data points). Guide was then
reactivated and a second inpatient intervention phase of four weeks (B0211 data points)
took place.
Following agreement from the multidisciplinary team and community support agencies, Mr M
was discharged to his own home (29 June 2012). In this domestic situation the morning
routine performance was assessed using the morning checklist, completed by Mr M’s sister.
Rightful assertion of privacy and variable visiting times meant that direct observations were
not possible as in the rehabilitation centre.
PAGE 20
j
SOCIAL CARE AND NEURODISABILITY
j
VOL. 4 NO. 1 2013

The domestic install had a baseline of six data points and an intervention phase of 11 data
points. Findings are reported under in-patient and home headings.
Data analysis
The single case study data were analysed using the non-overlap all pairs (NAP) method
(Parker and Vannest, 2009; Parker et al., 2011). NAP represents a new application of
established statistical methods, known variously as area under the curve, Mann Whitney’s
U and dominance statistics, to single subject designs. NAP has been demonstrated to be
superior to other non-overlap techniques in its precision, discrimination and relationship to
established effect size measures such as R
2
(Parker and Vannest, 2009). An assumption of
the method is that there is no underlying trend in the baseline data. The Mann Kendall test of
trend (Onoz and Bayazit, 2003) was non-significant p.0.05 (two tailed) for the baseline
period. To further explore stability we also examined the regression equations for
the baseline data. A cubic equation had a higher R
2
(0.168) and accounted for more of the
variance than the linear model. This indicated that baseline scores fluctuated rather than
gradually improved. Parker and Vannest (2009) give approximate values for evaluating
effect sizes based on the NAP statistic: weak effects 0-0.65, medium effects 0.66-0.92, large
or strong effects 0.93-1.0.
Findings
In-patient
During the first intervention phase the morning checklist score was significantly increased in
comparison with baseline (NAP¼0.754). This represents a medium effect size (Parker and
Vannest, 2009). This indicates that the number of prompts given by support staff significantly
decreased in the first intervention phase. In the B0phase the participant approached perfect
performance (4.94/5.00).
The participant was rated to have completed all the steps without prompt only once in the
baseline period (3.6 percent) and completed the sequence independently six times out of
12 datapoints (50 percent) during the first intervention period. Visual presentation of these
changes in performance can be shown in Figure 1. Given the short duration of the return to
baseline phase (A0¼3 data points) comparisons-based solely on this data are likely to lack
statistical power. If however the inpatient data are combined, comparing all inpatient
intervention data (B þB0) to all inpatient control data (A þA0) gives a NAP statistic of 0.
804 (a medium effect size (Parker and Vannest, 2009)).
Figure 1 Morning checklist score by phase
5
4
3
2In-patient Home
Intervention
Rehabilitation as usual
Guide
Mean prompt score
1
0
16-Nov-11
18-Nov-11
22-Nov-11
24-Nov-11
28-Nov-11
30-Nov-11
02-Dec-11
06-Dec-11
08-Dec-11
14-Dec-11
16-Dec-11
20-Dec-11
22-Dec-11
20-Apr-12
02-May-12
09-May-12
16-May-12
21-May-12
28-May-12
30-May-12
04-Jun-12
11-Jun-12
18-Jun-12
20-Jun-12
25-Jun-12
28-Jun-12
03-Jul-12
05-Jul-12
09-Jul-12
11-Jul-12
16-Jul-12
18-Jul-12
20-Jul-12
25-Jul-12
14-Nov-11
Date
VOL. 4 NO. 1 2013
j
SOCIAL CARE AND NEURODISABILITY
j
PAGE 21

Sequence performance errors were significantly reduced during intervention phase
(Figure 2). The participant made on average 1.04 (standard deviation 1.23) errors in
baseline (A) and an average of 0 (SD ¼0) in the first intervention (B) phase. This indicates that,
for this participant, Guide use reduced errors to near zero. During the intervention period in the
rehabilitation centre, there did not appear to be a habituation effect such that performance
was constant throughout the intervention period, dipping only on return to baseline.
Home
This pattern of improvement was also apparent at home. The NAP (A00 2B00 )¼0.74, medium
effect size (Parker and Vannest, 2009) indicating a significant improvement in morning
checklist ratings from baseline and intervention conditions (A00 2B00). Figure1 shows both
in-patient and home prompt scores.
On returning home without Guide (A00) there was an increase in the error score to an average
of 1.67 (SD 1.75). This resolved once Guide was activated (average B00 ¼1.36 SD 0.67) but
error rates were not reduced to zero, at least in the first-ten days. This may have been an
artefact of difference in observers or due to the change of environment.
In the inpatient baseline phase (A) the participant made errors of: getting up and going
straight back to bed, hesitating during sequence, not being able to find clothes that are in the
room, and not getting all the clothes ready to be fully dressed. After discharge (A00) the more
frequent errors were: not getting all clothes to be fully dressed, wearing dirty or mismatched
clothes, forgetting to pick up phone/GPS and inappropriate clothes for the weather.
Personal preference. The mean rating of how the morning routine went was 4.5 in the
baseline phase and 4.33 in the intervention phase (non-significant). Both mean scores of
satisfaction lay in the range between ‘‘very well’ ’ and ‘‘quite well’’. Mr M did not have a clear
preference for either support. There was a slight anomaly in these findings as Mr M reported
not wishing to have rehabilitation support workers support him on several occasions.
Implications
The prompting technology, Guide, reduced the participants errors to near zero in the
intervention phase of the study and led to ratings of ‘‘independent’’ on half of intervention
trials. This trial thus evidences that Guide can emulate the supportive action of carers in the
performance of a complex ADL sequence.
Figure 2 Performance errors by phase
5
4
3
2
Inpatient Home
Intervention
Rehabilitation as usual
Guide
Total errors
1
0
16-Nov-11
18-Nov-11
22-Nov-11
24-Nov-11
28-Nov-11
30-Nov-11
02-Dec-11
06-Dec-11
08-Dec-11
12-Dec-11
14-Dec-11
16-Dec-11
20-Dec-11
22-Dec-11
18-Apr-12
20-Apr-12
24-Apr-12
26-Apr-12
30-Apr-12
02-May-12
04-May-12
08-May-12
10-May-12
14-May-12
16-May-12
18-May-12
22-May-12
24-May-12
28-May-12
30-May-12
01-Jun-12
05-Jun-12
07-Jun-12
11-Jun-12
13-Jun-12
15-Jun-12
19-Jun-12
21-Jun-12
25-Jun-12
27-Jun-12
29-Jun-12
03-Jul-12
05-Jul-12
09-Jul-12
11-Jul-12
13-Jul-12
17-Jul-12
19-Jul-12
23-Jul-12
27-Jul-12
25-Jul-12
14-Nov-11
Date
PAGE 22
j
SOCIAL CARE AND NEURODISABILITY
j
VOL. 4 NO. 1 2013

The implications for practice of the use of this technology encompass the augmentation of
rehabilitation, facilitating discharge and home support. In terms of its use a rehabilitation
tool, Guide might augment the amount of prompting support for a specific routine without
increasing demands on staff. Rehabilitation support workers might then be freed to
address the emotional and motivational needs of those not-responding to automated
prompting.
Many service users object to being observed and prompted. The use of an automated,
non-judgemental and emotionally neutral prompter may be preferable to those who find the
interpersonal act of being prompted noxious (O’Neill and Gillespie, 2008; LoPresti et al.,
2004). Such technologies might therefore increase the user’s independence in ADL
sequences such as the morning routine.
The technology may aid in the transition from rehabilitation centre to home. For example,
if the person can carry out the sequence with prompting support, then Guide or a context
aware prompter may function as a cognitive prosthetic and allow that person to be
independent. Self-neglect is a common consequence of cognitive impairments. This
case study raises the intriguing possibility that tendency to omit personal care regimens
may be offset by context aware prompters.
Context aware prompting technologies are novel but are gaining an evidence base for their
effectiveness to support independent activity. There are no commercially available auditory
verbal context aware prompting systems.
There are limitations to the design reported. The participant was previously interested in
technologies and may have been more compliant as a result. He was also perhaps
motivated by a wish to be discharged to his own home.
Contemporary single nexperimental designs also include a variable which is not expected
to change in response to the intervention, omitted from this experimental design.
Increases in error rates and decreases in prompt score ratings of independence occurred
on return home and baseline. The transition to home was prepared for by many supported
visits and overnight passes. However, the emotional and cognitive demands of operating in
a new environment may have acted to increase errors.
Future studies might confirm these findings outside of the originating research group who
are currently recruiting for a randomised control trial due to report in 2014. Single nor case
control methodologies would be suitable and Guide software would be available to such
investigators.
References
Aunger, R. (2010), ‘‘Types of technology’’, Technological Forecasting and Social Change, Vol. 77 No. 5,
pp. 762-82.
Clarke, A. (2003), Natural-Born Cyborgs: Minds, Technologies, and the Future of Human Intelligence,
Oxford University Press, Oxford.
Cole, E. (1999), ‘‘Cognitive prosthetics: an overview to a method of treatment’’, NeuroRehabilitation,
Vol. 12, pp. 39-51.
Davies, D.K., Stock, S.E. and Wehmeyer, M.L. (2002), ‘‘Enhancing independent task performance for
individuals with mental retardation through use of a handheld self-directed visual and audio prompting
system’’, Education & Training in Mental Retardation and Developmental Disabilities, Vol. 37 No. 2,
pp. 209-18.
Gillespie, A., Best, C. and O’Neill, B. (2012), ‘‘Cognitive function and assistive technology for cognition:
a systematic review’’, Journal of the International Neuropsychological Society, Vol. 18 No. 1, pp. 1-19.
Kim, H.J., Burke, D.T., Dowds, M.M. Jr, Boone, K.A.R. and Park, G.J. (2000), ‘‘Electronic memory aids
for outpatient brain injury: follow-up findings’’, Brain Injury, Vol. 14 No. 2, pp. 187-96.
Kirsch, N.L., Shenton, M. and Rowan, J. (2004), ‘‘A generic, ‘in-house’, alphanumeric paging system for
prospective activity impairments after traumatic brain injury’’, Brain Injury, Vol. 18 No. 7, pp. 725-34.
VOL. 4 NO. 1 2013
j
SOCIAL CARE AND NEURODISABILITY
j
PAGE 23

Lancioni, G.E., O’Reilly, M.F., Seedhouse, P., Furniss, F. and Cunha, B. (2000), ‘‘Promoting independent
task performance by persons with severe developmental disabilities through a new computer-aided
system’’, Behavior Modification, Vol. 24 No. 5, pp. 700-18.
Leirer, V.O., Morrow, D.G., Tanke, E.D. andPariante, G.M. (1991), ‘ ‘Elders’ nonadherence:its assessment
and medication reminding by voice mail’’, The Gerontologist, Vol. 31 No. 4, pp. 514-20.
LoPresti, E.F., Mihailidis, A. and Kirsch, N. (2004), ‘‘Assistive technology for cognitive rehabilitation: state
of the art’’, Neuropsychological Rehabilitation, Vol. 14 Nos 1/2, pp. 5-39.
Mihailidis, A., Boger, J., Craig, T. and Hoey, J. (2008), ‘‘The COACH prompting system to assist older
adults with dementia through handwashing: an efficacy study’’, BMC Geriatrics, Vol. 8, p. 28.
Oddy, M. and Worthington, A. (2009), The Rehabilitation of Executive Disorders: A Guide to Theory and
Practice, Oxford University Press, Oxford.
Parker, R.I. and Vannest, K. (2009), ‘‘An improved effect size for single n research: non-overlap of all
pairs’’, Behavior Therapy, Vol. 40 No. 4, pp. 357-67.
Parker, R.I., Vannest, K.J. and Davis, J.L. (2011), ‘‘Effect size in single-case research: a review of nine
nonoverlap techniques’’, Behavior Modification, Vol. 35 No. 4, pp. 303-22.
Pijnenborg, G.H.M., Withaar, F.K., Evans, J.J., van den Bosch, R.J. and Brouwer, W.H. (2007), ‘‘SMS text
messages as a prosthetic aid in the cognitive rehabilitation of schizophrenia’’, Rehabilitation
Psychology, Vol. 52 No. 2, pp. 236-40.
Svoboda, E. and Richards, B. (2009), ‘‘Compensating for anterograde amnesia: a new training method
that capitalizes on emerging smartphone technologies’’, Journal of the International Neuropsychological
Society, Vol. 15 No. 4, pp. 629-38.
WHO (2002), Towards a Common Language for Functioning, Disability and Health (ICF), World Health
Organization, Geneva, available at: www.who.int/classifications/icf/training/icfbeginnersguide.pdf
(accessed 28 August 2012).
Wilson, B.A., Emslie, H.C., Quirk, K. and Evans, J.J. (2001), ‘‘Reducing everyday memory and planning
problems by means of a paging system: a randomised control crossover study’’, Journal of Neurology
Neurosurgery and Psychiatry, Vol. 70 No. 4, pp. 477-82.
van den Broek, M.D.V.D., Downes, J., Johnson, Z., Dayus, B. and Hilton, N. (2000), ‘‘Evaluation of an
electronic memory aid in the neuropsychological rehabilitation of prospective memory deficits’’,
Brain Injury, Vol. 14 No. 5, pp. 455-62.
Further reading
Mihailidis, A., Barbenel, J.C. and Fernie, G. (2004), ‘‘The efficacy of an intelligent cognitive orthosis to
facilitate handwashing by persons with moderate to severe dementia’’, Neuropsychological
Rehabilitation, Vol. 14, pp. 135-71.
Appendix 1. Morning routine protocol
P1. Good morning it is 8 o’clock... nearly time to get up (5-min break) – (Wake Up
Step)
P1.1: Good morning it is five past eight. Nearly time to get up and have some breakfast
(5 min).
P1.2 Morning soon it will be time to get up and have a shower before you go down for
breakfast (5 min).
P1.3 Ok now its time to get up (Get Up Step).
Q1.4 Have you got out of bed yet? N & NR ¼Q1.5 Y ¼P3.
Q1.5: Are you tired? Would you like five more minutes to wake up? Y & NR ¼P1.6,
N¼Q1.8.
P1.6 Ok (5 min).
PAGE 24
j
SOCIAL CARE AND NEURODISABILITY
j
VOL. 4 NO. 1 2013

P1.7 Its now 20 past eight time to get up. Q1.9.
P1.8 Then its time to get up.
Q1.9 Have you got out of bed? Y ¼P3, N & NR ¼Q2.
Q2 Would you like to have some breakfast? Y ¼Q2.1 N ¼Q2.3.
P2.1 If you get up now you will be in time for breakfast.
Q2.2 Have you got out of bed now? Y ¼P3 N ¼Q2.6.
Q2.3 If you do not have breakfast do you get hungry before lunchtime? Y ¼Q2.3.1
N¼Q2.4.
Q2.3.1 Do you want to be up before breakfast finishes? Y ¼P2.1 N & NR ¼Q2.4.
Q2.4: Would you like some nice hot coffee? N & NR ¼Q2.5 Y ¼P2.4.1.
P2.4.1 Get up soon to make sure you are in time for coffee. Q2.2.
Q2.5 Do you like to get up independently? N & NR ¼P2.6 Y ¼P2.5.1.
P2.5.1 If you get up now you can show you can do it on your own.
P2.6 Its time to get out of bed.
Q2.7 Have you got out of bed? N & NR ¼P2.7 Y ¼P3.
P3 Ok before going down for breakfast you need to have a shower (Motivate Shower
Step).
Q3.1 Are you going to get into the shower now? N & NR ¼Q3.2 Y ¼P4.
Q3.2 Do you feel hot and sticky? Y ¼P3.2.2 N & NR ¼P3.2.1.
P3.2.1 Even if you do not feel too bad having a shower will make you feel fresh and clean.
Q3.3.
P3.2.2 Having a shower will make you feel fresh and clean.
Q3.3 Are you going to get into the shower? Y ¼P4 N & NR ¼Q3.4.
Q3.4 Do your friends and family think you keep yourself clean and tidy? Y ¼P3.4.1 N
&NR¼Q3.5.
P3.4.1 Having a shower will make sure that you look clean and fresh.
Q3.5 Are you someone who likes to look clean and presentable? Y ¼Q3.3 N ¼Q3.6.
Q3.6 Do you like to do things for yourself without anyone having to remind you?
N¼Q3.7 Y ¼P3.6.1.
P3.6.1 If you have a shower without prompting it will show you can do it yourself.
Q3.6.2 Are you going to have a shower now? N ¼Q3.7 Y ¼P4.
Q3.7 Do you want to move out of [residential home] to live somewhere more
independent? N ¼P3.8 Y ¼P3.7.1.
P3.7.1 Getting up and having a shower by yourself shows that you are ready to be more
independent.
P3.8 You need to have a shower before going down to the communal areas.
Q3.9 Are you going to have a shower?
P4. That is great. Now you need to get together everything you need for a shower
(Shower Things Step).
Q4.1 Have you got a towel? N ¼Q4.1.1 Y ¼4.2.
Q4.1.1 Is there a towel in your room? N ¼P4.1.2 Y ¼Q4.2.
P4.1.2 Then we need to get some help.
Q4.2 Have you got some shower gel? N ¼Q2.3 Y ¼P2.4.
VOL. 4 NO. 1 2013
j
SOCIAL CARE AND NEURODISABILITY
j
PAGE 25

Q2.3 Can you see some shower gel in the bathroom? N ¼P2.3.1 Y ¼P2.4.
P2.3.1 The take some soap with you into the shower.
Q2.4 Have you got some shampoo? Y ¼P2.5.
Q2.4.1 Can you see any shampoo in the bathroom? Y ¼P2.5 N ¼P2.4.2.
P2.4.2 Then use shower gel to wash your hair.
P2.4.3 Do not forget to put your night clothes into the laundry basket.
P2.5 Good. You are ready for your shower.
P3.1 Have you got out of the shower? N & NR ¼Q3.2 Y ¼Q5.3.
Q3.2 Are you out of the shower now? N & NR ¼Q3.1 Y ¼Q3.2.
P3.2 Good. Now you need to get yourself looking clean and smart for the day ahead
(Dry Off Step).
Q3.3 Have you shaved this morning? Y ¼Q3.5 N & NR ¼P3.4.
P3.4 You need to have a shave every day.
Q3.5 Are you going to have a shave now? Y ¼P3.6 N ¼Q3.9.
P3.6 Do not forget to use shaving foam and a new razor (5 min).
Q3.7 Have you finished your shave? N & NR ¼Q3.8 Y ¼Q3.9.
Q3.8 Have you finished shaving? N & NR ¼Q3.7 Y ¼Q3.9.
Q3.9 Have you cleaned your teeth? Y ¼P4.1 N ¼P3.9.1.
P3.9.1 Clean your teeth before you go down for breakfast (2 min).
P4.1 Before you get dressed you need to make sure you are completely dry.
Q4.2 Have you dried yourself all over? Y, N & NR ¼4.3.
Q4.3 Have you dried your back and your legs? N ¼P4.4 Y ¼4.5 NR ¼R.
P4.4 Make sure you dry yourself thoroughly.
Q4.5 Have you put on some deodorant? N & NR ¼P4.6 Y ¼P5.
P4.6 Put on some deodorant before getting dressed.
P5 Great. Now you need to think about what clothes to wear today (Choose Clothes
Step).
Q5.1 Do you need to look smart today? NR ¼Q5.2 Y &N ¼P5.3.
Q5.2 Have you got any meetings or are you going out somewhere? Y, N &NR ¼P5.3.
P5.3 Also think about the weather. Is it particularly cold or rainy today? Y, N
&NR ¼P5.4.
P5.4 Now choose some suitable clothes.
Q5.5 Do the clothes you have chosen match? Y ¼P6 N&NR ¼P5.51.
P5.5.1 Choose some clothes that look good together.
P6 Right. Now put on your clothes.
P7 Okay the next step is to check that you are ready for the day ahead (Ready For
Day Step).
Q6.1 Have you made your bed? N & NR ¼P6.1.1 Y ¼Q6.2.
P6.1.1 Then put the duvet straight.
Q6.2 Have you got your mobile phone? N & NR ¼P6.3.1 Y ¼Q6.7.
P6.3.1 Then take your mobile phone with you.
P7 That is great. You are all set for the day.
PAGE 26
j
SOCIAL CARE AND NEURODISABILITY
j
VOL. 4 NO. 1 2013

Appendix 2. Morning checklist
CLIENT NAME:__________________ W/C:_______________
Level of prompting
M T W T F S S
Wake up
Get out of bed
Use toilet
Wash hands
Go into shower
Shower: Wash upper half
Wash lower half
Wash hair
Brush teeth
Dry self
Shave: Wet/Dry
Use deodorant
Select appropriate clothes
Find clothes
Dress
Brush hair
Make bed
Medication prompt by staff Y/N
Picks up phone/keys/cigarettes
Rating of personal appearance
(out of 10)
Time up
Completed by:
5 = Completes step independently
4 = Completes step after 1 verbal prompt
3 = Completes step after 2 verbal prompts
2 = Completes step after 3 verbal prompts
1 = Requires physical intervention/assistance to start, continue or complete step
R = Refuses to complete step.
N/E = No evidence
N/A = Not appropriate (e.g. woman who does not shave)
Errors (circle Y/N)
M T W T F S S
Stays in bed until after 10am Y/N Y/N Y/N Y/N Y/N Y/N Y/N
Gets up but goes straight back to bed Y/N Y/N Y/N Y/N Y/N Y/N Y/N
Does not take towel to shower Y/N Y/N Y/N Y/N Y/N Y/N Y/N
Does not take soap/shower gel to shower Y/N Y/N Y/N Y/N Y/N Y/N Y/N
(continued)
VOL. 4 NO. 1 2013
j
SOCIAL CARE AND NEURODISABILITY
j
PAGE 27

Sequence errors
M T W T F S S
No of times repeats a step
No of steps missed
No of times stuck on a step
Time taken
M T W T F S S
Does not get all the clothes necessary to be fully
dressed
Y/N Y/N Y/N Y/N Y/N Y/N Y/N
Does not take shampoo Y/N Y/N Y/N Y/N Y/N Y/N
Cannot find an item of clothing that is in the room Y/N Y/N Y/N Y/N Y/N Y/N
Y/N
Y/N
Dresses when still wet Y/N Y/N Y/N Y/N Y/N Y/N Y/N
Y/N
Once out of bed hesitates for 3+ seconds Y/N Y/N Y/N Y/N Y/N Y/N
Inappropriate clothes chosen for weather Y/N Y/N Y/N Y/N Y/N Y/N Y/N
Dirty/mismatched clothes worn Y/N Y/N Y/N Y/N Y/N Y/N Y/N
Poor personal hygiene Y/N Y/N Y/N Y/N
Y/N
Y/N Y/N Y/N
Unshaven Y/N Y/N Y/N Y/N Y/N Y/N
Forgets phone/keys/cigarettes Y/N Y/N Y/N Y/N Y/N Y/N Y/N
PTO
Service user satisfaction (1-5)
How well did that go?
5 Very well 4 Quite well 3 Ok 2 Quite poorly 1 Very poorly
M T W T F S S
Rating
Corresponding author
Brian O’Neill can be contacted at: brian.oneill@thedtgroup.org
To purchase reprints of this article please e-mail: reprints@emeraldinsight.com
Or visit our web site for further details: www.emeraldinsight.com/reprints
PAGE 28
j
SOCIAL CARE AND NEURODISABILITY
j
VOL. 4 NO. 1 2013