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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.
Safe and Sound
Soundscape research in special needs care
© 2015 - K.A. van den Bosch
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.
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
 
“Unnecessary noise, then, is the most cruel absence of care
which can be inflicted either on sick or well.”
- Florence Nightingale, 1860 -
Chapter One
Introduction
INTRODUCTION
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.
CHAPTER ONE
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
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
CHAPTER ONE
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
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
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
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
CHAPTER ONE
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
10
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
CHAPTER ONE
11
(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
12
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).
CHAPTER ONE
13
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.
INTRODUCTION
14
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
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
CHAPTER THREE
 
33
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.
WHAT PROFESSIONALS KNOW
34
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
CHAPTER THREE
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35
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.
WHAT PROFESSIONALS KNOW
36
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
Category
E1
E2
C1
C2
S1
Masking (of unwanted sounds)
Influencing behavior
X
Disruptive (disturbing current focus / activities)
Influencing behavior
X
Relaxing - Activating
Influencing behavior
X
Influencing behavior and mood
Influencing behavior
X
Calm
Influencing behavior
X
Unrest
Influencing behavior
X
Atmosphere (role of background sounds)
Atmosphere
X
X
X
X
Clarity (of activities, people)
Clarity
X
X
Predictability (of activities, people)
Clarity
X
Structure (sounds indicative of daily structure)
Structure
X
X
Rituals (sounds indicative of daily structure)
Structure
X
Safety (direct reference to role of safety)
Safety
X
X
Unsafely (direct reference to role of safety)
Safety
X
Recognition (of caretakers)
Recognition
X
X
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37
Table 2 - The answers per category, per organizational level.
Conclusions
It appears that, according to health care professionals, Influencing Behavior is the most
prominent role of sound in homes for people with PIMD (N=6, 28,6%). Influencing
Behavior entails that sounds can have activating or relaxing effects on the behavior of persons
with PIMD. This supports the claim that the auditory environment could affect the behavior
of people with PIMD and as such, should be considered more carefully.
The participating professionals also state that sounds, partially, determine the
atmosphere (Atmosphere, N=4, 19%). In the introduction it was mentioned that the
atmosphere, carried by the subtle background sounds, helps to answer the where-question on
a continual basis and therefore is crucial in forming and maintain a sense of place. In
addition, responses in the categories of Clarity, Structure, and Recognition were mentioned
as part of the role of sound. Sounds can indicate for example which activities follow or which
DSP are present. This might refer more to the foreground sounds, which help to answer the
what-question as discussed in the introduction. Lastly, Safety was mentioned, as such, in
14,3% of the cases (N=3), which implies a clear safety aspect in the role of sound for people
with PIMD.
Combined, the categories Atmosphere, Clarity, Structure and Recognition form a
majority of the answers provided (N= 12, 57,1%). This result provides support for our
hypothesis that the auditory environment is indeed crucial in determining a sense of place
based on the question "Am I in a safe place?”. This implies that the first role of sound is that
of an indication of safety, it is not so much the location, but the safety of the situation. The
second role of sound would be to clarify the situation. “What is happening here? What can I
expect?” Expectations make it easier to handle the complex world around us. Deviations from
expectations in the form of unknown or unexpected noises reduce predictability and elicit a
Organizational level
Category
Influencing behavior
Atmosphere
Clarity
Structure
Safety
Recognition
Executive
3
2
2
2
1
Context providing
3
2
1
2
1
Strategic
1
1
WHAT PROFESSIONALS KNOW
38
sense of unease. Overall, results showed a strong consistency between the knowledge of the
professionals and our theoretical framework.
Looking at the differences in the answers across the organizational levels, the most
remarkable result is that the Strategic level had fewest and least spread answers. It is also
striking that the Strategic level was the only level that mentioned Clarity as the role of sound.
The second answer given by the Strategic level was Recognition, which is closely related to
Clarity. The Strategic level group was also the only group not to mention Safety,
Atmosphere, Structure and Influencing behavior as direct roles of sound within the homes of
people with PIMD. This might be suggestive of the Strategic level having a less rich
understanding of the role of sound in the daily care, which entails that communication about
the role of sound for management and for those involved in daily care should not be the
same.
Discussion
There are several limitations to this study. First, we cannot guarantee that our sample was
representative. Considering that the participants registered voluntarily, thus showing an
interest in the topic, and the diversity of the professions in the group, it is likely that they
have a comprehensive insight in the topic. Secondly, using focus groups creates a social
situation in which certain participants might feel inhibited from fully participating. They may
provide socially desirable answers or no answers at all. We tried to minimize this by
emphasizing that we were not looking for consensus, rather for the full range of possible
answers. In addition we observed very lively interactions where everyone seemed to
participate in.
People with (severe) intellectual and visual disabilities could offer us a unique window
on basic human sound processing due to a reduced influence of higher cognitive (culturally
biased) processing. The information provided by the DSP support our conviction that the
main role of audition (throughout evolution) is to provide and maintain a sense of place.
Insufficient indications of safety arouse and motivate individuals to restore a sense of basic
(audible) safety.
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39
Our main recommendation therefore is to increase awareness about the role of sound
in our environment amongst the staff of organizations caring for people with PIMD. When
reflecting on the environment, and keeping the effects of a stressful auditory environment in
mind, staff will cope better with the everyday sounds that fill the soundscapes of people with
PIMD. In future work we hope to provide guidelines on how (audible) safety can be
enhanced and how this can be observed from the behavior of the clients. Increased awareness,
not only among the direct support staff, but in all layers of the organization, seems to be the
necessary first step to structurally improve the soundscapes of people with PIMD and with
that improve their quality of life. We should be aware of the fact that people with PIMD are
less autonomous. They often cannot ask if the radio can be turned down, or leave when a
soundscape is unpleasant. It is the task of the daily support professionals to recognize what is
good for their clients and to act appropriately, and it is the task of the management to
promote this. Yet the focus study suggests that, in particular, the management may not be
fully aware of the role and importance of sound in the day-to-day-care.
This chapter is based on: Van den Bosch, K., Vlaskamp, C., Andringa. T., Post, W., & Ruijssenaars, A. (2014).
Examining relationships between staff attributions of soundscapes and core affect in people with severe or
profound intellectual and visual disabilities. Journal of Intellectual & Developmental Disability. Paper accepted for
publication.
Chapter Four
The relationship between soundscape quality
and core affect
RELATIONSHIP BETWEEN SOUNDSCAPES AND CORE AFFECT
42
Abstract
Background: People with profound intellectual disabilities experience a high prevalence of
visual disabilities, making them more dependent on sound. However, research addressing the
influence of the auditory environment is scarce. Method: Observations of the auditory
environments (soundscapes) and moods of people with profound intellectual and visual
disabilities, in terms of core affect, were conducted in residential facilities by direct support
professionals. Appraisals of soundscape and core affect dimensions were combined and
analyzed by means of multilevel linear regression. Results: Findings endorse a positive
relationship between the observed pleasantness and eventfulness of soundscapes and core
affect of people with profound intellectual and visual disabilities. Conclusion: This study
suggests a relationship between soundscapes and moods of people with profound intellectual
and visual disabilities, as judged by staff members engaged in their environments. These
findings give reason to believe that improved soundscapes could ameliorate the moods of the
residents.
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43
Introduction
People with intellectual disabilities often experience visual disabilities. The prevalence of
these visual disabilities increases with the severity of the intellectual disability, with an
estimated 78% of people with a profound intellectual disability experiencing visual disorders (
Van Splunder, Stilma, Bernsen, & Evenhuis, 2006; Warburg, 2001). Auditory problems
although common, appear to be less prevalent (Evenhuis, Theunissen, Denkers, Verschuure,
& Kemme, 2001). As a result, many people with profound intellectual disabilities may
depend more on sound to interpret their surroundings than people without intellectual
disabilities, which is supported by research indicating that people with a visual disability alone
compensate for their visual deficit by relying more on auditory information (Dufour, Desprès,
& Candas, 2005). It is however not yet clear to what extent this auditory compensation holds
for people with severe or profound intellectual disabilities.
Despite the situation described above, research addressing the influence of the
auditory environment on the well-being of people with intellectual and visual disabilities is
limited (Kingma, 2005). Because people with an intellectual and visual disability will
probably rely more on audition, it is important to know the role of sound for them. Normally
sound informs people what is going on around them because particular sound sources
produce particular sounds (Gaver, 1993; Plomp, 2002). Non-disabled people can reason
about where the sounds came from and to what event they related to, so that they might not
need to feel unease. Also, they can detect and recognize a known sound source quickly and
because of that they can interpret and act on events in their environment (Andringa & Pals,
2010). Andringa and Pals (2010) conducted an experiment to study sound detection and
recognition. They found that people use prior knowledge and expectations to analyze and
interpret what they hear, but it also works the other way around: what people hear can be
used to generate hypotheses about their environment (Winkler, Denham, & Nelken, 2009).
Van den Bosch, Andringa and Vlaskamp (2013) suggest that this also holds for people with
profound intellectual disabilities, however their disabilities cause difficulties in analyzing their
environment and choosing optimal behavior and, therefore, in regulating emotions and
moods (Evenhuis et al., 2001).
RELATIONSHIP BETWEEN SOUNDSCAPES AND CORE AFFECT
44
The highly increased risk of having visual disabilities in people with severe or
profound intellectual disabilities, as compared with the general population, has important
implications for their living environment (Evenhuis et al., 2001). Many residential facilities,
either small scale or large scale, for people with intellectual disabilities have unfavorable
acoustic conditions and due to the lack of research and therefore knowledge regarding the
influence of auditory environments, these seem to have not been sufficiently taken into
account. Consequently it can be assumed that these auditory environments are not explicitly
adapted to the needs of people with profound intellectual and visual disabilities. For these
people, who already have reduced cognitive functioning as defined by their intellectual
disability, the constant processing of auditory information in unfavorable conditions and
accompanying arousal may dominate their cognitive resources (Van den Bosch, Andringa,
Başkent, & Vlaskamp, 2015). The resulting (prolonged) stress and arousal may deteriorate
their overall psychological well-being and quality of life (Petry et al., 2005).
One way of approaching auditory environments and the effect thereof on people is the
soundscape approach. Soundscapes are defined as “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).
Soundscapes therefore represent more than just a sound signal and include the auditory
environment as perceived and understood by people in a specific context. Axelsson, Nilsson,
and Berglund (2010), developed a model to measure the quality of soundscapes. The results
of their study suggest that soundscape perception can be described in terms of two main basic
components: pleasantness and eventfulness. For (non-disabled) people, an exciting
soundscape is pleasant and eventful, a calm soundscape is pleasant and uneventful, a chaotic
soundscape is unpleasant and eventful, and a monotonous soundscape is unpleasant and
uneventful. These associations observed with groups may vary depending on the individual,
and may vary even more for people with intellectual disabilities. Research further shows that
suboptimal soundscapes can induce a wide range of detrimental effects on the welfare of
people (CALM, 2004; Andringa, & Lanser, 2013). 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).
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45
It thus seems that there is a connection between how people feel and the state of the
auditory world surrounding them. One important concept concerning how people feel is ‘core
affect’ (Russell, 2003). Core affect concerns basic moods and consists of two dimensions;
pleasantness and activation or arousal. These resemble the dimensions of soundscape
appraisal. Pleasantness is, in this context, more than just “niceness”: it depends also on the
degree of perceived control people have over their environment. Russell’s (2003) model shows
that interactions with the environment can change a person’s mood, 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 e.g. difficult or impossible to
relax in an unpleasant and unsafe environment and therefore people actively seek a quiet and
pleasant environment to recover from stress (Kaplan, 1995).
People with severe or profound intellectual disabilities require support to meet their
needs and therefore to maintain their quality of life (Petry, Maes, & Vlaskamp, 2005). They
have limited control over their own situation and have few opportunities to make adaptive
choices regarding everyday activities and major life events (Maes, Lambrechts, Hostyn, &
Petry, 2007). This entails, according to the model of Russell (2003), that people with
profound intellectual disabilities could experience structurally less positive moods in terms of
core affect, kindled by unfavorable and non-adapted soundscapes.
Therefore, the aim of this exploratory study is to provide a first examination of the
relation between staff attributions of the quality of soundscapes and staff attributions of the
moods of people with severe to profound intellectual and visual disabilities in terms of core
affect. As a first step, the method of Axelsson et al. (2010), is used to describe the auditory
environment of people with severe or profound intellectual and visual disabilities. As a next
step core affect is used to describe how they are influenced by the environments (Kuppens et
al., 2012). If we know how people with profound intellectual and visual disabilities are
influenced by different auditory environments, we can eventually determine how to improve
their (auditory) living environment and to increase their quality of life.
RELATIONSHIP BETWEEN SOUNDSCAPES AND CORE AFFECT
46
Method
Participants
This study was conducted within a consortium consisting of the University of Groningen and
four healthcare organizations in the Netherlands. The healthcare institutions informed
parents and legal representatives about the aim of the study. For all participants informed
written consent was obtained. The organizations selected participants, based on the following
inclusion criteria:
1. A developmental age not exceeding 36 months.
2. A severe visual disability.
3. No significant hearing loss.
All further information regarding age, intellectual and sensory disabilities was obtained from
personal files. In total 36 participants were included, comprising 11 women and 25 men. The
mean chronological age of the participants was 49.7 years (SD = 12.2), with ages ranging
from 20 to 70 years. A specification of the intellectual disability in terms of developmental
age was provided from file information, it was however not always specified how this
measurement was obtained. Following the classification of the DSM-IV-TR (APA, 2000),
14 participants were reported to have a severe intellectual disability (39%), and 19
participants to have a profound intellectual disability (53%). File information revealed that for
three participants there was no up-to-date assessment with regard to the level of intellectual
disability, however, special education experts on site appraised them as meeting the inclusion
criteria. The mean reported developmental age of the participants was 24.3 months (SD =
16.3).
According to the personal files, all participants were reported to have a severe visual
disability, with visual acuity < 0.3 Log-MAR (or so-called 20-40 vision, based on the criteria
of the World Health Organization, 2007). The degree of reported visual disability can be
divided into six categories: 13 participants (39%) were at least functionally blind or had only
light perception; 5 participants (14%) had visual acuity up to 0.1; 6 participants (17%) had
visual acuity from 0.1 to 0.2; 7 participants (19%) had visual acuity from 0.2 to 0.3, and 3
participants (8%) had other visual disabilities (e.g., nystagmus). For two participants, there
CHAPTER FOUR
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47
was no current assessment with regard to the degree of visual disability specified in the file;
they were included nonetheless based on reports from the direct support professionals
indicating these participants met the inclusion criteria. All participants clearly reacted to
sound, and there was no significant hearing loss, as evidenced by the reports of specialized
audiology centers and evaluations from members of the direct support personnel.
The participants were residing in residential facilities operated by four organizations,
dispersed over six locations throughout the Netherlands. Five of these locations, operated by
three organizations (OID11,2,3, OID2, and OID3), specialize in care for people with an
intellectual disability. The other location, operated by the fourth organization, focuses
primarily on care for people with a visual disability (OVD1). Although these facilities differ
in their primary focus with regard to intellectual or visual disabilities, they are comparable in
terms of organization, provided care (residential and day-service), group size, ratio, and daily
structure.
The participants were observed by their attending direct support personnel (N=41).
Considering people with profound intellectual disabilities have highly diminished
communication options, and may only communicate via (distorted) facial expressions, sounds,
movements, body posture or muscle tension (Vos, de Cock, Petry, van den Noortgate, &
Maes, 2010), observers were chosen who could interpret these subtle signs the best, based on
their long experience with these clients (Vlaskamp & Cuppen-Fonteine, 2007). Data-
collection days were selected randomly across the days of the week, but in such an order to
ensure that only observers who had been familiar with them for at least six months rated the
core affect of participants. The participants were observed an entire day, they therefore were
observed by multiple members of the direct support professionals due to working hours.
Ethical procedures have been followed and for all of the participants, written consent
was obtained from their legal representatives, after they had been informed about the study
via written information. All members of the consortium gave verbal and written consent to
conduct research at specified locations. Formal ethical approval to conduct this study was
obtained by the institutional review board from the University of Groningen.
RELATIONSHIP BETWEEN SOUNDSCAPES AND CORE AFFECT
48
Instruments
As demonstrated by Axelsson et al. (2010), people (without disabilities) assess soundscapes
according to the dimensions of pleasantness and eventfulness. In emotion theory, Russell
(2003) defines core affect as an integrated mix of the similar dimensions pleasantness and
activation. The combined interpretation of the dimensions of core affect and the appraisal of
soundscapes yields four qualitatively different perceptual quadrants, which can be considered
four different types of core affect and/or soundscapes: Lively, Calm, Boring, and Chaotic
(Andringa & Lanser, 2013; Van den Bosch et al., 2015). As depicted in Figure 3, these
perceptual quadrants can be classified according to their relative pleasantness and
eventfulness, as well as according to the complexity of action selection and the content of
audible affordances.
Figure 3: Four perceptual quadrants (Lively, Calm, Boring, and Chaotic) and their basic
dimensions (Eventfulness vs. Pleasantness or Affordances vs. Complexity). In the figure, each of
these words is positioned at the end of an axis corresponding to a high value on the particular
dimension. The other side of the axis corresponds to a low value. This figure also depicts the relative
positions of the eight descriptions used on the score sheet.
!
Lively
Calm
Chaotic
Boring
Eventfulness
Complexity
Pleasantness
Affordances
Extreme, Messy,
Chaotic, Confused
Awful, Unpleasant, Irritating,
Annoying, Horrible
Lifeless, Uninteresting,
Monotonous, Expressionless, Boring
Uneventful, Unexciting,
Immobile, Passive, Static
Simple, Quiet, Calm,
Unobtrusive
Natural, Warm, Wonderful,
Comfortable, Cozy
Expressive, Living, Fascinating,
Interest arousing
Eventful, Mobile, Lively,
Dynamic, Full of life
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49
A score sheet was developed for this study to assess the observed soundscapes and core affect
(Assessment Auditory Environment: Van den Bosch, Vlaskamp, Andringa, Başkent, &
Ruijssenaars, 2014; see Appendix I). The score sheet is based on the Soundscape-Quality
Protocol by Axelsson et al. (2010), a reliable tool to assess a person’s appraisal of soundscapes.
The score sheet includes eight descriptions (D1–D8, see Table 3) consisting of terms that,
according to the study by Axelsson and colleagues (2010), correspond to the positions at the
ends of the horizontal, vertical, and diagonal axes of soundscape appraisal and core affect (see
Figure 3 and Table 3).
Table 3: Eight descriptions (D1–D8), as used on the score sheet for assessing the quality of
soundscapes and behavior.
Description
D1. Extreme, Messy, Chaotic, Confused
D2.
Awful, Unpleasant, Irritating, Annoying, Horrible
D3.
Lifeless, Uninteresting, Monotonous, Expressionless, Boring
D4.
Uneventful, Unexciting, Immobile, Passive, Static
D5.
Simple, Quiet, Calm, Unobtrusive
D6.
Natural, Warm, Wonderful, Comfortable, Cozy
D7.
Expressive, Living, Fascinating, Interest arousing
D8.
Eventful, Mobile, Lively, Dynamic, Full of life
Using eight Likert scales, observers indicated the extent to which these descriptions suited
the observed soundscapes and the observed core affect. A score of zero was interpreted as not
applicable and a score of 100 as entirely appropriate. A result form was used to convert the
scores on the individual scales of the score sheets to a single point for the observed core affect
and a single point for the soundscapes. First, the scores were standardized, after which the
scores on the two scales representing opposite ends of each axis were added together, and
then divided by two (e.g., (D1+D5)/2). This yielded a single result for each of the four axes,
which could then be drawn into a figure on the sheet. Averaging these four points yielded the
RELATIONSHIP BETWEEN SOUNDSCAPES AND CORE AFFECT
50
final score, which could be attributed to one of the four quadrants (Figure 3). This procedure
was performed twice, once for the core affect and once for the soundscape.
Behavioral and auditory observations were conducted concurrently, in order to assess
the soundscapes as appraised by the direct support professionals themselves, and core affect of
the participants. This enabled us to investigate possible relationships between these two
variables.
To obtain a representative sampling of the course of a day, the observation days were
divided into seven intervals of characteristic activities, as depicted in Table 4 (Zijlstra &
Vlaskamp, 2005). This daily structure is reflected in all four organizations, thus making the
data comparable across organizations. The aim was to observe each of the participants during
each of these intervals, for 10 (randomly chosen) consecutive minutes. Therefore, efforts were
made to follow participants during a single whole day, thus involving observations in the
residential locations as well as in the day services setting. All participants received day-
services at the same healthcare organizations as where they received residential support.
Table 4: Daily structure divided into seven intervals.
Interval
Name
Description
1. Morning (from the moment of getting up to leaving for day service)
2.
Morning Activity
(from arrival at day care until lunch)
3.
Lunch
4.
Afternoon Activity
(from lunch until time of departure)
5.
Afternoon
(from arrival at home until dinner)
6.
Dinner
7.
Evening
(from dinner until bedtime)
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51
Procedure
A researcher visited each location for one day of data collection (5 days for 5 locations), on
which all participants from that location were observed. The researcher gave the observers a
short briefing on the research and an instruction on how to use the score sheet during the
observations. These briefings and instructions took about 30 minutes per location, per shift.
It was explained to the observers that the goal of the observations was to rate the mood (or
core affect) of the participants, instead of focusing on specific behaviors and to observe or
appraise the soundscapes as the direct support professionals themselves experienced these.
Each observation lasted exactly 10 minutes.
At the first locations (OVD1, OID11, and OID12) 18 participants were observed.
After this round of data collection, the observers evaluated the period of data collection and
the score sheet through an unstructured interview with open questions regarding the
usability. These evaluations showed that the score sheet was relatively clear and simple to use.
Although it took more time than expected to complete the form (up to five minutes per
participant), the observers considered that to fall within practical limits.
After this evaluation, data were collected from OID2 and OID13. Following the data
collection, the score sheet was evaluated with the observers. Feedback concerned the
difficulty of the instructions and minor errors in the layout of the form. The final version of
the result form was corrected in order to improve readability and layout.
The observations at the last location, or OID13, were performed twice. During the
first observation period, the observers had not been properly informed about the observations,
thereby resulting in a considerable amount of missing data on this day. After consultation, it
was decided to conduct these observations again and to exclude the data from the first day of
data collection from the analysis.
Finally, data were collected from OID3. The observations were conducted in the
same way as with the other organizations.
Analysis
In the first step, an exploratory analysis was performed on the staff attributions of the
soundscapes and the observed core affect, using SPSS 21. Two variables were used to express
the appraisal of the soundscapes: pSound and eSound. The variable pSound is a continuous,
standardized variable representing the pleasantness component (see the horizontal axis in
RELATIONSHIP BETWEEN SOUNDSCAPES AND CORE AFFECT
52
Figure 3), and the variable eSound represents the eventfulness component (see the vertical axis
in Figure 3). Corresponding variables were used to express the observed core affect in the
participants: pBehavior and eBehavior. Differences in the relationship between core affect and
soundscapes between the organizations that focus primarily on caring for people with an
intellectual disability and the organization that focuses primarily on caring for people with a
visual disability were also analyzed. These exploratory analyses provided input for multilevel
analysis.
To investigate the relationship between the staff attributions of the soundscapes and
observed core affect, a multilevel linear regression model was used, with individual
participants at the highest level and repeated measurements for each participant at the lowest
level, thus considering the dependent observations within each participant, where some were
observed by multiple members of the direct support professionals. Multilevel linear regression
analysis, also called random effects model, was selected since this gives valid results in case of
missing data at random (Little & Rubin, 1987). The dependent variables reflected staff
attributions of the observed core affect (pBehavior and eBehavior). The independent variables
included staff attributions of the soundscapes according to the average (pSound and eSound)
and time of day (Interval). To determine whether the observed core affect differed between
the two types of organizations, these types were included as explanatory variables
(Organization), as well as interactions between type of organization and perceived soundscape
(both pSound and eSound). Differences in deviance were used to test the significance of the
contributions of several nested models. Four models were formulated for the variables
pBehavior and eBehavior: the Empty model (no explanatory variables), the Interval model
(time of day, defined by the aforementioned intervals, as an explanatory variable), the Sound
model (various aspects of sound), and the Sound and Organization model (sound and type of
organization as explanatory variables). Both fixed and random effects were examined.
Observed P-values less than 0.05, were considered significant. The analyses were performed
in MLwin 2.23, software specifically designed to carry out multilevel linear regression
analyses.
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Results
In all, 149 behavioral observations were registered. On average, four observations were made
for each participant, with only three participants having less than three observations. The
number of observations in each interval is displayed in Table 5 and displays the missing data
in especially the morning and evening intervals.
Table 5: Number of observations per interval.
Exploratory analysis
Figure 4 presents the staff attributions of the soundscapes, as observed by direct support
professionals. The horizontal axis shows the variable pSound (M=0.36, SD=0.33), and the
vertical axis represents the variable eSound (M=0.28, SD=0.41).
Figure 5 presents the staff attributions of core affect, as observed by direct support
professionals. The horizontal axis shows the variable pBehavior (M=0.36, SD=0.39), and the
vertical axis represents the variable eBehavior (M=0.16, SD=0.46).
Figures 4 and 5 also indicate the differences between organizations focused primarily
on care for people with an intellectual disability (OID1-3, ) and those focused primarily on
care for people with a visual disability (OVD1, +). The averages of the variables for both
types of organizations are shown in Table 6.
Interval
Name
Number of observations
Number of observational minutes
1. Morning 14 140
2.
Morning Activity
28
280
3.
Lunch
25
250
4.
Afternoon Activity
26
260
5.
Afternoon
20
200
6.
Dinner
18
180
7.
Evening
18
180
Total 149 1490
RELATIONSHIP BETWEEN SOUNDSCAPES AND CORE AFFECT
54
Figure 4: Quality of the observed soundscapes in terms of pleasantness and eventfulness.
Figure 5: Quality of the observed behavior in terms of pleasantness and eventfulness.
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Table 6: Means and standard deviations for the variables pBehavior, eBehavior, pSound, and
eSound, by type of organization (primary focus on care for people with an intellectual –OID- or
visual disability -OVD-).
OID1-3
OVD1
Total
Mean
SD
Mean
SD
Mean
SD
pBehavior
0.35
0.39
0.41
0.41
0.36
0.39
eBehavior
0.04
0.42
0.50
0.40
0.16
0.46
pSound
0.30
0.35
0.52
0.22
0.36
0.33
eSound
0.23
0.35
0.44
0.52
0.28
0.41
As suggested by the figures in the table, the results were predominantly positive, and
higher scores were assigned for all variables in the organizational type focusing primarily on
visual disabilities. This is particularly true for the eventfulness of the observed core affect
(eBehavior).
Multilevel analysis
The results of the multilevel analysis of the four models for the variable pBehavior are
displayed in Table 7. First it was examined whether the time of day, specified in intervals,
affected the degree of attributed pleasantness of the observed core affect (pBehavior) in the
Interval model. The results indicate that time of day does not significantly predict staff
attributions of the pleasantness of the observed core affect in the participating clients.
Second, analysis of the predictors pSound and eSound on pBehavior revealed a
significant effect (pSound: estimated regression coefficient = 0.569 [SE = 0.086]*, eSound:
estimated regression coefficient = 0.172 [0.066]*) in the Sound model. This result identifies
the staff attributed pleasantness and eventfulness of a soundscape as significant predictors of
the observed pleasantness of core affect in the participating clients (pBehavior).
Finally, the type of organization (primary focus on care for people with a intellectual
or visual disability) was assessed as an explanatory variable in the Organization model. In this
model, Organization was not a significant predictor (estimated regression coefficient = 0.080
[SE = 0.079]).
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56
The best-fitting model was thus the Sound model, in which both sound variables
(staff attributed pleasantness and eventfulness of the soundscapes) together provided the
largest difference in deviance compared to the empty model.
Table 7: Results of multilevel analysis for pBehavior
Empty model Interval model Sound model Sound and
Organization model
Estimation (se)
Fixed Effects
Intercept
0.361 (0.045)*
0.210 (0.104)*
0.353 (0.034)*
0.294 (0.067)*
Interval
Morning1
Morning activity
Lunch
Afternoon activity
Afternoon
Diner
Evening
-
0.076 (0.118)
0.152 (0.122)
0.215 (0.118)
0.188 (0.123)
0.247 (0.132)
0.152 (0.126)
Sound
pSound2
eSound2
0.569 (0.086)*
0.172 (0.066)*
0.593 (0.089)*
0.184 (0.067)*
Organization
Visual12
Intellectual
-
0.080 (0.079)
Random effects
Between variance
Residual variance
0.043 (0.017)
0.110 (0.015)
0.043 (0.017)
0.104 (0.014)
0.017 (0.010
0.089 (0.012)
0.015 (0.010)
0.089 (0.013)
Goodness-of-fit
Deviance
120.299
114.193
76.039
75.065
* p < .05
1 Reference category
2 Compared to the mean
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The results of the multilevel analysis for the variable eBehavior are displayed in Table
8, using the same four models described above for the variable pBehavior. The first model
concerns the repeated measurements and the extent to which the time of day (Interval)
affected the degree of attributed pleasantness of the observed core affect (pBehavior). As with
eBehavior, no significant effect was found in the Interval model.
Analysis of the Sound model reveals that only the variable pSound is a significant
predictor for eBehavior. This result indicates that the staff attributed pleasantness of a
soundscape is predictive of the rated eventfulness of core affect (eBehavior: estimated
regression coefficient = 0.396 [se = 0.113]*). The predictive value of eSound on eBehavior is
not significant (estimated regression coefficient = 0.165 [se = 0.086]). Considering that the
effect is in the expected direction with a P-value of < 0.10, and in order to maintain the
comparability of the models for pBehavior and eBehavior, the model with both sound
variables is presented.
In contrast to the results for pBehavior, type of organization is a significant
explanatory variable for eBehavior (estimated regression coefficient = -0380 [se = 0.097]*).
The results indicate that the core affect of the participants was rated as more eventful in the
organization that focused primarily on caring for people with visual disabilities. This suggests
the Sound and Organization Model to be the best predictive model for the variable
eBehavior.
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58
Table 8: Results of multilevel analysis for eBehavior
Empty model Interval model Sound model Sound and
Organization model
Estimation (se)
Fixed Effects
Intercept
0.164 (0.054)*
0.128 (0.123)*
0.158 (0.048)*
0.435 (0.082)*
Interval
Morning1
Morning activity
Lunch
Afternoon activity
Afternoon
Diner
Evening
-
0.002 (0.139)
-0.012 (0.143)
0.059 (0.139)
0.023 (0.145)
0.095 (0.155)
0.120 (0.147)
Sound
pSound2
eSound2
0.396 (0.113)*
0.165 (0.086)
0.317 (0.110)*
0.126 (0.084)
Organization
Visual12
Intellectual
-
-0.380 (0.097)*
Randomeffects1
Between variance
Residual variance
0.066 (0.025)
0.145 (0.020)
0.066 (0.025)
0.143 (0.020)
0.040 (0.019)
0.146 (0.020)
0.021 (0.014)
0.141(0.020)
Goodness-of-fit
Deviance
162.905
161.077
148.618
135.009
* p < .05
1 Reference category
2 Compared to the mean
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Discussion
The descriptive analysis of staff attributions of the observed pleasantness and eventfulness of
soundscapes and moods in terms of core affect displayed by people with profound intellectual
and visual disabilities shows that the averages of all four variables (pBehavior, eBehavior,
pSound, eSound) fall into the upper-right quadrant. This means that, in general, the observers
described both soundscapes and core affect as pleasant and eventful. However, considering
the explorative nature of this study, these and the following results, should be interpreted
with caution. With regard to the eventfulness of core affect (eBehavior), the average was
higher at the organization focused primarily on caring for people with a visual disability. The
multilevel linear regression analysis findings endorse a relationship between reported
soundscape and reported behavior observations, which we expected on the basis of the
research by Axelsson et al. (2010) in combination with Kuppens et al. (2012). The
combination of the pleasantness and the eventfulness of the soundscapes seem to have
significant predictive value for both of these elements of core affect. This combination of
pleasantness and eventfulness can be described as the “liveliness” of the soundscape.
In addition to the characteristics of the soundscapes, type of organization appears to
be a significant explanatory variable for the eventfulness of core affect (eBehavior). These
results suggest that the core affect of the participants was rated as more eventful in the
organization that focused primarily on the care of people with a visual disability, consistent
with the results of the descriptive analysis. This model, a combination of the explanatory
variables pSound, eSound, and Organization, is the best predictive model for eBehavior. One
possible explanation for this difference is that it is conceivable that environmental noise is
dealt with differently in these two different types of organizations. In facilities with a primary
focus on people with a visual disability there is more attention for acoustic aspects than in
facilities that primarily focus on people with intellectual disabilities, e.g. in meeting certain
acoustic standards (Van den Wildenberg, Van Welbergen, & Van der Burg, 2002). Facilities
with unfavorable acoustical properties may inhibit normal conversation, promote undesirable
vocalizations, or create an aversive ambient environment (Egli, Roper, Feurer, & Thompson,
1999). This might cause a less pleasant or eventful core affect in the clients residing in
organizations with a primary focus on people with intellectual disabilities.
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60
The results also indicate that time of day is not a significant predictor of staff
attributions of core affect. It could be due to trends in the staff attributions, as opposed to
actual core affect in the participants. For example, staff might change their expectations
throughout the day and rate core affect after lunch as eventful as before lunch, even though
there were less actual indications. Also, the bias towards positive ratings, given the seemingly
positive overall ratings, can be due to an inadequacy of the staff in reliably assessing core
affect as suggested by research from Hogg, Reeves, Roberts, and Mudford (2001). The
participants were observed an entire day, and therefore they were observed by multiple
members of the direct support professionals due to working hours. This variation is accounted
for by including time as a predictor variable in our analysis. However, the uneven number of
observations throughout the day challenges the validity of the assertion of time of day not
having a relationship with core affect. Further research into the relationship between the time
of day and staff attributions of core affect is recommended.
This is a newly developed assessment procedure, and an exploratory (or pilot) study,
in which refinement of the assessment procedure played an important role. Consequently
there is no information regarding the psychometrics of this assessment procedure yet. The
results however, seem to comply with previous research on soundscapes and the effects
thereof on (the moods, behavior and health of) people without disabilities (Andringa &
Lanser, 2013; CALM, 2004; Kaplan, 1995; Kuppens et al., 2012; WHO, 2000). Also, the
procedure was based on the Soundscape Quality Protocol by Axelsson et al. (2010), a reliable
tool to investigate the subjective appraisal of soundscapes, however now applied for the first
time in healthcare settings for people with profound intellectual disabilities. The validity of
this research (partly) stems from the consistency with previous literature, but further research
is needed to confirm this
This study is subject to several limitations, such as the choice not to control for
individual differences (e.g. level of intellectual or of visual disability) in making the statistical
comparisons. This choice was based on the nature of the target group and the facilities in
which they reside. In these residential facilities a number of people with profound intellectual
and visual disabilities are placed together, forming heterogeneous groups. The aim of this
study was to make a first assessment of the staff attributions of soundscapes in these groups
and so to ultimately optimize these soundscapes to improve the quality of life of
heterogeneous groups of people with profound intellectual and visual disabilities. In future
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61
studies, individual differences need to be included in the study design. Also, follow-up study
involving simultaneous observations by two members of the direct support professionals, or
other groups of observers such as researchers or family members, could allow analysis
regarding inter-rater reliability and further psychometric analysis to validate the assessment
procedure introduced in this paper. The amount of missing data does not necessarily have to
be considered a limitation of this study, since the missing data arose due to logistic reasons,
such as a higher workload for the observers in the mornings and evenings. Because the
missing data did not arose due to factors related to the dependent variables, and can be
considered missing at random, the results from the multilevel analysis are expected to be valid
(Little & Rubin, 1987).
One important question that remains is how people with profound intellectual and
visual disabilities actually experience soundscapes. Given their profound disabilities, it is
likely that they process sound in a different way than people without disabilities. That is the
main reason why the DSP in this study were asked to observe and appraise the soundscapes
as they themselves experienced these environments. At this point, it is unfeasible to make
correct judgments on how people with profound intellectual and visual disabilities experience
soundscapes. For example, people without intellectual and visual disabilities can distinguish
the importance of sounds but people with these disabilities might be able do this poorly,
more slowly, or not at all. All sounds may appear equally important to them, because
prioritizing might be difficult and they may have difficulties in attending to the sources
optimally. Also, our data does not allow any conclusions regarding the rotation of axes
representing core affect, pleasantness and eventfulness, for people with profound intellectual
disabilities. For example, people without disabilities might perceive a particular environment
as lively, while those with profound disabilities might perceive it as chaotic and
overwhelming. If this is the case, the axis should be rotated in a counter clockwise direction.
Only by researching how people with profound intellectual and visual disabilities react to
different kind of soundscapes, will we be able to unravel the actual perceptual processes of
people with profound intellectual and visual disabilities.
The ability of people with disabilities to interact with their environments depends in
part upon the sounds within these environments, and people with such disabilities might not
have the cognitive capacity to comprehend many contemporary soundscapes (Van den Bosch
et al, 2015). It is therefore important to investigate how the auditory environment can be
RELATIONSHIP BETWEEN SOUNDSCAPES AND CORE AFFECT
62
optimized for people with both intellectual and visual disabilities in order to make these
people feel safer and more comfortable in their living environment. Because these people
cannot adapt optimally to their environment, they need well-tuned conditions to flourish.
This may already be accomplished by investigating how people with intellectual and visual
disabilities react to sounds and by making simple changes to their environment like adding
pleasant background noise and using acoustically damping materials. As a result the
interactions between people with intellectual and visual disabilities and their direct caregivers
will be more efficient and effective because there will be less miscommunication and negative
attention, increasing the probability of people with these disabilities experiencing positive
moods.
This chapter is based on: Van den Bosch, K., Andringa. T., Post, W., Ruijssenaars, A., & Vlaskamp, C.,
(submitted). The relation between the auditory environment and challenging behavior in people with a severe or
profound intellectual disability.
Chapter Five
The relationship between soundscapes
and challenging behavior
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64
Abstract
This article focuses on the relation between the auditory environment and mood and
(challenging) behavior in people with severe or profound intellectual and multiple disabilities
(PIMD). Given the high prevalence of visual disabilities in this target group, a high quality
auditory environment is important. We describe a pilot study, in which 13 direct support
professionals used the smartphone application MoSART to appraise the auditory environment
during a period of four weeks. Pre- and post-test measurements were administered of the
moods (MIPQ) and challenging behaviors (LGP-PIMD) of 15 participants with a severe or
profound intellectual disability. Results showed that the implementation of MoSART was
accompanied by an increase of ‘lively’ appraised auditory environments, and significant
decreases of negative moods and severity of stereotypical behavior of the participants.
CHAPTER FIVE
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65
Introduction
Challenging behavior is common among people with an intellectual disability. The
prevalence of psychiatric and behavioral problems in this population is estimated at 30-50%
(Došen, 2005), entailing a three to five times higher risk of suffering from these problems
compared to the general population, with an even higher prevalence among people with
profound intellectual and multiple disabilities (Poppes, Van der Putten, & Vlaskamp, 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). Self-injurious behavior is defined as behavior that may cause
harm to a person's own body (Matson, Cooper, Malone, & Moskow, 2008). Examples are
beating, biting or scratching oneself. Stereotypical behavior is described as repeated body
movements or postures that are not part of a purposeful act, such as swaying back and forth,
smelling objects, yelling and screaming. The definition of aggressive / destructive behavior is
an offensive action aimed at people or objects like hitting, kicking, pushing or scratching of
other people (Rojahn et al., 2001). In addition to the above types of challenging behavior,
some authors stress that withdrawn behavior may also be regarded as challenging behavior,
giving its consequences (Poppes et al., 2010). Withdrawn behavior is described as behavior in
which the person fails to make contact with the environment. This includes warding off
physical contact, avoiding eye contact, being apathetic and having a closed posture. This type
of challenging behavior is especially frequent among persons with profound intellectual and
multiple disabilities (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 and integration
into the community, limitations in the way these people are seen by others, negative effects
on learning, personal development, and reduced participation in social activities (Matson et
al., 2011; Lundqvist, 2013). People with an intellectual disability who display challenging
behavior are also more at risk to be abused and neglected (Lowe et al., 2007). Challenging
RELATIONSHIP BETWEEN SOUNDSCAPES AND CHALLENGING BEHAVIOR
66
behavior is thus a major problem for many people with an intellectual disability, not only