(PDF) Safe and Sound: Soundscape research in special needs care

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Safe and Sound

Soundscape research in special needs care

Kirsten A. van den Bosch

1. The role of sound for people with severe or profound intellectual disabilities is to form a sense

of place, and to provide a basic sense of safety. [This dissertation]

2. People with severe or profound intellectual disabilities could offer a unique window on basic

human sound perception due to a reduced influence of higher cognitive (culturally biased)

processing. [This dissertation]

3. The detrimental effects of poor auditory environments on well-being and quality of life are

likely to be amplified in people with severe or profound intellectual disabilities. [This

dissertation]

4. The main objective in healthcare settings is to provide the best possible care, yet as long as the

auditory environment continues to be overlooked, this objective will not be realized. [This

dissertation]

5. Raising awareness among healthcare professionals is a necessary first step in improving the

auditory environments in residential facilities and daycare services. [This dissertation]

6. Healthcare professionals should have access to efficient tools by which they can document

and analyze the quality of (indoor) auditory environments. [This dissertation]

7. The simplest safety-relevant meaning attributable to soundscapes is of central importance in

understanding human perception of soundscapes. [This dissertation]

8. Moods serve as attitudes towards the world. [This dissertation]

9. “The weight of evidence in the literature is now sufficient for the first two dimensions of

calmness/pleasantness and activity/eventfulness to be regarded as a ‘standard’ model for the

perceptual dimensions of soundscapes.” – Davies and Murphy (2012)

10. Conducting interdisciplinary doctoral research across three academic faculties requires

formidable allotment of even more mental faculties.

11. “Unnecessary noise is the most cruel absence of care that can be inflicted on sick or well.” -

Florence Nightingale

12. “Het is de kunst om van geluidsoverlast een buurtfeest te maken.” – Loesje

Safe and Sound

Soundscape research in special needs care

Kirsten van den Bosch

This dissertation has been supported by The Netherlands Organization for

Health Research and Development under Grant 94308003(1), and the

Research School of Behavioral and Cognitive Neurosciences in Groningen.

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Safe and Sound

Soundscape research in special needs care

ISBN: 978-90-367-8144-2

ISBN: 978-90-367-8143-5 (electronic version)

NUR: 848

Cover design by David Oldenburger and Arryon Tijsma

Printed by GVO Drukkers en Vormgevers B.V.

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Safe and Sound

Soundscape research in special needs care

Proefschrift

ter verkrijging van de graad van doctor aan de

Rijksuniversiteit Groningen

op gezag van de

rector magnificus prof. dr. E. Sterken

en volgens besluit van het College voor Promoties.

De openbare verdediging zal plaatsvinden op

donderdag 29 oktober 2015 om 14.30 uur

door

Kirsten Anna-Marie van den Bosch

geboren op 8 februari 1988

te Rotterdam

Promotores

Prof. dr. C. Vlaskamp

Prof. dr. A.J.J.M. Ruijssenaars

Prof. dr. D. Başkent

Copromotor

Dr. T.C. Andringa

Beoordelingscommissie

Prof. dr. D. Botteldooren

Prof. dr. P.J.C.M. Embregts

Prof. dr. H.J.M. Janssen

Contents

Chapter One

Introduction

1

Chapter Two

The role of sound for people with severe or profound

intellectual and multiple disabilities

17

Chapter Three

What healthcare professionals know: Validating the

theoretical framework

29

Chapter Four

The relationship between soundscape quality

and core affect

41

Chapter Five

The relationship between soundscapes

and challenging behavior

63

Chapter Six

Soundscape sessions

81

Chapter Seven

Discussion

95

References

123

Summary

141

Samenvatting

147

Appendices

157

Publications

173

About the author

177

Acknowledgements

179

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“Unnecessary noise, then, is the most cruel absence of care

which can be inflicted either on sick or well.”

- Florence Nightingale, 1860 -

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Chapter One

Introduction

INTRODUCTION

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In her seminal work ‘Notes on Nursing: What it is and What it is Not’, Florence Nightingale

already understood and emphasized the deleterious effects of noise on both sick or well

individuals. However, with a strong focus on the visual domain in research, architecture, and

healthcare, the focus on sound in research on quality of life, despite Nightingale’s

conclusions, seems to have diminished. Although there is a well-established body of research

on the acute effects of noise, there is little knowledge about the effects of sound in long-term

healthcare settings, which holds in particular for special needs care. This dissertation explores

this issue, namely the role of sound in residential facilities and day care services for people

with severe or profound intellectual and multiple disabilities. It provides a theoretical

framework that allows for better understanding of soundscape and sound annoyance research,

guidelines on how to apply the theoretical framework and developed tools to this specific

population, and as such it substantiates Florence Nightingale’s insights.

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Severe or profound intellectual and multiple disabilities

In the DSM-5 (American Psychiatric Association, 2013), intellectual disabilities are defined

as neurodevelopmental disorders “with onset during the developmental period that includes both

intellectual and adaptive functioning deficits in conceptual, social, and practical domains.” This

entails prominent deficiencies in intellectual functions such as learning (from experience and

instruction), reasoning, judgment, and problem solving, as well as deficits in adaptive

functioning limiting independence, such as communication and social participation. The

severity of the intellectual disability is categorized based on adaptive functioning, determining

the level of support needed. Previously, this categorization was based on IQ scores and a

severe intellectual disability was associated with an IQ in the range of 40-25, and a profound

intellectual disability was characterized by an IQ not exceeding 25 points. However, IQ

measures are difficult to assess within this target group and the validity of these measures

drops towards the lower end of the IQ range (APA, 2013). Therefore, the APA adopted a

classification similar to that of the American Association on Intellectual and Developmental

Disabilities (AAIDD), which is based on the intensity of support needed. According to the

APA, people with severe intellectual disabilities require support for all daily activities and

constant supervision, and people with profound intellectual disabilities are dependent on

others for all aspects of daily physical care, health, and safety (APA, 2013). The AAIDD

makes a distinction between extensive support, which is often associated with a severe

intellectual disability, and pervasive support, associated with profound intellectual disabilities

(Schalock et al., 2010).

An intellectual disability as extensive as described above is predominantly caused by

genetic, congenital or acquired biological factors, leading to encephalopathies (disorders of

the brain) with implications for the entire central nervous system (Arvio & Sillanpää, 2003).

This explains the high comorbidity with other (motor, sensory, and psychiatric) disabilities,

characteristic for this target group. Most people with severe or profound intellectual

disabilities suffer from motor disabilities such as spastic quadriplegia, but also a high

prevalence of seizure disorders like epilepsy diminishes their freedom of movement and daily

functioning (Arvio & Sillanpää, 2003; Nakken & Vlaskamp, 2007). This group is described

as people with profound intellectual and multiple disabilities (PIMD), and is distinguished by

two defining key characteristics: a profound intellectual disability in combination with a

INTRODUCTION

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profound motor disability. These disabilities are often accompanied by additional severe or

profound secondary disabilities or impairments (Nakken & Vlaskamp, 2007).

Speech deficits are among the most prevalent related impairments (Arvio & Sillanpää,

2003) and most people with severe or profound intellectual disabilities function at the

preverbal stage of communication, indicating their spoken language is limited, and they can

only understand some simple instructions and gestures (APA, 2013; Goldbart, 1997).

Sensory impairments in all modalities are also common among these people. This includes

malfunctioning olfaction (smell) and gustation (taste) (Doty et al., 2002) and impaired tactile

and coetaneous senses (touch, pressure, temperature, and pain) (Oberlander, Gilbert,

Chambers, O’Donnell, & Craig, 1999). These sensory impairments are however often

overlooked and the assessment of these dysfunctions is extremely difficult, due to the limited

cognitive and communicative abilities of people with severe or profound intellectual

disabilities.

More obvious and notable sensory impairments include auditory and visual

disabilities. The prevalence of visual disabilities increases with the severity of the intellectual

disability, with an estimate of 70-85% of people with a profound intellectual disability

experiencing visual disorders, in most cases caused by impaired development of the visual

cortex in the occipital lobe (cortical blindness) (Evenhuis, Theunissen, Denkers, Verschuure,

& Kemme, 2001; Van Splunder, Stilma, Bernsen, & Evenhuis, 2006; Warburg, 2001;

Woodhouse, Griffiths, & Gedling, 2000). Auditory problems, although common, appear to

be less prevalent, with estimates between 30-80%, in people with PIMD (Evenhuis et al.,

2001; Meuwese-Jongejeugd et al., 2006).

The lower prevalence of hearing deficits compared to visual deficits in people with

severe or profound intellectual disabilities can be explained by a more prominent role of

(preserved) subcortical areas in hearing than in vision (Andringa & Lanser, 2013). Although

visual and auditory impairments seem hard to miss, they are still an “unnoticed, undiagnosed

and untreated problem” (Newsam, Walley, & McKie, 2010). Some studies estimate that up to

85% of ocular disorders and 63% of hearing loss remain unnoticed in people with intellectual

disabilities (Kerr et al., 2003; McCullough, Sludden, McKeown, & Kerr, 1996). Reasons for

this clinical failure include diminished communicative opportunities, assessment difficulties,

and diagnostic overshadowing, where behavioral manifestations indicative of sensory

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impairments are misattributed to the intellectual disability (Carvill, 2001; Evenhuis, Mul,

Lemaire, & de Wijs, 1997; Lennox, Diggens, & Ugoni, 1997).

The combination of intellectual and visual disabilities can cause the individual to be

more vulnerable to develop behavioral problems and psychiatric illnesses (Carvill, 2001) and

not surprisingly, sensory problems are associated with the onset of challenging behavior

(Poppes, Van der Putten, & Vlaskamp, 2010). Challenging behavior is a common problem

among people with an intellectual disability. The prevalence of psychiatric and behavioral

problems in this population is estimated at 30-50% (Došen, 2005), with an even higher

prevalence among people with PIMD (Poppes et al., 2010). Challenging behavior is defined

by Emerson et al. (2001) as culturally abnormal behavior of such intensity, frequency, and

duration that the physical safety of the person or others is endangered, or behavior that is

likely to lead to restrictions in the use of, or the denial of access to, communal facilities. In

literature, challenging behaviors are commonly divided into self-injurious behavior,

stereotypical behavior, and aggressive / destructive behavior (Rojahn, Matson, Lott,

Esbensen, & Smalls, 2001). In addition to the above types of challenging behavior, some

authors stress that withdrawn behavior may also be regarded as challenging behavior, given

its consequences. Withdrawn behavior is described as behavior in which the person fails to

make contact with the environment, which is especially frequent among people with PIMD

(Poppes et al., 2010).

All these different types of challenging behavior have a range of negative

consequences for the person involved. Examples are limited independence in general and

integration into the community, possible stigma’s, negative effects on learning and personal

development, and reduced participation in social activities (Lundqvist, 2013; Matson et al.,

2011). People with an intellectual disability who display challenging behavior are also more at

risk to be abused and neglected by their caretakers (Lowe et al., 2007). Challenging behavior

is thus a major problem for many people with an intellectual disability, not only because these

individuals literally damage themselves, but also because it limits opportunities to participate

in activities and to build or maintain relationships with others (Poppes et al., 2010).

Taken together, the combination and severity of their disabilities entails that people

with severe or profound intellectual disabilities make up an incredibly heterogeneous group,

characterized by a high degree of vulnerability and lack of autonomy, with a great dependence

on others for the gratification of their daily needs (Nakken & Vlaskamp, 2007). The

INTRODUCTION

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participating individuals with intellectual disabilities included in this dissertation, all have in

common that they are in need of pervasive support. They all are diagnosed with either a

severe or profound intellectual disability (according to the old classification of the DSM-IV-

TR [APA, 2000]), and suffer from severe visual impairments or display grave challenging

behavior, by which intensive supervision is required.

The effects of noise on well-being

Since there is hardly any information available on the effects of noise on people with severe or

profound intellectual disabilities, we will examine literature concerning people without

disabilities as a starting point of our investigation. Research on the effects of noise on the

well-being of non-disabled people indicates that the sound in our environment plays an

important role in physical and psychological well-being. Noise is commonly defined as loud

or unwanted sound that causes disturbance. Recently, the World Health Organization (2011)

published a report, quantifying the amount of healthy life years lost to the effects of

environmental noise (in Europe). They studied the detrimental effects of noise in five

categories: cardiovascular disease, sleep disturbance, tinnitus, cognitive impairment in

children, and annoyance. All in all, it was calculated that every year at least 1 million healthy

life years are lost in Western Europe, due to traffic-related noise alone.

Cardiovascular diseases are one of the most studied adverse effects of noise exposure

and include, amongst others, hypertension, high blood pressure, ischaemic heart disease, and

myocardial infarction. Reviews of these studies (Ising & Kruppa, 2004; WHO, 2011) show

that most of these effects are conform to the noise-stress hypothesis, which states that noise

is a nonspecific stressor that activates the autonomic nervous system and endocrine system.

This stress response elicits changes in stress hormones such as cortisol and (nor)epinephrine,

affecting the individuals’ metabolism, and increasing the risk for cardiovascular diseases.

These effects seem to occur above noise levels around 65 dB(A) (Babisch, 2002; Ising &

Kruppa, 2004). Forasmuch as intellectual and related disabilities are caused by a damaged or

underdeveloped cortex, it could be assumed that the autonomic nervous system is essentially

still functional. Therefore, there is no reason to believe that these noise induced and stress

related symptoms would not occur in people with severe or profound intellectual disabilities.

CHAPTER ONE

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Sound has the power to wake us up when we sleep, and therefore it can contribute to

sleep disturbances. Ample undisturbed sleep is fundamental in maintaining and restoring

good health, performance, and well-being (Banks & Dinges, 2007; Colten & Altevogt,

2006). Consequently, noise can have a full array of short- to long-term effects on sleep,

ranging from awakening during the night, sleepiness during the day, to chronic insomnia

(WHO, 2011). Sound can wake us up because it is partly processed subcortically. The first

and fastest signal detection is mediated by the amygdala, which induces the release of stress

hormones when a sound is categorized as potentially dangerous (Ising & Kruppa, 2004). It is

therefore no surprise that disrupted sleep is associated with heart rate elevations, increased

risk of cardiovascular and coronary diseases, and impaired immune function (Buxton et al.,

2012).

Even at relatively low sound levels, elevated levels of stress hormones can be measured

(Evans, Bullinger, & Hygge, 1998), and long-term exposure to noise during the night could

lead to permanently increased cortisol levels (Mashke, Harder, Ising, Hecht, & Thierfelder,

2002). From research on sleep disruptions in hospitals it became clear that the probability of

disruptions in sleep increases when the sounds one is exposed to become louder, that

electronic sounds are more alarming than other sounds, and that continuous sounds induce

less arousal than non-continuous sounds. However, conversations amongst the personnel

were also found to be highly alerting (Buxton et al., 2012). For people with severe or

profound intellectual disabilities, who often experience trouble sleeping and therefore take

naps during the day, it could mean that their sleep is considerably disturbed by all the sounds

in their environment, with all kinds of detrimental health effects as a result.

Tinnitus is the experience of hearing sound, when there is no actual external stimulus,

and is often described as ringing in the ears. Tinnitus is known to induce stress, sometimes

leading to sleep problems, depression, anxiety, and many more adverse effects. There is a

strong relation between noise exposure and tinnitus, with 50-90% of patients who experience

chronic noise trauma reporting tinnitus (WHO, 2011), and noise-induced hearing loss is

thus one of the most common causes of tinnitus (Han, Lee, Kim, Lim, & Shin, 2009). This

gives reason to believe that people with severe or profound intellectual disabilities could also

suffer from tinnitus. However, since tinnitus is only diagnosable via self-report, it is extremely

difficult to reliably assess within this target group.

INTRODUCTION

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Cognitive impairment in children relates to the extent to which noise hinders their

cognitive capacities. It seems that noise has a greater impact on children than adults (Klatte,

Hellbrück, Seidel, & Leistner, 2010) and considering that people with intellectual disabilities

are often described as functioning on a premature level, it could be valuable to look at

research on non-disabled children as opposed to adults. Children need better listening

conditions, or better signal-to-noise ratios, to recognize speech (Fallon, Trehub, &

Schneider, 2000). This is probably caused by the fact that they have less knowledge to

generate proper signal expectations to compensate for the degraded speech signal (Saija,

Akyürek, Andringa, & Başkent, 2014) and they have greater difficulty focusing attention.

Especially working memory seems to be sensitive to distractions caused by sound (Beaman,

2005). These effects count even more for children with special educational needs (Klatte et

al., 2010).

Unfavorable listening conditions are often the result of bad acoustic conditions, such

as long reverberation times. Reverberation is the persistence, through minimally attenuating

reflections, of a sound after it is produced. Because of the long reverberation, unwanted

sounds remain audible longer, they increase the noise level, and reduce speech intelligibility

effectively. This causes people to raise their voices to make themselves heard, causing even

more noise, a phenomenon known as the Lombard or café effect (Klatte et al., 2010; Lubman

& Sutherland, 2002; Whitlock & Dodd, 2008).

Even when speech is fully intelligible, bad acoustics require more cognitive resources

to decode the degraded signal, leading to an increased listening effort. In classrooms this

could lead to stress, fatigue, and annoyance, with a worsened atmosphere (Evans & Hygge,

2007) and less positive social relations between teachers and students as a result (Klatte et al.,

2010). Teachers in classrooms that have a long reverberation time are also known to report in

sick more often than colleagues teaching in classrooms with good acoustics (MacKenzie &

Airey, 1999).

Research indicates that prolonged noise in classrooms can even have adverse effects

on language acquisition and pre-reading skills (Maxwell & Evans, 2000), and on the

development of phonological working memory, which is essential for a child’s cognitive

development (Klatte et al., 2010). Studies on the effects of environmental (road traffic and

aircraft) noise on the performance of young children (7-11 years) also show deficits in long-

term memory and reading comprehension, recognition memory, and intentional and

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incidental memory (Hygge, Evans, & Bullinger, 2002; Lercher, Evans, & Meis, 2003

Stansfeld et al., 2005). Fortunately, the study by Hygge et al. (2002) gives reason to believe

that these effects can be reversed after the exposure ceases, with the cognitive capacities of the

participants returning to normal within 18 months. However, these results should be

interpreted with caution, since it is conceivable that a child who has been exposed to noise for

years on end could suffer from a permanent delay in development.

Considering that people with severe or profound intellectual disabilities already have

less cognitive capacity as defined by their intellectual disability and often experience sensory

impairments, it could very well be that the above described effects of noise on cognitive

functioning are exaggerated in these people. Especially when the amplified effects of noise on

the functioning of children as compared to adults are considered. Together with the increased

risk of cardiovascular diseases due to stress, and the role of noise in sleep disturbances, it

could be that noise serves as an important harmful factor in the well-being of people with

severe or profound intellectual disabilities.

Soundscape research

Annoyance is the last category of detrimental effects of noise that is addressed in the report

from the World Health Organization (2011). The WHO reports that people who experience

sound annoyance suffer from various consequences, such as helplessness, depression, anger,

anxiety, agitation, dissatisfaction or disappointment (Fields et al., 2001; Job, 1993). These

adverse effects indicate a qualitative difference compared to the physiological effects such as

cardiovascular disease or sleep disturbance. Annoyance seems to be a psychological, or

emotional, response to sound.

Sounds can evoke all kinds of emotional reactions, from positive to negative (Bradley

& Lang, 1999). These reactions depend mainly on the meaning people give to the sounds,

and less so on the acoustical characteristics of the sound. This meaning arises from the

interactions between the listener, the sound source, and the context of the situation

(Tajadura-Jiménez, 2008). Traditionally, research on noise was focused on acoustic

parameters such as loudness in decibels, dB(A), or reverberation time, as discussed above.

However, it appears that merely one third of noise disturbance can be accounted for by

INTRODUCTION

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acoustics alone (Guski, 2001), and a growing body of research indicates that it is not the

physical properties of sound, but the message conveyed within the sound (the meaning

people attribute to the sound) that has the largest effect on health effects caused by noise

(Ising & Kruppa, 2004). Some experimental studies endorse the hypothesis that sounds are

unpleasant due to their intrinsic characteristics, or psychoacoustic properties, as opposed to

their intensity, or loudness (Neumann, Waters, & Westbury, 2008). It is even demonstrated

that qualitative unpleasant sounds can be experienced as more displeasing than electric shocks

or loud tones (Neumann & Waters, 2006) and that emotional sounds elicit greater

physiological responses (e.g. startle reflex, skin conductance) than neutral sounds of similar

loudness (Bradley & Lang, 2000). In real world settings it appears that an unwanted sound

obscuring more pleasant (safety-indicating) sounds is enough for it to be experienced as an

annoying intrusion (Andringa & Lanser, 2013). Similarly, the mere reduction of noise levels

does not always lead to more positive perceptions of that environment (Adams, Cox, Moore,

Croxford, Refaee, & Sharples, 2006; Dubois, Guastavino, & Raimbault, 2006); on the

contrary, it can even lead to anxiety (Stockfelt, 1991).

In this dissertation we will use the terms auditory environment and soundscape. An

auditory environment is the audible part of a sonic environment of a listener or group. Unlike

the sonic environment, the auditory environment implies a perceiver. The field of science that

considers the whole of the auditory environment, as it is appraised, is called soundscape

research. Essentially soundscape researchers acknowledge both positive and negative effects of

sound on the perceiver, and in doing so, the soundscape approach acknowledges a central role

for non-acoustic properties of sound. Soundscapes therefore represent more than just the

sound signal, but instead refer to “an environment of sound (sonic environment) with emphasis

on the way it is perceived and understood by the individual, or by a society. It thus depends on the

relationship between the individual and any such environment” (Schafer, 1977). Schafer

introduced two classes of soundscapes, high and low quality ones. A soundscape of high

quality (hi-fi) contains hardly any (constant) loud sounds and few mechanical sounds.

Because of this, there is little overlap between the foreground sounds, and the sounds from

the wider surroundings that can be heard. This allows for a distant sonic horizon and a high

signal-to-noise, or foreground-to-background, ratio. Low quality soundscapes (lo-fi) are

associated with an industrial, mechanized world and have sonic horizons that are much closer

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(Schafer, 1977). High quality soundscapes thus contain many meaningful sounds that often

match the nature of the environment.

Soundscape research goes beyond the focus on noise and its adverse effects on health,

but takes a more holistic approach, focusing on the (subjective and attributed) meaning in

sound (Botteldooren, De Coensel, & De Mur, 2006; Cain, Jennings, & Poxon, 2013;

Schulte-Fortkamp, 2002). The variance in emotional meaning appears to be largely explained

by two main factors, namely, pleasantness and arousal (Bradley & Lang, 2000). Similar

components have been found by Axelsson, Nilsson, and Berglund (2010) who studied how

people appraise auditory environments, and who developed a model to measure the quality of

soundscapes that we will use in this dissertation. The results of their study suggest that

soundscape perception can be described in terms of two main basic components: pleasantness

and eventfulness. Additionally, research by Cain, Jennings, and Poxon (2013) identified

calmness and vibrancy as two independent emotional dimensions of soundscapes and their

appraisal. These factors relate to the pleasantness and informational content of a soundscape.

For non-disabled people, an exciting soundscape is described as a combination of pleasant

and eventful, and oppositely a lifeless soundscape is unpleasant and uneventful. These

associations observed within groups may vary depending on the individual and may vary even

more for people with intellectual disabilities.

In general, it is argued by soundscape researchers that understanding the acoustical

properties of a certain place is far less important than understanding how that place

influences a person emotionally. This entails that the properties of soundscapes should

describe the affective experiences from the listener, as opposed to describing the physical

properties of the sound itself (Cain et al., 2013). Since people with severe or profound

intellectual disabilities have more difficulty in processing and understanding the world around

them, it is fair to assume that they experience difficulties in attributing meaning to certain

sounds. This increases the probability of them appraising soundscapes as unpleasant, as

compared to the non-disabled population.

INTRODUCTION

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Core Affect

There is an essential connection between how people feel and how they appraise the state of

the auditory world surrounding them. Feelings of individuals are addressed by numerous

concepts, definitions, and approaches within scientific research. Concepts such as emotions,

moods, and (core) affect till date have yet to be ascribed with clear and concise definitions.

This has led to what Gross (2010) called, in his review and outlook on the future of emotion

research, a jumble of conceptual confusion. He also justly points to the importance of clarity

in definitions of the concepts used, so that there is no confusion at the reader’s end.

In this dissertation ‘core affect’ will be a key concept in the theoretical framework we

present. Russell (2003) describes core affect as the heart of all affective experiences. Core

affect is a non-reflective, omnipresent, consciously accessible state, although not always

salient. Core affect does not have one specific stimulus (unlike emotions). Instead, it changes

gradually over time, and is shaped by many different influences (Thayer, 1989; Watson,

Wiese, Vaidya, & Tellegen, 1999), some of which are beyond human awareness, such as

environmental changes or subliminal stimuli (Russell, 2005).

Most importantly, core affect is a varying integral blend of the dimensions

pleasantness and arousal. This entails that core affect ranges from utmost ecstasy to

excruciating agony, and from drowsiness and sleep to a crisp alertness (Russell, 2003).

However, a person always has some sort of core affect state, even when feeling neutral

(Diener & Iran-Nejad, 1986; Diener, Sandvik, & Pavot, 1991). Core affect defines simple

affective feelings that are always present (and reportable in every waking state), and therefore

it is the basic component of moods and emotions, which are described below.

Russell and Barrett describe emotions as ‘prototypical emotional episodes’ (1999).

Emotions are short-lived and associated with objects or events that are perceived as relevant

(Levenson, 1999). Emotions are thus responses to specific situations and prepare individuals

for a certain event to ensure that he or she can cope with that event in a particular way. Frijda

(1986) calls this action readiness, because emotions activate specific action tendencies and

prepare the individual for a particular coping strategy. Basically, emotions activate and merge

physical and psychological functioning to ensure survival in possibly dangerous situations

(Tooby & Cosmides, 1990).

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Perceptual processes can directly activate some of these emotions, which are called

basic emotions (Izard, 2007). Izard (2007) distinguishes six basic emotions that, combined

with the action readiness of Frijda (1986), form a number of general coping strategies that are

directly elicited when perceiving objects and events. If an emotion is not appropriate for a

given situation, it has to be regulated. Emotion regulation is an individual’s deliberate or

automatic attempt to influence which emotions he or she has, when he or she has them and

how these emotions are experienced or expressed (Mauss, Bunge, & Gross, 2007). For people

with severe or profound intellectual disabilities it can be assumed that it is more difficult or

perhaps even impossible to regulate their emotions, since their disabilities cause difficulties in

analyzing their environment and choosing optimal behavior (Evenhuis, Theunissen, Denkers,

Verschuure, & Kemme, 2001).

Moods are defined as prolonged periods of core affect and have, unlike emotions, no

specific provoking object as incentive (Russell & Barrett, 1999). Moods often have a lower

intensity than emotions and a slow response synchronism; they may emerge without a clear

cause and can last for days (Scherer, 2005). Where emotions primarily influence actions,

moods seem to be related to a degree of perceived control (over one’s life) and have a stronger

influence on cognition (Siemer, 2005). Whereas core affect only consists of two dimensions,

moods can consist of more than just pleasantness and arousal, and mood is thus a much

richer concept. However, considering practical applicability, we sometimes address moods in

terms of core affect, and these terms will be used interchangeably in the remainder of this

dissertation.

The concept of core affect allows for a more principled understanding of human

perception of soundscapes. The dimensions of core affect, pleasantness and arousal, closely

resemble the dimensions of soundscape appraisal, pleasantness and eventfulness.

Furthermore, Russell’s (2003) model shows that interactions with the environment can

change a person’s core affect, which is supported by in vivo research showing that peoples’

appraisal of their environments reflects their mood, and vice versa (Kuppens, Champagne, &

Tuerlinckx, 2012). It is, for example, difficult or impossible to relax in an unpleasant

environment and therefore people actively seek a quiet and pleasant environment to recover

from stress (Kaplan, 1995). So it seems that the way people describe their inner state is

coupled to the way they describe the state of their surrounding world.

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Focusing on core affect might also be beneficial in research addressing the affective

lives of people with severe or profound intellectual disabilities. Research indicates that these

people have deficits in the communication (and recognition) of emotional expressions, and

show more subtle or atypical facial expression, even when they experience extreme states such

as pain or anxiety. This makes it extremely hard for the supporting professionals to react

appropriately (Adams & Oliver, 2011). Furthermore, focusing on emotions means focusing

on only a part of their continual affective lives. The concept of core affect seems to have great

potential to serve as an insightful contribution to both soundscape research as research on the

affective lives of people with severe or profound intellectual disabilities.

The research project

In 2009 a consortium was formed between the departments of Special Needs Care and

Artificial Intelligence of the University of Groningen and four organizations in The

Netherlands that provide care for people with intellectual disabilities, namely: Talant (part of

care group Alliade), Royal Dutch Visio, Bartiméus en ‘s Heeren Loo Zorggroep. Starting in

March 2012, for a period of three years, research was conducted regarding the role of sound

in residential facilities for people with severe or profound intellectual and multiple disabilities,

partially financed by ZonMW. The main goal of the project was to study the role of the

auditory environment for people with severe or profound intellectual and multiple disabilities

in residential facilities and day care services, and to provide practical guidelines for the direct

support professionals to improve these auditory environments.

The two main research questions were:

1. What is the role of sound for people with severe or profound intellectual and multiple

disabilities in residential facilities and day care services?

2. How can the auditory environment be analyzed, documented and improved in a way

that will enable concrete intervention-oriented measures to be taken?

CHAPTER ONE



15

Dissertation structure

Since there is no existing basis of research on the impact of sound on the physical and

psychological well-being of people with severe or profound intellectual disabilities, we build

this dissertation on emotion and soundscape research, also drawing from approaches from

Artificial Intelligence regarding the modeling of human sound perception derived from

people without disabilities. By combining knowledge regarding the influence of sound on

disabled and nondisabled populations, we gain a richer understanding of the role of sound in

the lives of people with a severe or profound intellectual disability, which we apply in the

(residential) care practice for people with severe or profound intellectual disabilities.

We adopt an applied exploratory research approach, including qualitative and

quantitative methods, starting with the formulation and validation of a theoretical framework

(part one), followed by the development and implementation of an assessment procedure

(part two), resulting in an attempt to create controlled positive and safe auditory

environments for people with severe or profound intellectual disabilities (part three).

Chapter Two

In the first part of this dissertation we will present a theoretical framework on the role of

sound in residential facilities, based on techniques from soundscape and emotion research.

We propose a taxonomy of soundscapes based on the dynamic interplay between how people

appraise their auditory environment and how they describe their mood, or core affect, and the

concept of audible safety.

Chapter Three

To test the validity of the proposed theoretical framework, we conduct a focus group study

with 34 healthcare professionals working with people with PIMD. By eliciting their latent

knowledge regarding this subject, we examine whether it complies with our theoretical

framework.

INTRODUCTION



16

Chapter Four

In the second part, we present staff observations of the auditory environments and core affect

of 36 people with profound intellectual and visual disabilities residing in these environments.

For this purpose, we have developed and tested a score sheet (Assessment Auditory

Environment). We combine the appraisals of soundscape and core affect dimensions and

analyze the results by means of multilevel linear regression.

Chapter Five

To investigate the hypothesis that low quality auditory environments contribute to the

display of challenging behavior, we conduct an observational study. For this purpose, we have

digitized the Assessment Auditory Environment as a smartphone application, called MoSART

(Mobile Soundscape Appraisal & Recording Technology), and implemented it by the direct

support professionals during a period of four weeks. These measurements are accompanied by

pre- and posttest measurements of the moods (MIPQ) and challenging behavior (LGP-

PIMD) of 15 participants with a severe or profound intellectual disability.

Chapter Six

In the third and last part of this dissertation we describe a more controlled attempt at

studying the effects of five different auditory environments (Beach, Forest, Urban, Music, &

Silence) on the core affect of people with severe or profound intellectual disabilities and their

challenging behavior. Thirteen participants were presented with these soundscapes in a

dedicated room, together with their direct support professionals, who conducted pre- and

posttest core affect observations.

Chapter Seven

In the last and concluding chapter of this dissertation we present a summary of, and

contemplate on the meaning and significance of the discussed findings. Empirical

implications for soundscape research and clinical implications for the daily practice in

residential facilities for people with severe or profound intellectual disabilities are presented.

Furthermore, we will discuss limitations of the present study and suggestions for further

research.

This chapter is based on: Van den Bosch, K., Andringa, T., Başkent, D., & Vlaskamp, C. (2015). The role of

sound in residential facilities for people with profound intellectual and multiple disabilities. Journal of Policy and

Practice in Intellectual Disabilities. Paper accepted for publication.



Chapter Two

The role of sound for people with severe or

profound intellectual and multiple disabilities

THE ROLE OF SOUND



18

Abstract

Introduction: We propose that an important role of audition is to establish audible safety.

Individuals with profound intellectual and multiple disabilities heavily rely on sound to make

sense of the world around them. Therefore, when a soundscape does not provide positive

indications of safety, these people will not feel at ease, which may contribute to challenging

behavior. Methods: By combining soundscape research addressing how people appraise

auditory environments, and emotion research on core affect, we conclude that our moods can

be viewed as attitudes towards the world. The main dimensions underlying the appraisal of

our inner state (core affect) as well as the outside world appear to be very similar, namely:

pleasantness and activation or eventfulness. Results: The result is a proposed qualitative

classification of soundscapes in terms of their pleasantness and eventfulness, and complexity

of action selection and audible affordances, namely: Lively, Calm, Boring and Chaotic.

Conclusion: The simplest safety-relevant meaning attributable to the soundscape is key in

understanding soundscape quality, and allows for effective soundscape-design for quality of

life. Implications for practitioners: These ideas particularly apply to people with profound

intellectual and multiple disabilities and therefore, we believe that they will benefit from an

environment that is reassuring by providing meaningful audible safety.

CHAPTER TWO

19

Introduction

Research on people with severe or profound intellectual and multiple disabilities (PIMD) has

covered a wide range of topics, including the development and evaluation of interventions

with a strong focus on sensory stimulation. However, there has been minimal attention to the

auditory environment per se and its potential (positive or negative) effects on individuals with

PIMD (Kingma, 2005). This paper proposes a theoretical framework regarding the role of

sound in homes for people with PIMD.

The minimal attention directed at the auditory environment is remarkable

considering the high prevalence of visual impairments amongst people with intellectual

disabilities compared to the non-disabled population (Warburg, 2001), especially considering

that this prevalence grows with the severity of the intellectual disability (Evenhuis,

Theunissen, Denkers, Verschuure, & Kemme, 2001; Woodhouse, Griffiths & Gedling,

2000). According to studies in the Netherlands (Van Splunder, Stilma, Bernsen, & Evenhuis,

2005), nearly 70% of individuals with severe intellectual disabilities are visually impaired,

which in most cases is caused by impaired development of the visual cortex in the occipital

lobe (cortical blindness). Such cerebral visual impairment (CVI) does not show a consistent

pattern among PIMD individuals. Each individual is impaired in a unique way by CVI and

even within individuals the condition may vary depending on environmental factors and time.

A complicating factor is that in individuals with severe intellectual disabilities a visual

impairment often remains unnoticed (Vlaskamp, 2005). This is due to the fact that people

with PIMD have greatly diminished capabilities to express themselves: they do not have the

verbal capacity to speak and even their body language can be greatly distorted. As a result,

they may be unable to complain about a loss of vision or symptoms of visual impairment.

With the (partial) loss of one of the senses, people become more dependent on the

remaining ones (Occelli, Spence, & Zampini, 2013). For example, in the case of visual

impairments, auditory input becomes more important, compensating the negative effects of

degraded eyesight with auditory information (Dufour, Després, & Candas, 2005). Thus, it is

likely that many individuals with visual impairments heavily rely on auditory information to

make sense of the world surrounding them. If so, the auditory environment could

substantially affect their psychological well-being. One of the assumptions of this paper is

that this auditory compensation applies equally to people with PIMD, since they seem less

THE ROLE OF SOUND



20

often affected by hearing problems than by visual impairment (Evenhuis, et al., 2001). The

lower prevalence of hearing deficits compared to visual deficits in these populations with

PIMD can be explained by a more prominent role of subcortical areas in hearing than in

vision (Andringa & Lanser, 2013). Important auditory processing is, to a large extent

subconsciously, performed in the midbrain. For example hearing direction, separating and

grouping the signal into separate components, auditory scene analysis (Winkler, Denham, &

Nelken, 2009), and probably auditory gist processing (Harding, Cooke, & König, 2007), are

midbrain processes that generally seem to be preserved in these populations.

Therefore, due to the presumable high reliance on sounds, supportive auditory

environments are likely to be crucial for well-being in this population. It is important that the

effects of auditory environments on people with PIMD are well understood so that they can

be optimized by caregivers to promote overall well-being and quality of life.

In this paper, we present a theoretical framework using techniques from soundscape

and emotion research that can quantify such effects, like core affect, and present a taxonomy

of four types of auditory environments, or soundscapes, in which the concept of audible safety

plays an important role. Our ultimate goal is to assess soundscape quality and contribute to

guidelines for policies to optimize living environments (or habitats) for people with PIMD to

enhance psychological well-being and quality of life and to minimize the prevalence of

behavioral problems.

CHAPTER TWO

21

Theoretical framework

Audible Safety

The capacity to hear and listen – audition – has an evolutionary history of millions of years

(Hester, 2005). One important function of audition, from an evolutionary perspective, is to

“warn”. If the safety of an environment can be estimated (heard) it allows an individual to

relax or attend to other matters instead of being vigilant. Audible safety indications do not so

much indicate safety, as well as normalness. In fact, the most pleasant sounds are also

profoundly “normal” (Guastavino, 2006; De Coensel & Botteldooren, 2006). Humans tend

to like the songs of birds, the soft sounds of domesticated animals, children playing, the

neighbour cleaning their house, the murmur of a quiet conversation on the street, and their

child singing in the room. These are all sounds that match activities that one is typically

engaged in in safety. Consequently we use the judgment of other individuals (including

individuals of other species) to inform us about the safety of the environment (Andringa &

Lanser, 2013).

We argue that auditory information normally contributes to forming a ‘sense of place’,

which provides clarity about the current location and situation and as such allows an

individual to generate expectations (Morgan, 2010; Tuan, 1975). Following the dual pathway

model of auditory signal processing (Wang, Wu, & Li, 2008), which suggests two auditory

streams of cortical processing, namely a ventral "What” and a dorsal “Where” pathway, we

propose that this sense of place arises from the answers to two questions: "Where am I?” and

“What is happening?” Based on this sense of place, one can form expectations and anticipate

what is to come. An absent, confused, or unstable sense of place can lead to uncertainty and a

sense of insecurity because it becomes difficult or impossible to generate situationally

appropriate behavior. We hypothesize that for people with PIMD, the process of forming a

sense of place relies more on recognition of certain situations than for people without PIMD,

due to reduced cognitive capabilities. Therefore, we propose that for people with PIMD, the

main question answered by audition is "Am I in a safe place?” This question consists of two

components: (1) "Do I know this place?" and (2) "Is this place safe in its current state?"

Only very recently in evolution (less than a few million years) has audition been used

for speech and even more recently for non-natural sounds (Andringa & Van den Bosch,

2013). Non-natural sources, like ventilator, traffic, or other machine sounds, act as distractors

THE ROLE OF SOUND



22

that make it more difficult for people to establish audible safety and they contribute, for that

reason, to sound annoyance. For sound annoyance to occur, it is not necessary that the sound

source has particularly annoying acoustic properties. The simple fact that a machine sound

obscures more pleasant (safety-indicating) sounds is enough to be experienced as an annoying

intrusion (Andringa & Lanser, 2013). For example, the sound of traffic is often not

particularly unpleasant; it may even resemble the sound of the ocean, which people typically

like to hear. But traffic sounds can also mask subtle environmental sounds indicative of

normality and safety. As a result, the main effect of the blanket of non-natural sounds that

covers our daily living environments is to further disconnect individuals from their (natural)

environment. Unfortunately, this means that, in such situations, it may be even more difficult

to determine whether everything is normal and safe. The predictable result is that people

become more vigilant, alert, and aroused. Consequently, they are less likely to relax and/or be

engaged in an undisturbed activity, and perhaps more likely to be fatigued in the long run

(Andringa & Lanser, 2013).

For people with intellectual disabilities in a long-term care situation, such as in a

residential facility, these consequences may be amplified. For example: if you are unable to

ignore a sound and cannot escape it (e.g., because cannot leave the corresponding

environment because you are wheelchair-bound), you will evaluate the sound as annoying,

become more stressed, and appraise the overall situation as unpleasant. This is even more

likely for people with minimal or no opportunities to influence their (auditory) environment,

such as people with PIMD. According to Kahneman (1973) human cognitive resources are

limited, and when processing load for one task increases (e.g. for establishing audible safety)

this will reduce the amount of resources available for other concurrent tasks. For people with

PIMD, who already have reduced cognitive functioning as defined by their intellectual

disability, the constant process of determining audible safety in complex auditory

environments and the accompanying arousal could dominate or even exceed their cognitive

resources. Therefore, if not paid particular attention, the living environments of people with

PIMD could – effectively – be structurally deprived of useful positive indications of safety.

The resulting (prolonged) stress and arousal may affect their overall psychological well-being

and quality of life negatively (Petry, Maes, & Vlaskamp, 2005), also perhaps contributing to

behavioral problems.

CHAPTER TWO

23

Assuming audible safety is indeed of such great importance for people with PIMD,

we can design for optimized audible indications of safety. These indications should either be

relaxing and reassuring, or encouraging activation. This could be achieved, for example,

through providing auditory environments that are pleasant to be in with individual sounds

that are fun, casual, and interesting for people with PIMD, such as the sounds of animals or

toys. In a safe environment, people with PIMD will become motivated to engage in activities

and social interactions. This can prevent boredom for these people, encouraging them to

explore their environments more and thus learn to master the possibilities and limitations of

their environment.

Soundscapes

Research focusing on the psychological aspects of auditory perception is conducted in terms

of soundscapes. A soundscape is defined as an environment of sound, with an emphasis on

how it is perceived by an individual or society (Schafer, 1977). Research shows that

suboptimal soundscapes can induce a wide range of detrimental effects on the welfare of

people (CALM, 2004). When a soundscape is perceived as unpleasant, people experience

annoyance, and the adverse effects may range from relatively harmless problems with

concentration to serious problems related to general health, well-being, and quality of life

(WHO, 2000). These negative effects on individuals are not only detrimental for the listeners

themselves, but eventually contribute to greater social and economic costs to society (Grahn

& Stigsdotter, 2003). To reduce the negative impact of unpleasant soundscapes on the

welfare of people we need to gain more insight in which soundscape characteristics elicit

these unwanted effects.

The concept "core affect" allows better understanding of human perception of

soundscapes. Core affect originates from emotion theory and refers to mood (Russell, 2003)

as relation between the individual and the world (Kuppens, Champagne, & Tuerlinckx,

2012). While emotions often are short-lived and not always present, one can always describe

in what kind of mood one is. This always-present feeling is called core affect and can be

mainly described by the combination of two features: pleasantness and activation (Figure 1a).

To give an example: the corresponding core affect for playful enjoyment can be described as

pleasant and active. Vice versa, gloominess can be described as unpleasant and passive.

THE ROLE OF SOUND



24

Figure 1. Core affect and appraisal of auditory environments

(adapted from Andringa & Lanser, 2013).

Axelsson, Nilsson and Berglund (2010) have studied how people appraise auditory

environments and showed that such appraisal is commonly based on the pleasantness and

eventfulness of the auditory environment (Figure 1b). Therefore, it seems that the way

individuals describe their inner state, or mood, is coupled to the way they describe the state of

the surrounding world. This idea is supported by research showing that there is a strong,

mutual, and continual relationship between moods and how people appraise their

surroundings (Kuppens, et al., 2012; Andringa & Lanser, 2013).

!

Retaining or

regaining control

Activation

Distressed

Pleasant

Interested

Unpleasant

Deactivation

Relaxed

Bored

Learning and

playing in

safety

No sense of

safety or control

Restoring

resources and

caring

Indications of

insecuri ty or

unsafety

Eventful

Chaotic

Pleasant

Exciting

Unpleasant

Uneventful

Calm

Monotonous

Stimulating

and safe

Missing

indicati ons of

safety

Ample

indicati ons of

safety

a) Core Affect

b) Appraisal

CHAPTER TWO

25

Taxonomy of soundscapes

Based on the similarity between how one feels (core affect) and how one appraises their

environment, in combination with the assumption of audible safety, researchers proposed

(Andringa & Lanser, 2013) to define soundscapes in four categories: Lively, Calm, Boring

and Chaotic (Figure 2).

Figure 2. Four types of soundscapes (Lively, Calm, Boring and Chaotic) and their basic dimensions

(Eventfulness vs. Pleasantness, or Affordances vs. Complexity) (adapted from Andringa, Van den

Bosch, & Vlaskamp, 2013).

These types of soundscapes can be classified according to their pleasantness and

eventfulness, or complexity and affordances (Andringa & Van den Bosch, 2013). Figure 2

shows these types, with the degree of pleasantness on the horizontal axis and degree of

eventfulness on the vertical axis. In contrast to Figure 1, there are two diagonal axes included:

bottom left to top right represents increasing affordances and bottom right to top left

!

Lively

The environment offer s many

interesting and meaningful affordances

and is indicative of safety

High complexity

Pleasant

Many affordances

Calm

The environment forms a stable,

consistent and harmonic whole,

with many indications of safety

Chaotic

The environment is difficult to

understand, not stable to

interpretation or indicative of danger

Boring

The environment offer s no or few

positive and meaningful affordances

and is not indicative of safety

Eventful

Problems

Challenges

Exploration

Play

Consolidation

Growth

Frustration

Incapability

(-) Audible Safety (+)

Unpleasant

Uneventful

Few affordances

Low complexity

THE ROLE OF SOUND



26

represents increasing complexity. Affordances indicate the extent to which the environment

offers (pleasant) options for self-selected behavior. The complexity of an environment

indicates how difficult it is to choose situationally appropriate behavior. Some situations offer

rich possibilities for behavioral options while other, potentially dangerous, situations leave

few appropriate choices.

On the pleasant side, a lively soundscape represents many affordances that offer

interesting options to attract attention and is indicative of safety. It is a stimulating and safe

environment, characterized by the presence of pleasant foreground sounds. Exploration (of

the environment) is behavior typically seen in lively soundscapes (upper-right quadrant). A

lively soundscape offers many affordances representing interesting options to engage in. In an

interesting, fascinating environment, one's curiosity is stimulated, encouraging the person to

explore and learn. It is a stimulating and safe environment, characterized by the presence of

pleasant foreground sounds.

Calm soundscapes provide sufficient indications of safety and allow full flexibility to

relax and recover after challenges or stress. They are characterized by pleasant background

sounds (such as a forest) and few foreground sounds. Relaxation is behavior associated with a

calm soundscape (Booi & van den Berg, 2012; Botteldooren & De Coensel, 2006; Shepherd,

Welch, Dirks & McBride, 2013). People look for a park or beach when they want to relax,

and people with PIMD do just the same, for example, when they are enjoying a rich garden

environment in the company of a trusted care giver.

Boring soundscapes contain little meaningful audible affordances and do not

necessarily guarantee safety. Unpleasant background noise and the absence of indications of

safety are characteristics of such environments (e.g. a loud air conditioning). Submission (to

environmental influences) is behavior that fits a boring and impoverished soundscape (lower

left quadrant). It is neither pleasant nor active, because the environment has nothing

interesting to offer. It is a monotonous, dull environment that offers little reassuring. People

in this quadrant have no sense of security or control over their environment because they do

not have the appropriate behavioral repertoire act. This situation endures as long as the

person remains stuck in the impoverished environment. Because of the lack of interesting

stimuli that are new and safe, familiar behaviors (often stereotypical ones) will be activated to

for self-protection and to prevent further deterioration. However, this stereotypical behavior

does not help to structurally improve the situation.

CHAPTER TWO

27

Lastly, chaotic soundscapes can be difficult to interpret (e.g. by an abundance of

sound-producing activities) or might be indicative of unsafety. This is often caused by the

presence of unpleasant sounds in the foreground (for example, construction work next to a

busy street). It is important to realize that the quality of soundscapes and associated behavior

are strongly related: it is difficult to stay calm in a chaotic situation. Therefore, a chaotic

soundscape makes people feel distressed (upper-left quadrant, Figure 1a).

Discussion

We propose that the quality of soundscapes is best understood in terms of how we

appraise these soundscapes with regard to safety and pleasantness (and not in terms of

acoustic properties, such as loudness). The framework we propose may explain why

certain loud sounds may not necessarily lead to experiencing discomfort, when one

consciously chooses to be exposed to those sounds, such as attending a concert or a

party. It may also explain why the subtle sound of a mosquito at night can be greatly

irritating, despite being a very soft one. Further research is needed, experimental or

observational, to test the claims of this framework, and its usefulness for people with

PIMD.

In today's industrial society, it is difficult to prevent the environment becoming filled

with unwanted sounds. The monotonous 'blanket' of unnatural sounds promotes people to

stay alert and therefore they may not be able to properly relax. However, a potential solution

is to create enough diversity in soundscapes so that an escape from these unnatural sounds is

possible. When there are enough opportunities to experience pleasant environments, with

calm or lively soundscapes, people with or without PIMD can relax and escape from the

hectic soundscapes. A bad mood, a negative core affect, reflects a negative evaluation of the

person about his or her environment (and the challenges and opportunities it provides).

Especially for people with PIMD living in a residential facility, chances are that low quality

auditory environments lead to structural challenging behavior (unintended, as support staff

would not deliberately promoted such a negative core affect). This behavior should be seen as

a sign of active resistance against an unsafe or otherwise sub-optimal living environment.

THE ROLE OF SOUND

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28

As described in previous sections, indicating safety is an important role of sounds in

the environment. A high quality soundscape helps to continually confirm audible safety. It

therefore needs to meet the basic requirements of offering ubiquitous indications of safety

and providing ample affordance (ideally the living environment should always provide

indications of safety). If the overall situation is clearly indicative of safety through audible

activities, even quiet distinctive and unpleasant sounds may not be so disturbing because they

occur in a reassuring environment. But if there are few indications of safety (e.g., through

masking sounds of air conditioning systems), or if there are indications of unsafety (e.g., the

sounds of anxious people or loud machines), then everyone (PIMD or not) is forced to be

alert and pay attention to (the negative aspects of) the soundscape. To acknowledge the role

of audible safety and translating – on the basis of experience and common sense – one ’s own

relation to good and bad soundscapes towards the needs and wishes of people with PIMD,

will be a first and important step towards offering audible safety to them. We can close our

eyes but not our ears. Therefore, we must pay close attention to the design and maintenance

of positive soundscapes to ensure highest quality of life for individuals with PIMD.

This chapter is based on: Van den Bosch, K.A., Andringa, T.C., & Vlaskamp, C. (2013). The role of sound and

audible safety in special needs care. Paper presented at INTER-NOISE 2013, the 42nd International Congress

and Exposition on Noise Control Engineering, Innsbruck (pp. 2267-2272). Innsbruck: INCE.



Chapter Three

What healthcare professionals know:

Validating the theoretical framework

WHAT PROFESSIONALS KNOW



30

Abstract

Soundscape research applicable to residential facilities for people with profound intellectual

and multiple disabilities (PIMD) is scarce. The aim of this study is to determine the role of

sound for persons with PIMD, because we expect it provides insight into the role of audition

for them. We hypothesize that sound is important in developing a sense of a safe place: when

the auditory environment does not provide positive indications of safety, individuals within

this environment will not feel safe. Feelings of unsafety and insecurity are likely to play a

major role in the onset of problem behavior and thus reduce the quality of life for people with

PIMD. To test the validity of this claim, we organized focus groups for PIMD professionals,

where we examined whether their latent knowledge corresponded to our theoretical

framework. In total 34 professionals attended. Results showed a strong consistency between

the knowledge and experience of the professionals and our theoretical framework, indicating

that, for people with PIMD, the auditory environment is crucial in determining the answer to

the question "Am I in a safe place?" We conclude that the (re)introduction of positive

indications of safety and soundmarks associated with daily structure, in the environment of

people with PIMD are likely to improve their quality of life.

CHAPTER THREE



 

31

Introduction

Particular sounds can be stressful for everyone and they might be even more stressful for

people with an intellectual disability. The response of people with profound intellectual and

multiple disabilities (PIMD) might teach us something about the more fundamental aspects

of noise perception, because their response is minimally filtered or modified by higher

cognitive (and culturally biased) processing. Individuals with PIMD can be characterized as

having a profound intellectual disability and a profound motor disability, which is

accompanied by additional severe or profound secondary disabilities or impairments (Nakken

& Vlaskamp, 2007).

Currently, the concept of Quality of Life (QoL) is used as a guide in the treatment,

support, and care for people with PIMD. The goal of assessing the QoL of people with

PIMD is to preserve and optimize the aspects that are most meaningful in life and improve

the things that negatively affect the quality of life (Maes, Vlaskamp, & Penne, 2011).

According to the Quality of Life Model (Buntinx & Schalock, 2010) it is a key issue to

ensure that people with PIMD experience a maximum sense of basic safety. A diminished

sense of basic safety, caused by not (properly) understanding and mastering the structure of

the (auditory) environment, can cause a variety of behavioral problems (Maes, Vlaskamp, &

Penne, 2011). It is therefore remarkable that research regarding people with PIMD has, until

now, hardly focused on contextual settings. Research on the auditory environment within

residential facilities for people with PIMD is especially scarce. When considered that people

with PIMD have a very high prevalence of visual impairments (Evenhuis, Theunissen,

Denkers, Verschuure, & Kemme, 2001; Woodhouse, Griffiths, & Gedling, 2000) research

on this topic seems highly relevant.

This paper aims to address the role of sound and audible safety in the living

environments of people with PIMD. We hypothesize that sound is crucial in developing a

sense of place: when the auditory environment does not provide positive indications of safety,

persons within this environment will not feel safe (unless non-auditory safety indications are

present). First, we will address the concept ‘sense of place’ and its relation to auditory

environments in a short theoretical introduction. Next, the latent knowledge of 34 healthcare

professionals was elicited with a focus group study, to examine whether it complied with our

theoretical framework. Our ultimate goal is to assess soundscape quality, contribute to

WHAT PROFESSIONALS KNOW



32

guidelines for policies to optimize living environments for people with PIMD to enhance

psychological well-being and quality of life, and through this to minimize the prevalence of

behavioral problems.

Sense of place

People with visual disabilities use the sound in their environment to compensate for the loss

of visual information. When the visual impairment is combined with a severe cognitive

impairment, the auditory information in the surroundings can easily become too complex to

comprehend in real-time. We argue that auditory information normally contributes in

developing a 'sense of place’, which allows one to generate expectations for the location and

situation someone is in (Morgan, 2010; Tuan, 1975). The first key question answered by

audition is "Where am I?” On the basis of this question it is possible to generate a sense of

what is happening and expectations for what might happen (the last one being important to

guide knowledge driven perception). So the second key question to be answered by audition

is “What is happening?” Together the answers to these questions form a sense of place. Lack

of it can lead to uncertainty and a sense of insecurity because one is not able to generate

situational appropriate behavior.

Andringa and Lanser (2013) argue that the subtle background sounds of an auditory

environment, which are always present, are important to answer the ‘where’ question. It is the

overall auditory “atmosphere”, or ambiance, that makes you realize whether you are indoors

or outdoors, in a large or small space, safe or not, etc. In addition, the striking foreground

sounds, which are striking because they demand attention, predominantly answer the 'what'

question. Unpleasant foreground and background sounds arouse and force you to be alert. In

contrast, a combination of pleasant fore- and background sounds allows the freedom of mind

to address needs proactively. In an environment with sufficient positive indications of safety

and the absence of indications of insecurity, people are not forced to be alert.

We hypothesize that the main role of sound, especially for people with severe

intellectual disabilities, is to answer the question: "Am I in a safe place?", which consists of

two components, namely: 1) "Do I know this place?" And 2) "Is this place in its current state

safe?" (Van den Bosch, Andringa, Başkent, & Vlaskamp, 2015). We expect that these are

core questions for audition since its evolutionary inception. For humans, who managed to

create living environments that are inherently safe and as such do not require constant

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vigilance, the safety role of sound has become less prominent. Yet the observation that

audible safety has become less important in human cultures is indicative of its importance:

otherwise the creation of inherently safe environments would not have been a priority.

However, for people with severe intellectual disabilities this inherent safety might be less

meaningful because they do not understand the larger cultural guarantees for safety.

With this research we hope to improve the living environments of people with severe or

profound intellectual disabilities (and visual impairments) by first gaining more insight in the

role of sound, and in particular audible safety, in so far known and experienced by care givers.

We therefore organized a focus group study in which we tested if the latent knowledge of 34

healthcare professionals regarding the role of sound for people with PIMD complied with

our hypothesis. We did this because, for obvious reasons, the clients themselves cannot

provide us with an assessment of their auditory environments, and administering

physiological measurements is too invasive and impractical for this target group. Moreover,

our goal is to increase awareness with regard to the importance of the auditory environments

and that, in this case, cannot be established by means of physiological measurements. In

addition, we need to know what caregivers know about the role of the auditory environment

and what they expect of its role, so that we can translate our scientific knowledge and insights

to the daily practice of working with intellectually disabled individuals.

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Method

Participants and sampling

Focus groups (Acocella, 2011; Fern, 1982) were used to maximize the collection of high

quality information. Participants were recruited from five organizations, from predominantly

the Northern part of the Netherlands, that provide residential accommodation to clients with

severe or profound intellectual and visual disabilities. Purposive sampling was employed in

initial recruitment to enable specific targeting of information rich cases (Patton, 2002). The

number of participants was not predetermined; rather, participation ended when the full

range of professional experiences about auditory environment was captured. Both excessively

homo- and heterogeneous grouping was avoided as was hierarchical positioning to prevent

inhibition during the discussions (Acocella, 2011). A total of 34 healthcare professionals

voluntarily participated in this study.

Procedure

Data-gathering procedure started with a presentation explaining the goal of the meeting:

namely to acquire the diversity of latent knowledge of these professionals regarding the

auditory environment in the homes of people with PIMD. In this presentation, the scope of

the research was discussed and the theoretical framework of the study was clarified. This part

focused on the mutual influencing of mood (core affect) and the appraisal of the (auditory)

environment (Andringa & Lanser, 2013; Kuppens, Champagne, & Tuerlinckx, 2012).

Consecutively, guidelines for the discussion in the focus groups were given. This phase took

about 30 minutes.

Hereafter, the participants were divided into 5 focus groups. The participants were first

divided into three levels based on their role in the organization; ‘executive’ including direct

support professionals (DSP) (N = 12), ‘context providing’ representing behavioral scientists

(N = 14), and ‘strategic’ including the management and policy functions (N = 8). This

resulted in two executive level groups with six participants, two groups of seven participants

at the context providing level and one strategic level group of eight participants.

The groups were presented with the following question: “What is the role of sound in

homes of people with PIMD as seen from your expertise?” They were given 75 minutes to

brainstorm and orientate on the question. Three skilled moderators were present to facilitate

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the focus groups. After a lunch (45 minutes) in which the topic was still discussed actively,

the focus groups were given another 60 minutes to converge on what they have discussed

before and to write down the answers to the question on flip charts. It was mentioned

multiple times during the day that the aim was not to reach consensus within the groups, but

to provide a diversity of possible answers covering all available expertise and experience.

Finally, the groups were asked to present their results on flipcharts. Each group had five

minutes to do so. These presentations led to a lively session in which many groups discovered

important commonalities and, quite often, relevant additions to their own results. This

session ensured that an initial consensus among the participants was formed, in which the

groups were strengthened in the way they had approached the topic. However this did not

influence the information on the flipcharts that had already been compiled and finalized.

Only the information on the flipcharts was used for further analysis.

During the whole day, audio recordings were made and field notes were taken to note

narrative summaries and relevant non-verbal data. These were not used for this study. The

analysis below is based on the information as written by the participants on the flipcharts.

Analysis

The workshop leaders (and authors of this paper) gathered the next day to analyze the

collected data on the flipcharts. First, the responses of the participants were written down per

group and clarified when needed. The authors discussed the answers given by the five groups

in general. Following deliberation, corresponding terms were rephrased in uniform terms and

the workshop leaders addressed the frequency, similarities, and diversity in the responses.

The text written on the flip charts was digitized and sent to the members of the

respective focus group with the request to check for accuracy and completeness. The feedback

obtained clarified some examples given and did not affect the analysis.

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Results

As Table 1 shows, the most frequent mentioned roles of sound in homes of people with

PIMD were Influencing Behavior (N = 6) and Atmosphere (N = 4). The participants

mentioned all answers under Atmosphere literally, and Influencing Behavior refers to answers

suggesting that sounds can have a relaxing or activating effect on behavior. In addition,

Clarity (N = 3), Structure (N = 3) and Safety (N = 3) were mentioned. These answers refer to

the predictability of the structure of the day and the role of sound in determining whether a

situation is safe or not. Finally Recognition (N = 2) was mentioned as a role of the auditory

environment, which involves the recognition of personnel.

Table 2 shows that the groups on the executive level generated most answers (10, on

average 5 per group), the context providing groups generated nine answers (on average 4.5

per group) and the group on the strategic level generated fewest and least diverse answers (2).

Table 1 - The given answers and corresponding categories per focus group.

Organizational level

Answers

Safe and Sound: Soundscape research in special needs care

Figures