Influencing Participation Through Assistive Technology

Influencing Childrens’ Growth and Development with Assistive Technology

Children have an “inborn drive to discover and learn” (p. 1)¹⁹ that motivates them to understand the world around them, strive for independence, establish a sense of self, and connect socially with others. When a disabling condition is present, children may have difficulty with accessing play, learning, or self-care activities. Burkhart offered four “secrets” to support children’s successful engagement: (1) create motivating activities, (2) develop opportunities for active participation, (3) present information and materials using multiple modalities, and (4) use authentic learning scenarios in natural contexts.¹⁹ Research indicates that AT can be instrumental in helping young children with disabilities learn valuable life skills such as social skills, including sharing and taking turns, communication skills, attending, fine and gross motor skills, self-confidence, and independence.^{7,54,76,105,107} As children grow, they may use technology to develop independence in many activities of daily living (ADLs) and instrumental activities of daily living (IADLs), complete school assignments, develop prevocational and vocational skills, increase opportunities for social participation, and play games or participate in leisure activities. The use of AT can create exciting opportunities for children to explore, interact, and function in their environments.

For children with disabilities, introducing the appropriate types of technology systems as early as possible may enable the child to participate in important learning situations that otherwise, because of his or her disabilities, may not be possible. For more than 20 years, researchers and clinicians have documented and discussed the unique opportunities that all types of AT offer for teaching and for advancing the life choices of children with disabilities.^{9,10,33,43,54,61,85,101,105}

Because technology is constantly changing, this chapter presents problem-solving strategies, principles, and frameworks for decision making versus in-depth descriptions of specific devices or systems. The frameworks and guidelines for decision making that are presented should not be viewed as limiting strategies. Rather, they are meant to be a starting point. Each practitioner needs to adjust the concepts given the individual needs of the client and family, teaming issues, availability of resources, and many other factors unique to each situation.

Definition and Legal Aspects of Assistive Technology

AT comprises a broad range of devices, services, strategies, and practices used to address functional problems encountered by individuals who have disabilities.²⁸ Assistive technology is legally defined by Public Law (PL) 108-364 The Assistive Technology Act of 1998, as amended: “any item, piece of equipment or product system whether acquired commercially off the shelf, modified, or customized that is used to increase, maintain or improve functional capabilities of individuals with disabilities.”

PL 108-364 further defines an AT service as any service that directly assists an individual with a disability in the selection, acquisition, or use of an AT device. The law includes several clarifications to enhance the definition of AT service: (1) evaluating needs and skills for AT; (2) acquiring assistive technologies; (3) selecting, designing, repairing, and fabricating AT; (4) coordinating services with other therapies; and (5) training both individuals with disabilities and those working with them to use the technologies effectively.

In a similar manner, the Individuals with Disabilities Education Improvement Act (IDEA) (PL 108-446) defines both AT devices and services as a means of providing a free and appropriate public education (FAPE). IDEA 2004 requires that individualized education program (IEP) and individualized family service plan (IFSP) teams consider a child’s need for AT devices and services at least annually during the development of the IEP/IFSP. Additional information regarding other legislation related to AT can be found in Table 20-1.

In this chapter, assistive technology is used as a broad term that encompasses devices ranging from low technology to high technology. Low-tech devices (e.g., pencil-and-paper communication boards and built-up foam handles) are inexpensive, simple to make, and easy to obtain. High-tech devices (e.g., wheelchairs, augmentative communication devices, and computers) are generally expensive, more difficult to make, and more difficult to obtain. Mid-tech devices fall somewhere in between and may consist of hand-made or commercially available items.

This chapter discusses general information regarding the use of AT with children, followed by specific examples of application. Other chapters in this text specifically address the other areas of AT (see Chapters 16 and 21). Many of the principles and decision-making strategies discussed in this chapter can be generalized to all areas of AT.

Models for Assistive Technology Assessment and Decision Making

The occupational therapy practitioner uses a variety of theories and practice models to guide the occupational therapy process (evaluation, intervention, and outcome monitoring). Practice models specifically related to AT help occupational therapists make decisions regarding its use and facilitate the integration of AT within the practice of occupational therapy.

Assessment tools and models to guide AT evaluation and service delivery have been developed by a number of professionals.^{7,16,28,91,109,113} Each of these models provides a framework for evaluating needs, making decisions, and implementing intervention. Using a model for service delivery helps to ensure that the evaluation process is systematic and complete. Three models are highlighted in this chapter.

The Human Activity Assistive Technology (HAAT) model,²⁸ the Student Environment Task Tool (SETT) framework,¹¹³ and the Matching Person and Technology (MPT) assessment process⁹⁰ follow the person-environment-occupation (PEO) model⁶⁵ and emphasize an occupation-based approach to AT practice. These models provide frameworks for decision making regarding the selection, implementation, and evaluation of AT.²⁸

Child- and Family-Centered Approach

The social context of AT use can be considered the most influential and important, because it is often the social environment, including the attitude of others, that creates a disability more than the physical barriers in the environment.²⁸ Any person (e.g., parent, sibling, teacher) who interacts with an individual using AT, either directly or indirectly, is considered part of the social context. The simple presence of a disability can be socially stigmatizing, and the introduction of AT can add additional burden, particularly when individuals within the social environment do not support use of the technology. It is important to recognize key individuals who provide assistance to the child using AT across environments (e.g., home, school, work), because technology use is facilitated when assistance is received from consistent individuals.

Each person’s unique culture influences the manner in which he or she interacts with others and the importance of participation and engagement in various activities and life roles.²⁸ Some cultures do not value the independence that AT provides individuals with disabilities, or an AT device may be abandoned if it replaces an important life function of another family member. For example, the grandmother who views communicating for a child with cerebral palsy as one of her roles may resist the child’s use of an augmentative communication system. Cultural factors must be considered in providing AT devices and services. Box 20-1 summarizes some sociocultural factors that the therapist may need to consider when evaluating, designing, and selecting AT systems for children.

Abandonment

Despite the many promises of technology, one third or more of individuals discontinue their use of their AT device.⁹⁰ Abandonment can mean the device is no longer needed, but more often it signifies a mismatch between the user and the device. When a device fails to live up to its promise of potential, freedom, and independence, disillusionment with the idea of AT may result. Failure to take into consideration the user’s preferences, ideas and desires for an AT device is a primary reason for abandonment.^77,90 Users of AT, their families, and/or educational staff may have high expectations for an AT device and can be devastated when expectations are not fully met with far-reaching results.

Learned Helplessness and Self-Determination

Psychologist Norris Hansell theorized that there are seven essential and interrelated attachments necessary to create a sense of connectedness and quality of life.⁴⁹ These include having the supports necessary for existence (food, water, air, information); identity; connection with other persons; connection to groups; connection to a social role; money and purchasing power; and a system of meaning, each implying reciprocity with others. When this reciprocity is thrown off balance by internal or external circumstances, a sense of isolation, helplessness, and hopelessness can occur. “Human beings can be proactive and engaged, or, alternatively, passive and alienated, largely as a function of the social conditions in which they develop and function” (p. 68).⁸⁸ Ryan and Deci determined the needs for competence, relatedness, and autonomy as essential for social development and personal well-being.⁸⁸ AT can build bridges or create additional barriers between the user and the environment in which he or she wishes to participate.

Children with disabilities can become passive and unmotivated because of a lack of learning opportunities or a lack of independent control over their environment. This can result in decreased interest in or skills to interact with the environment.³⁵ When children perceive that they have little control over outcomes within their environments, the phenomenon of learned helplessness can result. Learned helplessness is a secondary disability and is the belief that one cannot exert personal control over outcomes experienced when interacting with the environment.^1,69 Children with learned helplessness exhibit low self-esteem, directly affecting how they interact and perform functional skills. They usually demonstrate a lack of initiation and an inability to cope with the events around them. In addition, when opportunities for integrating basic cognitive and perceptual skills are missed in early childhood, these children do not develop a foundation for learning higher-level concepts. Strategies and adaptations that allow these children the maximum amount of independence possible as early as possible decrease the chance for them to learn that they have no control over their environment.

The opposite of learned helplessness is self-determination. Self-determination is defined as “acting as the primary causal agent in one’s life and making choices and decisions regarding one’s quality of life free from undue external influence or interference” (p. 24).¹¹⁰ Self-determination is an umbrella term that encompasses several common concepts used in describing children’s personal, social, and skill development. These concepts include self-efficacy (outcome and efficacy expectations), self-esteem, and self-advocacy. Efficacy expectations are personal beliefs regarding one’s capability to realize a desired behavior in a specific context (judgment of what one can do with the skills one has). Outcome expectations are personal beliefs about whether a particular behavior will lead to a particular consequence (being able to determine if one’s goals are realistic). Self-esteem is the belief that one has in oneself, or self-respect. Self-advocacy refers to an individual’s being able to speak for him or herself, make decisions for him or herself, and know what his or her rights are, particularly when those rights have been violated or diminished. The individual is able to take ownership of his or her needs, rather than expecting someone else to take responsibility for them because he or she has a disability.^104,110 Appreciating and being able to function with a sense of interdependence are also crucial parts of self-determination.

Self-determination is a set of skills that can be taught and learned. Key characteristics and components include autonomy, self-awareness, choice making (i.e., often children with disabilities are not given the opportunities to make effective choices), decision making, problem solving, goal setting and attainment, internal locus of control, positive attributions of efficacy and outcome expectations, and self-knowledge.¹¹⁰ With the increased emphasis on transition services and preparing children for life skills beyond school, occupational therapists should promote the development of self-determination for children of all ages. This includes ensuring that services develop skills of interdependence and independence, addressing the participation and productivity of children, recognizing that self-determination can mean different things to different people, and recognizing that self-determination is a quality-of-life issue that can be addressed across settings, environments, and opportunities. AT devices can help with the development, practice, and effective use of self-determining behaviors for children with disabilities.

Practice Settings

“The institutional context refers to larger organizations within a society that are responsible for policies, decision-making processes, and procedures” (p. 43).²⁸ The International Classification of Function, Disability, and Health (ICF) categorizes economic, legal, and political components as services, systems, and policies. This institutional overlay has major implications for both the acquisition and use of AT, with regards to funding, legislation related to environmental and community access, as well as standards that govern product design, function, and safety standards.²⁸

Differences in practice settings in which occupational therapy practitioners who use AT may be employed are outlined in Table 20-3. The role of the OT practitioner in each of these settings is governed by a combination of professional scope of practice, the expertise of other members of the team, and the agency or funding source.

Occupational Therapy Process and Assistive Technology in the Schools

According to the most recent statistics published by the U.S. Department of Education, Office of Special Education Programs, as required under the IDEA, an estimated 7.1 million children from birth to 21 years of age receive special education services.¹⁰⁸ Most children who need AT receive those services in school. AT devices and services are provided if necessary for a child to receive FAPE in the least restrictive environment (LRE). The need for AT must be considered, at least annually, for all children who receive services under IDEA. When AT is a necessary part of the student’s program, then the school district is responsible to make sure that it is available to the child. It is not uncommon for the expertise of an occupational therapy practitioner to be requested when the team is considering AT for a student. Guides and models for considering AT for students in special education are available online (see Appendix 20-A on the Evolve website for Internet resources).

Baush, Ault, and Hasselbring indicated that appropriate AT devices and services can help a student improve, increase, or maintain performance to perform or develop functional skills (e.g., self-help, mobility, or communication), access curriculum (e.g., multimedia presentations or books on tape), become a more efficient learner (e.g., pencil grips and raised lined paper to improve writing legibility), or compensate for lack of skills (e.g., word prediction software to assist with spelling or reduce keystrokes).⁸ The roles and responsibilities of IEP team members, including the occupational therapist, providing AT services within a school setting are listed in Box 20-2.

The Transdisciplinary Team

The provision of AT services occurs across disciplines, and the training and experience of the service providers has not been widely studied¹¹² (Research Note 20-1) and the profession of “assistive technologist” does not exist.⁹⁵ Professionals specialize in AT on the basis of personal interest and self-study. Several universities offer certificate programs and advanced degrees in AT. In addition, the Rehabilitation Engineering and Technological Society of North America (RESNA) has established a mechanism for verifying a minimum level of competence for individuals serving as AT providers through an examination process that provides credentialing for persons working as assistive technology practitioners (ATPs). The ATP usually has a background in a rehabilitation discipline such as occupational therapy, physical therapy, speech-language pathology, or engineering.

As with many other specialty areas in pediatrics, the successful implementation of AT requires a cohesive and effective team that emphasizes shared vision and ownership. The team’s input is critical to making decisions regarding AT because devices are used across the child’s environments and address multiple performance goals that cross professional boundaries. Decisions that the transdisciplinary professional team and the family make together are most likely to meet the multifaceted needs of the child. The child and the family are considered members of the team in all forms of service delivery.

The specific members of the team may be different in various situations depending on the type of device being introduced to the child, the expertise of the individuals involved, and the specific setting. For example, in a clinical setting, the team may include the child and family, occupational therapist, physical therapist, speech-language pathologist, doctor, nurse, rehabilitation engineer, and social worker. In school-based practice, the team may include the child and family, occupational therapist, physical therapist, speech-language pathologist, educator, administrator, and psychologist.

In some settings, occupational therapy assistants and aides provide some of the AT services. Assistants are particularly helpful in training a child to use a system once the therapist has set up and established the program. Assistants and aides may also be involved in practicing use of the device with the child and helping others use the systems. Therapists working in AT service delivery must determine which activities are appropriate to delegate and which activities are specialized and require the training and skills of a therapist.

Assistive Technology Evaluation and Intervention: A Dynamic Process

The occupational therapist has a key role on the AT evaluation team. The unique perspective on occupation and engagement in meaningful activities that the occupational therapist offers the team is helpful in determining needs, problem-solving potential solutions, and evaluating outcomes. The assessment of client satisfaction has been one of the key factors in determining the effective implementation and usefulness of AT in the lives of individuals with disabilities.^{30,31,90,92,104}

In addition to evaluation and intervention services, AT services may also include device procurement, training, skill acquisition, monitoring, and other services that support and enable the child’s participation in home, school, and community activities. Because of the complexity of many AT systems, specifically those that are high-tech, the therapist needs a systematic procedure for follow-up and adjustments to help ensure the viability of the system over time. These steps of the process are dynamic rather than linear and sequential. For example, intervention may begin by addressing prerequisite skills for AT use before completing the AT evaluation and procuring a specific device. Once a system has been chosen and purchased, evaluation, monitoring, and decision-making processes continue throughout intervention.

Device Procurement

It can take up to several months to procure an AT device. When funding issues stall the process, members of the team may be involved in writing letters of justification to insurance companies and other third-party payers. Careful documentation during the trial periods with different devices can help with this process. Documentation can include videos or pictures of the child using the system that demonstrates how the system helps improve his or her function.

Once the system has arrived, the team works to put the system together, test the system, and begin training. Some companies provide vendors that can help with the process, and others have videos that come with the system. However, it is not uncommon for a system to be delivered with minimal instructions. This can be daunting to the family if the system is delivered directly to the home and family members and other support providers are unsure how to use it. Comprehensive intervention and education are needed to help the child and family incorporate the device into their daily lives.

Funding

Occupational therapy practitioners working in the area of AT are often involved in helping procure the appropriate devices. In particular, they often provide the documentation used in applying for funding. Funding can come from various sources, including Medicaid, grants, private insurance, nonprofit agencies such as United Cerebral Palsy, private foundations, schools, and individual payment. In some states, funds are available through the Department of Developmental Disabilities, the Department of Health, or the Department of Social Services to help purchase AT devices. As students enter high school and begin the transition to work and career sites, the state’s vocational rehabilitation agency may also assist with the funding of devices. In addition, there are some alternative sources of funding that the team may want to consider.²¹ These include community service organizations, equipment loan programs, used and recycled equipment, and technical assistance projects. Often these alternative sources can take additional time and effort to research and contact. However, when a family or system has limited resources, pursuing creative funding options can result in the successful procurement of a device. When families cannot afford new devices or secure funding, they may explore AT reuse programs such as the Pass It On Center coordinated by the U.S. Department of Education’s Office of Special Education and Rehabilitative Services (OSERS), because these programs often do not have eligibility requirements.⁷⁵ Occupational therapists should learn about the different funding options available within their state and region to contribute to the team’s effort to obtain funding for AT devices.

Funding of AT in school districts often raises unique issues. The school district is the payer of last resort, but it is ultimately responsible for AT devices that the child needs to learn in the school environment.^21,106 Public or private insurance can be applied to obtain AT devices and services when they are determined to be medically necessary.⁹⁶ The use of these funds must be voluntary on the part of the parents and with their written consent. School districts can also work with community service organizations or associations (e.g., the Muscular Dystrophy Association) to purchase AT devices or pay for services. If the AT device is purchased with the parents’ funds or insurance, then the device belongs to the child and the child’s family. However, if the school district purchases the device, then the school district owns the device.^74,109

Often the occupational therapist writes or assists with writing a letter of justification to support the funding of an AT device. Strong supporting documentation that clearly demonstrates the necessity of the device to strengthen the child’s engagement in occupation is an important part of the process. This documentation is based on the evaluation data gathered by the team and takes into consideration the language and priorities of the funding agency.²¹ If the letter is written to a health insurance agency, then medical necessity must be emphasized; if it is directed to an education-related funding source, then it must address the child’s ability to access and participate in educational programming. Requests to vocational agencies must address employment potential and skills.^21,93,109 Other key elements in the letter may include information about the child, the device, the evaluation procedures including results of any trials conducted, and the environment(s) in which it will be used; how the child will benefit from the device; alternative or potential outcomes of not being provided the device; supporting photos or measurements; and information about the cost of the device and other options considered.

Implementation of AT Services

An AT implementation plan should include: person(s) responsible, conditions of use, frequency of use, and duration of use. The team considers all of the tasks and contexts in which the AT will be used. Thus, for example, if a student requires a voice output communication system, it should be readily available at all times throughout his day (e.g., at lunch or recess to socialize, during instruction to ask or answer questions, during independent work to indicate needs and wants, and at home to interact with his/her family).

The introduction of an AT device, especially a complex device, can change the focus of a child’s program. Time must be spent on training and practice within the child’s natural environments (i.e., school, home) as the family and professionals make efforts to integrate use of the device into the child’s everyday activities. Thus, the development of skills needed to use the device often becomes the focus of intervention. Involvement by every member of the team encourages skill generalization to various settings and situations of the child. When staff are encouraged to work as a team and time provided for them to communicate, the effectiveness of AT is likely to increase.¹⁶ The AT devices should be readily accessible; if the device or strategy takes longer than 60 seconds to access and set up, it is less likely to be used. Examples of forms used to document an implementation plan (e.g., the NATRI Assistive Technology Implementation Plan and the QIAT Plan for Evaluation of Effectiveness of AT Use) can be accessed at the Evolve website.

Education Tech Points: A Framework for Assistive Technology Planning, as developed by Gayle Bowser and Penny Reed, identifies key points to assist educational teams in making decisions regarding the use of AT services and facilitates identifying resources that can be written into the child’s IEP.¹⁶ These points are beneficial for AT teams to consider regardless of the practice setting. Implementation and periodic review of the plan will help avoid the potential abandonment of recommended AT devices and services. Considerations related to AT implementation and day-to-day operations may include the following¹⁶:

Measuring Progress and Outcomes

Not only does good AT decision making require an eye on the future, but evaluating the outcomes of AT takes a long-term commitment³² to ensure that it continues to support the child’s engagement and participation in purposeful activities. Often it is difficult to operationalize and define global outcomes specific to AT.⁴⁴ The goal of outcome measurement is to determine the efficacy and utility of AT devices and implications for abandonment. It is important that occupational therapists as members of AT teams select appropriate outcome measures to help determine whether devices and services have the intended effect.

Data collection is critical to evaluating AT’s success. The team should be involved in a collaborative discussion regarding how data will be collected. Data collection should be simple and straightforward enough for all team members including family members to understand and complete with ease. Often, there are various ways to measure effectiveness or differing ideas on what the desired response or outcome of the child should be. For example, when designing a data sheet for switch use, one needs to consider which part of the body will be used to activate the switch, how much wait time will be allowed before a prompt is given, the type of prompt to be given (e.g., visual, verbal, hand-over-hand,), and how to define objectively what constitutes success for the given task (e.g., single switch activation, activation or deactivation of an electronic device, holding a switch for a specified amount of time). The occupational therapist can guide the team in a discussion of how to measure the child’s performance.⁹⁵

Data collected over time can support the continued use of AT devices already in place or justify the need for follow-up evaluation. Often data are collected on targeted goals and objectives and are dependent upon the service settings in which the device is used. Possible factors to measure include changes in the child’s performance or level of function, change in level of participation, how often the device is used and under what circumstances, overall consumer satisfaction, goal achievement, quality of life, and cost analysis/savings. Table 20-5 outlines a number of assessments that may be used to evaluate outcome measures for AT.⁵

Often, once the child and family have a basic understanding of the AT system and begin to use it independently, the occupational therapist may discharge the child from direct services. However, discharge from a regular routine of intervention should include a follow-up plan. The therapist can perform follow-up in several ways, from a telephone call to an extended clinic visit or simple review and analysis of data collected. The type of follow-up and when it should occur depends on the complexity of the system and the skills of the child, family, and other professionals working with the child. A predetermined schedule for follow-up (e.g., at intervals of 6 months or less or sometimes 1 year or more) is a component of effective service delivery. Problems and delays in service can be prevented with planned periodic review.¹⁶

In addition to outcomes for individual users of AT, instruments are available to assist AT teams in conducting quality assurance studies for the services that they provide. Quality Indicators for Assistive Technology (QIATs)⁸⁰ and the School Profile of Assistive Technology Services⁸¹ are both used in school settings to support the development and delivery of AT services. Use of these indicators as guidelines can support outcomes for the child, the family, the classroom, and the system.

Access

Providing physical access to homes and schools may include both devices and services.⁵⁶ Modifications to buildings, rooms, and other facilities allow children with physical or sensory impairments to navigate both inside and outside of buildings using curb cuts, ramps, and door openers; labeling of key areas with pictures, text, and Braille; the provision of accommodations for individuals of varying sizes; or those who use wheelchairs to access restrooms, water fountains, pay phones, or elevators. Occupational therapy practitioners are trained to identify ways to improve performance and safety in the natural context to arrange resources, and to modify the environment to decrease or eliminate barriers.

Bus modifications for entry and exit and safe and appropriate seating can help with transportation to and from school and school-related activities including field trips, sports, and recreation. Within the building, doors, walkways, handles, light switches, and stairs can be modified to provide equal access to all students. Outside the building, seating and playground modifications can allow or enhance safe mobility and participation in recreational activities.⁴⁵

Universal access has become an important concept that guides school and clinic purchase of new technology, particularly new computer systems. Most schools and clinics have established guidelines for ensuring universal access as they update and expand their computer systems. When all children, including those with disabilities, have equal access to technology, costly modifications for individuals can be avoided. Often the complexity of AT is not considered when general technology is purchased, so that computers do not support some of the software programs or adaptive peripherals needed by children with disabilities. A team of professionals, consumers, technology developers, and standards organizations must plan together to ensure that technology is accessible to all.

Universal Design

Ronald Mace, founder and program director of The Center for Universal Design,²⁴ was an internationally known architect and visionary who used the term universal design to describe the concept of making all products and the built environment physically pleasing and usable to the greatest extent possible by everyone, regardless of their age, ability, or status in life. Mace used a wheelchair for mobility purposes, and his work relating to accessible design was instrumental in the passage of national legislation prohibiting discrimination against people with disabilities, the Fair Housing Amendments Act of 1988, and The Americans with Disabilities Act of 1990. The principles of universal design are outlined in Box 20-5.

According to The Center for Universal Design, “the intent of UD is to simplify life for everyone by making products, communications, and the built environment more usable by as many people as possible at little or no extra cost.”²⁴ Universal design is a proactive approach that can eliminate many barriers, but does not replace the need for individualized AT. Although typical furnishings, toys, and instructional materials found in homes and classrooms may meet the needs of many, items that are “easier to handle, larger, less slippery, color coded or in some ways more inviting and functional” (p. 5)⁸² may be required for others.

Positioning and Ergonomics

Positioning and ergonomics conceptually include the physical positioning of the child for comfort, function, and work; location of the child within the environment; and location of supports in relationship to the child. A child’s positioning should never be static in nature. Seating, positioning, and mobility devices are often the foundation for successful use of all other AT, and they may be used to improve body stability, provide proximal trunk and head support, allow for exploration of the environment, and reduce localized skin pressure.⁷⁸ The right seating and positioning equipment allow users to interact with their environment and perform tasks that are meaningful and life sustaining. “A task performance position is one that the person must be able to assume and maintain and in which the person can move” (p. 3).⁵⁵

The environment cannot and should not come to the child; the child should be able to enter into and interact within the environment. One size does not fit all (Figure 20-4). With any population, there are variances in physical size and stature, and access methods can make it a challenge to provide adjustability to fit everyone comfortably. Computer use is rapidly becoming the rule (and the computer the tool of choice) rather than the exception in home, work, and school environments. Ergonomic working arrangements allow users to work in neutral, relaxed positions that consider energy conservation, which is important to maximize productivity for all users while protecting health and minimizing the risk of injury. Productivity is the result of a comfortable marriage of the user and the tool.

As technology becomes a more important part of children’s lives at home and school, so does the need to pay attention to the health aspects of using computers. Proactive approaches to ergonomics programs should be embraced, particularly with regards to prolonged computer usage. American children typically spend between one and three hours a day at a computer, putting them at high risk for wrist, neck, and back problems.²⁹ If children, or those advocating on their behalf, learn at an early age how to adjust a workstation, they will make similar adjustments later in life. These habits and skills can be established as early as the preschool years. Many schools have chosen not to include ergonomics programs because of the costs often associated with implementation. Box 20-6 outlines some minor changes that have minimal or no costs associated with them.

Alternative and Augmentative Communication

Verbal communication is an inherent function of human beings and lends quality and detail to our social interactions with one another. Communication is not designed to be a solitary activity, because the purpose of communication is to exchange and share information with another individual. Children with disabilities may present with a range of performance levels related to receptive and expressive language. It is important that we consider the continuum of AT options available to support communication at any level. As stated by the National Joint Committee for the Communications of Persons with Severe Disabilities, “all persons, regardless of the extent or severity of their disabilities, have a basic right to affect, through communication, the conditions of their own existence.”⁷³ In addition to this basic right, the committee has outlined specific communication rights that should be ensured during all daily communication acts with persons with disabilities (Box 20-7).

Alternative and augmentative communication (AAC) is defined as communication that does not require speech and that can be individualized to the unique needs of the child. An AAC system uses a combination of all the methods of communication available to a child. This can include “any residual speech, vocalizations, gestures, and communicative behaviors in addition to specific communication strategies and communication aids” (p. 7).³⁴ The overall purpose of AAC is to enable the transmission of a message to another individual. According to Beukelman and Miranda, even students with severe disabilities can benefit from AAC use.¹¹ Research indicates that individuals with complex communication needs who do not gain successful access to AAC are at high risk for abuse, crime, unemployment, and limited social networks.^17,27

AAC interventions, much like other AT tools, should be dynamic and include not only the individual child, but also his/her primary communication partners. Beyond the obvious function of self-expression, AAC can help to support the development of language, emerging literacy skills, enhance participation in educational settings, facilitate friendships, and support interactions with family members and people in the greater community.²⁸ When one family member relies on AAC, it always has an impact on the entire family unit.⁴⁷ For this reason, it is imperative to use a collaborative approach when evaluating and implementing AAC supports. Various members of the team will bring different levels of expertise to share: child and parents will have the best knowledge of daily communication needs and routines, teachers will have knowledge related to literacy and instruction, speech-language pathologists are experts in language development, and occupational and physical therapists provide services related to positioning, accessing, and physically using the AAC system.

Attitude and acceptance of AAC play a role in its impact on the quality and function of interactions. AAC systems must be designed with layout and components that match the desires, preferences, abilities, skills, and environmental contexts of the child. Many parents are fearful that AAC will interfere with speech development, when in fact it has been found to enhance it.¹⁴ A family-centered approach should be used when AAC is integrated into the child’s daily experiences and interactions, to ensure caregiver support of its use.⁶⁸

Communicative interaction has four purposes⁶⁷: expression of wants and needs, information transfer, social closeness, and social etiquette. It is important for practitioners to also be aware of the three types of AAC communicators³⁶: emergent communicators who have no reliable method of symbolic expression, context-dependent communicators who do have symbolic communication but are limited to specific contexts because they are only intelligible to familiar partners or may have insufficient vocabulary, and independent communicators who can communicate with anyone on any topic. Research indicates that children who use AAC are most frequently identified as “responders,” whereas typically developing peers consistently act as the “initiators” of communication.²⁵ These classifications can serve as a foundation for identifying and establishing an AAC system in conjunction with the use of strategies that facilitate communication (Box 20-8).

AAC devices can be viewed on at least two continua, including no-tech to high-tech systems and aided or unaided communication methods. Depending on their age, contexts, and skills, children may use a combination to aided and unaided communication and a combination of low- and high-tech devices. Unaided or body-based communication is no-tech and consists of vocalizations, gestures, facial expressions, sign language, pantomime, eye gaze, and/or pointing. All people use some combination of unaided communication. Children with disabilities often use gestures, facial expressions, and body language as allowed by their functional skills.

Aided communication systems are distinguished as either nonelectronic or electronic communication aids and require the child to be able to use a symbol system.²⁸ Nonelectronic aids are considered low-tech and include communication boards or books, picture-based systems, or paper and pencil. Picture-based systems are used increasingly with children in preschool, children with severe disabilities, and children with autism (Figure 20-9). Some children may find it easier to use visual-based systems of communication and to process content delivered using such systems. Visual representation such as objects, photographs, realistic drawings, line drawings, and written words can be used to increase understanding, communication, and social connectedness, and can take many forms depending on the environment and the circumstances under which they are used. Visual bridges⁵² can be designed to assist students to communicate about themselves using a combination of written words, objects, photos, computer-generated picture symbols, clip art, or other visual cues. Visual bridges can also be used during reading and writing activities. Emergent readers benefit from graphics paired with text to reinforce the meaning of print. Visual supports can be used during the development of schedules, augmentative communication systems, games, sequencing, and academics.

For individuals who have difficulty understanding two-dimensional visual representation systems such as photos, drawings, and graphics, Bloomfield suggests the use of True Object-Based Icons (TOBIs).¹⁵ TOBIs are any drawing, picture, or photo cut out in the actual shape or outline of the item they represent, thus providing visual information to the communicator (Figure 20-10). Tangible symbols are another example of providing symbolic representation of language, allowing communicators to relate to objects and experiences beyond their immediate context. Tangible symbols⁸⁷ are two- and three-dimensional manipulatives that can be objects, parts of an object, or an associated object that conveys meaningful information to the user or represents their communicative intent. For example, a small bit of chain might indicate time to swing, or a circle formed from a pipe cleaner may indicate “morning circle” (Figure 20-11).

Electronic communication aids or devices are generally considered more high-tech and may include speech generating devices, talking frames, cell phones, or computers. Speech-generating devices may produce digitized or synthesized speech output.²⁸ Digitized speech records a person’s actual voice and allows flexibility in selecting a child, male, or female voice; however, it requires a lot of memory for storage and is limited to only what is recorded and stored. Synthesized speech is generated electronically but has the advantage of text-to-speech capabilities. The intelligibility of synthesized speech can vary depending on the type of system.

For children with severe disabilities or young children, several different types of simple AAC devices can be used. One example can be seen in Figure 20-12, A. This device has a recorded message that is activated each time the user presses the switch (Figure 20-12, B). Another simple AAC device that is good for individuals who are ambulatory is shown in Figure 20-12, C; it is worn like a watch and can have several prerecorded messages. The messages are easy to change, and symbols can be used to help the user remember the messages (Figure 20-12, D). Devices like those in Figure 20-12, E, are good for children who may eventually use more high-tech AAC.

High-tech electronic communication aids generally are either computer-based systems or dedicated systems. Computer-based systems are often considered for children who are using or will be using some sort of computer-assistive technology in addition to a communication system. Computer-based systems are made up of computers that can perform as a communication system through the use of specialized software and other modifications, but can also carry out other functions such as environmental control. Ideally, computer-based systems should be able to be mounted on wheelchairs or easily portable in some other manner. Dedicated systems operate primarily as electronic communication aids (Figure 20-13) with hardware and software features specifically designed for communication purposes. These systems are available in various sizes and weights and provide auditory, visual, or printed output. All electronic communication devices are programmed with individualized overlays. The board’s overlays can indicate as few as 2 and as many as 128 choices to the child.

A number of factors must be considered in designing a high-tech AAC system, the first of which is to assess the child’s symbolic representation.¹² What type of symbol will the child be able to use? Receptive understanding of functional objects, visual matching, and spelling and literacy skills related to word recognition are all cognitive skills that will help define the symbol system that is necessary. Examples of symbol systems include real objects, photographs, pictographs, Blissymbols (featuring grammar and syntax categorization by parts of language), and traditional orthography (use of letters and words). Examples of Blissymbols, Rebus, and PicSyms can be seen in Figure 20-14.

The control interface or manner in which a child interacts to provide input to the device may include use of a keyboard; single, dual, or multiple switch arrays; and joystick, mouse, or other alternative pointing devices.²⁸ A child may make selections either directly by pointing or touching, or he or she may use an indirect method such as auditory or visual scanning, directed scanning, or coded access. To allow a child to communicate faster than the rate of keying in text, encoding (or symbol) systems are used. This language uses sequenced multiple-meaning icons to retrieve words, phrases, or sentences. Like word prediction, many communication systems come with message prediction. Some of the more advanced systems can learn the communication “style” of the user and begin to predict with greater accuracy.

In addition to the input method, AAC devices use two visual display types (screens). A dynamic communication display offers thousands of graphics (some that are electronically animated) and text options. The display changes (using the same message-formation process that produces natural speech) based on the choices of the user. They are often accessed via a touch screen; however, alternatives are available. Dynamic displays, such as the one in Figure 20-13, are helpful for children who may have difficulties with memory, but they do require a high level of visual attention, constant decision making, and the need for mastery of object permanence. Visual scene displays offer “hot spots” that are contextually embedded within graphics that provide more meaningful and individualized interactive displays (Figure 20-15). Drager³⁸ made a comparison of visual scene displays and more traditional grid layouts used by typically developing 2½-year-old children during communicative tasks during a birthday party. Findings indicated that performance was better using the visual scene display.

Once a device has been obtained, programming of the device and training of the child and all communication partners are essential for success. Collaborative efforts should be taken to identify vocabulary that includes conversational messages (greetings, information sharing, and requests), core vocabulary (for literate or preliterate children to encourage language and cognitive development), and fringe vocabulary (unique to the individual child’s activities, preferences, family, environments, favorite expressions, etc.).²⁸ Vocabulary needs will vary by context, communication mode, and individual characteristics.¹³ Beukelman and Mirenda have developed core vocabulary and high-frequency word lists for a variety of settings and age groups, which can be found at http://aac.unl.edu/vbstudy. The child should be taught specific functions of communication such as requesting; rejecting/protesting; gaining attention; engaging in greetings, farewells, and other social niceties; commenting; achieving social closeness; asking for information; and confirming/denying.³⁷ Communication competence⁶⁷ should be the targeted outcome for any child using an AAC system (Box 20-9).

As with all other AT, communication systems are constantly being upgraded and changed. Continuing education courses and additional training can familiarize therapists with the terminology, communication strategies, and available hardware and software. AAC can help equalize opportunities for children to interact with peers, siblings and family members, and adults within relevant environments (e.g., school staff).

Computers

Use of personal computers by individuals of all ages is becoming more prevalent in school, home, and work settings. The computer is a flexible, motivating, and powerful instructional tool that can facilitate individualized teaching and learning. Computers with or without specialized software provide children with multiple means of communicating, playing, exploring, self-expression, interacting with the environment, learning cause and effect, and completing school and work-related tasks with greater degrees of independence. Most children with and without disabilities have had some exposure to a computer system by the time they enter school. At home, the computer might be used for recreation, entertainment, communication, work, and study. Social connections with others can be formed through e-mail, instant messaging, and social networking sites. For example, some adolescents with disabilities describe social networks and friendships that they have been able to develop using the computer, Internet access, and appropriate software programs.¹⁰⁴

Swinth and colleagues found that children as young as 6 months of age could access a switch to play a simple cause-effect game on the computer.¹⁰⁶ A computer can motivate children to learn and develop a large repertoire of skills. It provides simulations of experiences that children with motor disabilities cannot otherwise experience. The computer is also infinitely patient with drill and practice and can provide the repetition needed for some children to learn. An almost endless variety of software programs, input devices, and output devices are available to customize computers to meet the individual needs of each child.⁴ Young children can be introduced to a progression of systems that follows their developmental and functional needs. For a child who is born with a disability, success using simple systems precedes the use of more complex systems. Table 20-6 outlines benefits of computer use for children.

At school, children typically use word processing programs, the Internet, e-mail, and virtual classrooms in some aspect of their education. Software programs for children and adults cover most academic subjects as well as recreational and competitive activities. For example, math software and Internet sites include features such as virtual manipulatives or drills; creative writing software has recording features, sound, graphics, and animations; keyboarding software teaches typing as software and website designers continue to add features that make their products and sites accessible to a growing range of people and abilities.

For all children, the judicious use of computers and software can help develop literacy or strengthen skills through the use of games, screen readers, and online books. “Virtual field trips” allow students to visit and explore environments that might otherwise be inaccessible, and computer simulations can provide preparation for social situations, academic tasks, prevocational training, and driver education. For children who are unable to recognize print in traditional formats, modifications to access the same text as that for their peers can decrease their dependence on the support of others in the environment to read or write for them. Often the computer is a magnet for children who have difficulty engaging in traditional classroom activities. When, as a result of motor, emotional, or attentional difficulties, children are challenged to produce art products or written work, the computer can assist in generating digital artwork or text that is neat and uniform in appearance. Producing more accurate, legible, or attractive work can increase self-esteem and self-expression and decrease frustration. The multimedia features of the computer can support learning rules, turn taking, and social skills.⁹⁴ As with any tool, the user must be aware of its features and trained in its applications and maintenance to receive full benefits. Competencies that school-based occupational therapists should possess include the ability to operate major computing systems used in public schools and troubleshoot system problems, establish networks using telecommunications systems, operate general application programs, apply teacher utility tools, and provide computer-based instruction.⁴⁸

To successfully access a computer system, the user must be able to provide input into the system, receive output (or information) from the computer, and process that information to use it in a functional, meaningful manner. Various types of computers (e.g., Macintosh or personal computer [PC]) are available in the home, school, clinical, and work settings. Before recommending the purchase of software programs or adapted access devices, the memory and technology of the system must be evaluated to determine its compatibility with the program. Now, many software programs are both PC and Mac compatible. For example, alternative keyboards can be used on either machine without significant reconfiguration. However, because certain hardware and access devices remain specific to either the PC or the Mac, therapists should attend to these specifications.

Electronic Aids for Daily Living

Originally, EADLs were known as environmental control units. These are systems that allow a child to control appliances in the environment. EADLs allow the child to interact with and manipulate one or more electronic appliances, such as a television, radio, CD player, lights, telephone, or fan. This can be accomplished using voice activation, switch access, a computer interface, or adaptations such as X-10 units (transmitters and receivers) that use a communications “language,” allowing compatible products to interact with each other using the existing electrical wiring. The EADL should meet the child’s primary needs, as well as any long-range goals. The system should also be fairly easy to assemble, learn to use, and maintain. As mentioned previously, EADLs can be integrated into a child’s computer system. They also can be stand-alone systems. Some of these systems have discrete control interface (an electronic device is either turned on or off, such as lights, fans, or a television set), and others are capable of continuous control interface (devices that operate in successively greater or smaller degrees of control). Lowering and raising the volume on a television and dimming a light are examples of continuous control. A common EADL setup used with children is shown in Figure 20-19. Many EADL options are available for a variety of settings.

Universal Design for Learning

One aspect of universal access that is gaining increased attention in the schools is universal design for learning.⁸⁶ School administrators have placed increased emphasis on the development and implementation of a universally designed curriculum that allows all children equal opportunity to learn and demonstrate what they have learned. AT and accessible software are important elements of a universally designed curriculum.⁵¹ Universal design for learning (UDL) involves developing and improving learning environments where all children are included. A UDL framework provides multiple means of (1) representation, to give learners various ways of acquiring information and knowledge; (2) expression, to provide learners alternatives for demonstrating what they know; and (3) engagement, to tap into learners’ interests, offer appropriate challenges, and increase motivation.⁵³

Instructional Technology

Sometimes students with disabilities require technology that is helpful or sometimes used by students without disabilities. For example, most classrooms have tools like calculators and word processors. Students with disabilities might need to use calculators or word processors, or use them with modifications to participate in math or writing activities. This need redefines common classroom tools as AT that may be a required service in the IEP; therefore, it is important to consider how important the tool is to the student’s learning and participation.

Schools use many kinds of instructional technology, providing software in most academic areas and for students of all ages. Some examples include literacy software for children to develop letter-to-sound correspondence, math software for drill and practice of math facts, keyboarding software, and content-area software to reinforce concepts of science and social studies. Student assignments may include copying or producing written work using a word processor, research using the Internet, and email. A computer, computer-based device, or software program may be AT if it provides specific input or output that a user needs to access needed information. Features in software applications including adjustable user settings and alternate keyboard access can help reduce barriers and positively influence participation. Occupational therapy practitioners who are aware of the accessibility needs of their clients can advocate for the purchase of accessible instructional software. The National Center on Accessible Information Technology in Education promotes the use of electronic and information technology for individuals with disabilities in educational institutions at all academic levels, and features a searchable database of questions and answers regarding accessible educational and instructional technology on its website (http://www.washington.edu/accessit/). Features to consider in evaluating accessibility of instructional software are outlined in Box 20-10.

Assistive Technology for Literacy Skills

The primary goals of IDEA 2004 and the No Child Left Behind Act (NCLB) of 2001 are improving student achievement and providing students with disabilities access to the general education curriculum; however, providing access does not guarantee increased participation, especially for children who have reading and writing difficulties.²³ Literacy skills include the complicated processes of reading, writing, and spelling as forms of communication; reading is the communication process of constructing meaning from written text, and writing is the communication process of composing meaningful text.

Literacy begins with the recognition that words correspond to speech and that words are made up of sound. Repeated exposure to literacy experiences such as looking at books, exposure to signage, and writing demonstrates the importance of words. We live in a world that requires literacy. Traditional print such as books and newspapers, as well as information and communication technology including word processors, presentation software, the Internet, and e-mail, is used to relay information. In a text-based society, nonreaders are at risk for difficulties with managing information, and reduction in academic skill acquisition, societal integration, and quality of life. Limited literacy skills also affect the likelihood of successful competitive or supported employment.⁶⁰

Children who struggle with learning to read and write need to be supported by individuals who can accurately assess their strengths and weaknesses, select, and apply AT tools and strategies effectively. AT can help children with disabilities in language acquisition. They can learn that words are something to pay attention to. They can learn about the world around them by simply listening to stories. Most important, they can increase their opportunities for social closeness. Koenig and Holbrook define functional literacy as “the application of literacy skills and the use of a variety of literacy tools to accomplish daily tasks in the home school, community, and work setting” (p. 265).⁵⁹ A multitude of software, word processors, text readers, and electronic books are available on the Internet to support children’s literacy. An essential element related to the effectiveness of technology in supporting literacy is its interactive quality, which allows children to get involved with the content as they manipulate the media.⁴² Literacy software programs interact with children, similar to a parent’s reading to children and involving them in the book by turning the pages, looking at pictures, and asking questions. Technology allows children to control the process and “hook” their interest. Koenig reiterates the importance of starting early with children “regardless of the severity” of their disability.⁵⁸ All individuals can benefit from these experiences, although the benefits realized by each child will be different.

The National Center for Technology Innovation (NCTI) website (http://www.techmatrix.org/) serves as a database of published research and commercial products that are reviewed for universal design features that support student literacy. This site reviews products for features such as text-to-speech capabilities, in-line dictionary support, customizable views, and progress monitoring options, and allows the searcher to create a customized matrix by subject and/or type of learning support.

Reading Skills

Children most at risk for reading difficulties are those with less verbal skill, phonologic awareness, letter knowledge, and familiarity with the basic purposes of and mechanisms for reading.²⁰ Research on early reading development emphasizes the pairing of written words and sounds for helping children’s decoding skills. For children with physical, visual, communication, or cognitive delays, traditional books may restrict their ability to interact with and access books. One of the methods that can be used to provide successful literacy experiences is through adapting books. Adapted books provide print access that follows the Universal Design for Learning (UDL) framework. Adaptations can include making books easier to use (turning pages or holding) and text easier to read (simplified, changed) and remember. The original story or subject is maintained, but may contain modified language, clear visual representations, and manageable page layouts to increase the potential for participation. Adapted books can be used by themselves, or with AT ranging from low-tech homemade devices to switches, voice output communication aides, Braille and large print materials, sign language, or adapted props.

Copyright laws allow the creation and use of books in an alternate format solely for the purpose of making the book accessible to persons with disabilities; however, it is important to review copyright laws and how they pertain to each situation in which an adapted book is being contemplated. A copy of the original book is required when using an adapted book. Books can be adapted to provide physical access to text by creating space between pages with page “fluffers” (foam, weather stripping, sponges, giant paper clips, clothespins), using book holders for stabilization (recipe book holders, card holders, acrylic display frames, easels), or by reproducing them so that they can be listened to or viewed with technology (Figure 20-20). Accommodations for print difficulties include change in font size and color, magnification, contrast, audio output, tactile display, icon-enhanced text, scaffolded information, and multimedia. Electronic books combine reading, writing, listening, and speaking and provide a multisensory approach with related pictures, sound, and video, and appeal to different learning styles. Through the appropriate provision and support, technology can allow children to control their own learning.

The ability to read is essential for many daily life activities and participation in varied environments at home, school, work, and in the community. Reading contributes to play and leisure, academics and world knowledge, communication and social awareness, following directions and schedules, shopping and meal preparation, and work-related tasks. When the ability to read print text is affected by visual, visual motor, visual processing, decoding, tracking, attentional, or cognitive difficulties, AT can provide alternatives to traditional print text. For example, Edyburn proposed a process of scaffolding digital text to meet the varied reading and cognitive needs of children by reducing the amount of text, as well as adding additional visual cues in the form of pictures or symbols. He used the term cognitive rescaling to describe “a process of altering the cognitive difficulty of information” (p. 10).⁴⁰ Other accommodations for print disabilities include the use of commercially available talking photo albums, specific reading software, e-text, audio recordings, screen readers, and multimedia.

Assistive Technology for Writing

The act of writing not only requires motor and sensory skills but also includes cognitive processes in the form of recognizable language and vocabulary, generation of ideas, organization of ideas, expression of ideas, and use of correct grammar, punctuation, and spelling. With handwriting as the most common reason for referrals to occupational therapy in school-based practice, practitioners are well aware that writing skills can be enhanced with no-tech or low-tech aids and devices. Simple adaptations, like smooth-writing pens that are comfortable to hold or adapted paper, can make the difference between needing physical assistance and working independently. Universally designed tools, such as a pen, become AT when needed to achieve targeted goals. Service delivery in the natural context, using tools that are intuitive, may mean borrowing or adapting tools that already exist in the classroom.

For individuals who may have motor difficulties that affect the ability to write for function, alternatives for written production should be explored such as the use of a keyboard and mouse (or alternative mouse) or a portable word processor or notebook computer. Beyond the physical components, writing can be conceptualized as a cognitive process that includes the following steps: prewriting/brainstorming ideas, drafting/composing and organizing initial ideas, editing, and, finally, publishing the final product.²⁸

Standard word processing and multimedia software, often available in the classroom, features sizable and colored fonts, line spacing options, spell and grammar checking, opportunities for outlining and highlighting, use of tables to organize information, use of macros and abbreviation expansion, general accessibility features, and incorporation of multiple media to represent ideas. More specifically, concept-mapping software allows the user to conceptualize information graphically using a combination of pictures and/or text. It is helpful for planning, organizing, and drafting and frequently offers templates for getting started (Figure 20-21).

Other software products allow the child to complete a written assignment with visual and/or auditory feedback. Word prediction and word completion can reduce the number of keystrokes necessary and as a result may increase overall speed.²⁸ After a child types in the first few letters of a word, the program will attempt to predict whole words and presents a list of choices for the child to scan and select (Figure 20-22). Many word prediction programs include customizable dictionaries that suggest alternative word selections, which can facilitate improvement in the quality of a child’s written work. These features are beneficial to support spelling for children who have good word recognition skills. Spell-checking programs have proved to be helpful editing tools, specifically when integrated into a word processing program; however, grammar checkers have not.⁶⁶ Other options may include use of a traditional or electronic dictionary or thesaurus for children who have word retrieval deficits.

In combination with visual supports, some children benefit from the use of auditory feedback. Text-to-speech software converts printed digital text to synthetic speech. This feature is available in a number of software applications, free Internet downloads, and on recent versions of Windows and Macintosh operating systems. Synthesized text-to-speech screen readers support drafting and editing, which can help a child more readily detect errors because the text is read out loud. They also reduce the visual load for individuals with visual processing deficits, and are a valuable alternative for auditory learners. Users with print disabilities can also access contents of web pages, e-mail, e-books, or printed documents scanned with optical character recognition (OCR) software and converted to digital text. Pairing print with digital speech output is available in a number of applications. The age and gender of the “voice,” reading rate, dynamic highlighting, and color of font and background can be manipulated to address the individual needs or preferences of the user.

Conversely, some children require speech-to-text (or voice recognition) options that allow them to dictate thoughts and commands to a program that produces written text for them. Speech input technology responds to the human voice by producing text or executing verbally dictated commands to navigate through computer applications.²⁸ Speech-to-text software was initially envisioned as a business tool, but has been found to be an effective strategy to support children’s learning. Speech recognition presents words through speech, so to produce accurate dictation, the user must have appropriate oral mechanisms.⁵⁰ The process results in a multisensory written language experience. Voice quality, pitch, volume, and articulation have a direct impact on the quality of the product generated, as well as set-up and positioning of the user. In addition to specific dictation software products, recent versions of Windows and Macintosh operating systems include speech recognition features. A substantial training component is required to use this type of technology, and the environmental context in which it is used must be examined closely. Speech input can be accomplished by dictating to another individual or a tape recorder as a less costly alternative. This allows individuals with intelligible speech to express themselves, even when writing is problematic for attentional, motoric, or cognitive reasons.

Assistive Technology for Math

Mathematics is a part of typical school curriculum and is considered a functional life skill. Mathematical concepts include sorting, numbers, differences in attributes (color, shape, size), patterns, counting, sequence, graphing, and numeration. Ideally, a combination of individualized instructional strategies and numerous opportunities to use and manipulate concrete objects to count, sort, compare, and combine is used to reinforce concepts of same/different and greater than/less than/equal to. Children with sensory, cognitive, or physical disabilities may need additional support (e.g., grippers, nonskid materials) or alternatives to hands-on manipulation such as “virtual manipulation” (http://nlvm.usu.edu/en/NAV/vlibrary.html) to allow active participation in math exploration.⁶

Children with visual processing or visual motor deficits affecting their ability to see likenesses and differences in shape and form, difficulties with copying and writing, physical limitations, or cognitive challenges can benefit from a wide array of AT supports when instructional strategies, curriculum modifications, use of manipulatives, flashcards, and repetition are not enough. Math difficulties may affect future financial management skills, with resultant decrease in independence. To determine whether a child needs AT in the area of mathematics, the IEP team should consider whether the child is able to effectively participate in math instruction and complete math requirements of the curriculum or work setting without the use of aids/devices. If not, then a determination must be made regarding which tools would most effectively reduce barriers to accessing the curriculum.

Common classroom math tools such as rulers, compasses, protractors, and calculators can be modified to make them easier to handle or keep in place. Low-tech math solutions may include use of a customized number line; TouchMath® (a multisensory teaching approach that links manipulation with memorization of math facts), enlarged or masked math worksheets; graph or grid paper for aligning problems; alternatives for responding such as math stamps for drawing graphs, clocks, and number lines; and use of simple calculators (Figure 20-23). Providing alternative visual representation of math problems with graphics can increase the child’s understanding.

A calculator is an electronic, mechanical, or onscreen device for the performance of mathematical computations. Calculators accept keypad input and display results on a readout screen, paper tape, or computer screen. Calculators speed up calculation time, provide feedback and an alternate way to “write” numbers, and may improve accuracy. Calculators come in many sizes with features such as big number buttons and large keypads, and range in operational capacity from simple to complex. Handheld calculators can help a learner who has problems writing numbers in the correct order; talking calculators vocalize data and resulting computations through speech synthesis; special-feature calculators allow the user to select options to speak and simultaneously display numbers, functions, entire equations, and results; on-screen computer calculator programs offer features such as speech synthesis, and some allow the user to adjust the display including size and color of the keys and numbers. Specialized calculators use realistic money bill and coin buttons to count money or teach the value of different coins. Children can practice addition and subtraction with coin denominations. Individualizing the calculator for the user’s unique needs may include providing tactile cues, enlarging or masking buttons, stabilizing or angling the calculator to improve access, using a colored filter over the display to change contrast between the numbers and the background, or providing a tool to access the buttons.

Access software or electronic math worksheets provide the opportunity to engage in the same curriculum as for typical peers by using a different platform to enter answers.⁸⁴ For example, instead of pencil and paper, a computer and a peripheral device such as a joystick, touch screen, interactive whiteboard, or alternate keyboard are used to record responses. These software programs help the user organize, align, and work through math problems using the computer. Numbers that appear onscreen can also be read aloud with a speech synthesizer. Microsoft Excel provides a computer equivalent to a paper ledger, with extensive graphing capabilities. Grids comprise columns and rows (intersections called cells). Each cell may contain labels, data, or formulas (mathematical equations that do all the work). Interactive math websites are available on the Internet. Textbook manufacturers may provide digital copies of textbooks on CD-ROM and most maintain websites with additional teaching resources and information.

Assistive Technology and Transition

Transition planning is essential to pave the way to successful change. Transitions are an inevitable part of life, yet the passages from preschool to elementary school, elementary school to high school, and high school into early adulthood can result in a loss of continuity. For an individual with disabilities, transitions can be especially challenging if the supports that provide access to participation are not available or prove unsuitable in the new environment. Critical information, as well as competencies, can be lost if positioning, teaching methodologies, and information regarding specialized technology are not passed along from one stage and setting to the next. IDEA mandates the provision of both AT services and transition services for students with disabilities. When a student with a disability requires AT to accomplish one or more functional skills, the use of that AT must be included in effective transition planning. Transition plans for AT users address the ways the student’s use of devices and services are transferred from one setting to another. AT transition involves people from different classrooms, programs, buildings, or agencies working together to ensure continuity. Self-determination, advocacy, and implementation are critical issues for transition planning. Although the involvement of occupational therapy is important during the student’s transition into adulthood, only 16% of all occupational therapists (compared with 29% who work in school settings) provide transition services for students ages 13 to 21.²

In addition to ensuring that AT devices and support services accompany students during transitions, service providers should assist clients and their families in becoming responsible users of AT. As Wehmeyer asserted, if students with disabilities are to actually achieve greater control over their lives, then it is important to provide (1) opportunities to exert control and make choices; (2) supports and accommodations needed; and (3) opportunities to learn new skills to increase participation.¹¹¹ The goal of self-management and independent use should begin the first time a child uses AT, steering him or her onto a path of optimal independence as an adult. Competencies should be developed in the area for which the AT device was chosen (e.g., communication, writing) as well as in how to use and care for the device, when to use it, and the social implications and responsibilities of using the device.²² Development of self-determination skills to ensure that AT becomes an integrated part of typical routines will aid in successful transitions from home to school and from school to the community.²²

For individuals beginning or ending their public school education, transition planning is included in legal mandates. Explicit documentation is needed during all transitions to ensure the individual transitioning has the support needed. Documentation can take the form of text, photos, and videos. For students who require AT devices or services to receive FAPE, transition plans should contain a statement of needed AT devices and services, and indicate agency responsibilities and linkages, if appropriate. The child should be allowed to take an AT device home or to other environments if it is necessary for FAPE. Various agencies may be involved, and the decision regarding who is responsible for providing the AT services needed for successful postgraduation activities should be determined in advance by the transition team.

Involvement of occupational therapy practitioners during the transition process assists the youth in the development of work, community, and independent living skills. Working as a member of the transition team, the occupational therapy practitioner may access and address student-related factors, including social, sensory, motor, and perceptual abilities; task-related factors, such as analysis of physical and perceptual requirements of the task; and environmental factors, such as analysis of noise level, clutter in the environment, and accessibility of work or living space. The QIAT Consortium has identified areas of best practice for AT transition⁷⁹ (Box 20-11), and although their guidelines focus mainly on the late high school transition to postsecondary and work placement, they serve as a reminder of the goals of the transition process and help identify key elements that need to be addressed in a transition plan.

Evidence-Based Practice and Assistive Technology

Although there is research available documenting the benefits and limitations of many AT devices,^39,41,89,102 AT outcome measurement and trials of AT services are limited. Because of the ever-changing nature of this field, the complexity of the devices, and the need for individualized decisions, it is difficult to build a large evidence base in this area of practice that is consistent with the available technology.⁴¹ Some AT companies are adding research information regarding their products and AT outcomes to their websites. Whenever possible, AT research should guide and support decision making and provide further foundational knowledge about AT devices and services. When evidence is not available, occupational therapy practitioners working in this area must engage in data-based decision making with each client to document whether the use of the device results in increased participation across environments. Occupational therapists should be good consumers of AT research and should also measure and document AT outcomes as part of best practice services.

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