Assistive Technologies for Cognitive Augmentation

Intellectual Disabilities.

Intellectual disability is typically defined as a disability where the person has a below average score on an intelligence or mental ability test and a limitation in functional skills (Wehmeyer, Smith, and Davies, 2005). These functional skills include but are not limited to communication, self-care, and social interaction (http://www.cdc.gov/ncbddd/dd/ddmr.htm). The terms developmental disability, cognitive disability, or mental retardation are often used to describe individuals with intellectual disabilities. Intellectual disability can range in severity from mild to severe.

Learning Disabilities.

LDs are disorders in which the person has near-normal mental abilities in general but a deficit in the comprehension or use of spoken or written language. These disabilities may be manifested as a significant difficulty with reading, writing, reasoning, or mathematical ability. Because students with LDs tend to perform poorly on standardized tests, it was long thought that LDs were a mild form of intellectual disability. This assumption is untrue; LDs can be thought of as a deficit in the processing and integration of information in an area (e.g., reading) as opposed to limitations in the basic ability in that specific area of learning. People with LDs have typical age-related capacity in all areas. Table 10-2 lists abilities associated with learning disabilities. However, processing deficits lead to the hallmark difficulties that are commonly experienced (Johnson et al, 2005).

Attention Deficit Hyperactivity Disorder.

ADHD is defined as a pattern of inattention, hyperactivity, or impulsivity that is more frequent or severe than for typical people of a given age (www.nimh.nih.gov/publicat/adhd.cfm). The delay aversion hypothesis of ADHD posits that the child with ADHD distracts himself or herself from the passing of time when he or she is not in control by daydreaming, inattention, and fidgeting (Daley, 2006). Children (and adults) with ADHD have a normal capacity to learn and to use their skills but have confounding factors that make it difficult to fully realize that potential (Schuck and Crinella, 2005). Particularly, those with ADHD can be easily frustrated, have trouble paying attention, are prone to daydreaming and moodiness, and are fidgety, disorganized, impulsive, disruptive, or aggressive.

Autism Spectrum Disorder.

ASD is a developmental disorder that is characterized by varying degrees of impairment in communication and social interaction skills or the presence of restricted, repetitive, and stereotyped patterns of behavior. A commonly used definition for autism is that of the Diagnostic and Statistical Manual of Mental Disorders–Fourth Edition (DSM-IV) (American Psychiatric Association [APA], 2000), which classifies autism as a pervasive development disorder (PDD). As the term implies, this disorder covers a wide spectrum of conditions, with individual differences in number and kinds of symptoms, levels of severity, age of onset, and limitations with social interaction. Major subtypes of ASD include autistic disorder, Asperger’s syndrome, Rett syndrome, childhood disintegrative disorders, and PDD not otherwise specified (NOS). Individuals with ASD typically demonstrate deficits in communication skills including delay in, or total lack of, spoken language and spontaneous speech; unusual speaking patterns (e.g., echolalia or idiosyncratic language); and underdeveloped social interaction skills (including problems interpreting facial expressions, gestures, and intonation while interacting with other people). They might also seem evasive, avoid eye contact, and appear to lack initiation and desire to share joy or interest. Children with ASD also have inflexible adherence to specific routines and demonstrate unusual persistence and intense focus on a specific subject or activity. Many children with ASD have unusual (hypersensitive or hyposensitive) responses to sensory information, which could lead to the lack of or aversive response to sensory input.

Individuals with ASD also have strengths and unique abilities. For example, some individuals with ASD have unusually good spatial perception and visual recall or accurate and detailed memory for information and facts, are able to concentrate for long periods of time on particular tasks or subjects, and are more attentive to details then most people. These abilities may allow them to excel in areas of music, science, math, physics, and other specialized areas.

Dementia.

The word dementia comes from the Latin de mens, which means “from the mind.” Dementia is best defined as a syndrome, or a pattern of clinical symptoms and signs, that can be defined by the following three points: (1) decline of cognitive capacity with some effect on day-to-day functioning, (2) impairment in multiple areas of cognition (global), and (3) normal level of consciousness (Rabins, Lyketsos, and Steele, 2006). Dementia is distinguished from congenital cognitive disorders (such as intellectual disability, LDs, etc.) by its age of onset and its degenerative component. It is also important to note that, although it must affect multiple areas of cognition, not all areas are affected. Rabins, Lyketsos, and Steele (2006) define the “three pillars of dementia care.” First is to treat the disease, which helps identify current needs and future necessities as the disorder progresses. Second is treatment of the symptoms. By treating the symptoms, the quality of life of the client will improve in the cognitive, functional, and behavioral domains. Medications and technology are the two main ways to accomplish this task. Third, client support is important and leads to ensuring that the client’s needs are met and quality of life is improved as much as possible.

Traumatic Brain Injury.

People who have a TBI often lose significant cognitive function. A TBI may occur when the head or brain is struck by an external force, such as from a fall, gunshot wound, or motor vehicle accident. The causes of TBI are described in Table 10-3. The extent of the trauma to the brain is the determining factor in diagnosing TBI, not the injury itself. For instance, it is possible to incur TBI as the result of both open-head injuries (the brain is exposed to air) and closed-head injuries (no brain exposure). The effect of a TBI on an individual’s cognitive ability varies from case to case, in terms of both severity and the set of skills affected. Not all head injuries give rise to TBI, and there is an accepted method for diagnosing such an injury. One tool available to assist with diagnosis is the Glasgow Coma Scale (GCS), a rating system used for describing the severity of a coma (Dawodu, 2006). The GCS ranks comas on a scale of 3 (most severe) to 15 (mildest) according to eye response, verbal response, and motor response categories. A score on the GCS of 12 or lower is a mild brain injury and below 8 is considered a severe injury.

If the GCS does not indicate TBI, one of the following two criteria must be satisfied for a TBI diagnosis: either the client has amnesia for the traumatic event or the individual has a documented loss of consciousness. It is common to have a recovery period after the injury. This recovery usually plateaus within 12 months after injury, and the extent of recovery is both variable and unpredictable (Cicerone et al, 2005). A good measure of the extent of an individual’s recovery from a TBI is his or her return to preinjury activities of daily living. Two main recovery indicators are the return to work and the return to driving, both important tasks for independent living. Data on the return to work are summarized in Table 10-4, and similar data for the return to driving are shown in Table 10-5 (Novack, 1999). In both cases, very little improvement was observed beyond 12 months after injury. Typical cognitive and behavioral difficulties that a person with TBI may encounter are listed in Table 10-6 (Novack, 1999; Rehabilitation Engineering Society of North America, [RESNA], 1998). Two areas of importance are memory and language skills because these may benefit from intervention with assistive technology.

Stroke.

A stroke, or CVA, is an incidence of irregular blood flow within the brain causing an interruption in brain function. A stroke may arise from a lack of blood flow to the brain (known as an ischemic stroke) or from ruptured blood vessels in the brain (a hemorrhagic stroke). The neurological damage incurred as the result of a stroke produces symptoms that directly correspond to the injured area within the brain (O’Sullivan and Schmitz, 1994). A CVA causes acute damage to the brain; there are no degenerative effects after the onset of injury. As with TBI, persons who have sustained a stroke often have a recovery period where portions of the brain learn to compensate for damaged areas. Typical cognitive and behavioral difficulties associated with stroke are shown in Table 10-7. Most recovery (as observed by the return to activities of daily living) occurs within 6 months after onset (Bruno, 2005). The majority of persons with CVA are able to return home after the initial hospitalization period. A summary of discharge locations after hospitalization for stroke is shown in Table 10-8. These data suggest that the number of people returning home after a CVA is increasing, which might be attributed to improvements to hospital care at the onset of stroke. Children may have a more pronounced recovery than adults because their brains have a greater degree of plasticity. Also, women may display greater recovery of lost language skill than men because the language centers of the brain are larger in women than in men.

Considerations for Individuals With Mild Cognitive Disabilities.

On one hand, the application of assistive technologies to meet the needs of individuals with mild cognitive disabilities is easier than for more severe disabilities simply because the human skills are greater than for some other disabilities. On the other hand, the needs that these individuals have are more subtle and harder to define than in the case of physical disabilities or more severe cognitive disabilities. For example, learning disabilities typically involve significant difficulties in understanding or in using either spoken or written language, and these difficulties may be evident in problems with reading, writing, mathematical manipulation, listening, spelling, or speaking (Edyburn, 2005). Although there are assistive technologies that are specifically designed to address these areas (discussed later in this chapter), many of the technological tools are useful for all students and are part of instructional technology (Ashton, 2005). Even the so-called assistive technologies have features (e.g., multimedia, synthetic speech output, voice recognition input) that are useful to all learners. Chapter 1 distinguishes between educational technologies (or instructional technologies) and assistive technologies. This distinction works well for sensory and motor assistive technologies. The distinction is much more blurred for cognitive assistive technologies (Ashton, 2005; Edyburn, 2005). For example, some spell checkers, word prediction, and talking word processors have been specifically designed for individuals with learning disabilities (e.g., Co-Writer and Write-Outloud, Don Johnston, Inc, Volo, Ill., www.donjohnston.com. These programs are discussed later in this chapter. As Ashton (2005) points out, each of these technologies is potentially useful to all students, not just those with learning disabilities. In that sense they are educational or instructional technologies. Edyburn has suggested that the term technology-enhanced performance be used instead of assistive technology. The advantage of this conceptual shift is that emphasis is placed on performance and outcomes, not on assessment and selection of the technology. The emphasis on human performance is important and reflected in the HAAT model. However, the move away from assistive technology to technology-enhanced performance does not recognize the unique features of assistive technologies that are described in Chapter 1 (see Box 1-1), particularly that of being an individualized system that meets unique needs for an individual.

Edyburn (2005) carries the concept of technology to enhance performance further by pointing out that many other productivity tools can function as “assistive technologies” for individuals with mild disabilities. He cites the example of the Ask Jeeves Web search engine (www.askjeeves.com), which could provide assistance to a child who has difficulty retrieving information. Edyburn poses the following question: if the student knows that he or she can find the names of all the U.S. presidents using this or another search engine, then isn’t that as useful an educational outcome as having memorized the names for a test? The question of information retrieval using the Web is part of the larger issue of compensation versus remediation in cognitive assistive technologies (Edyburn, 2002). Throughout this text a four-part approach to assistive technology applications has been emphasized: human, activity, assistive technology device, and context (the HAAT model of Chapter 2). When the ATP is dealing with motor disabilities, the starting point is a careful description of the activity to be performed. An evaluation of the individual’s skills relevant to the activity leads to a clear picture of what assistive technology needs he has. The context (physical, social, and cultural milieu and institutional environment) then moderates the choices of assistive technologies. The assistive technology includes both soft technologies (training, strategies) and hard technologies (devices) or, in Edyburn’s (2002, 2005) terminology, remediation (soft technology) and compensation (hard technology).

For sensory or motor disabilities, we don’t much care how the function is accomplished as long as the activity can be satisfactorily completed. Other issues, such as how much energy it takes to walk versus to use a power wheelchair for someone with severe cerebral palsy, are matters of personal choice. The situation changes dramatically, however, in dealing with cognitive assistive technologies. Should the child in our example be required to learn the presidents’ names (remediation) or be allowed to use an assistive technology (Ask Jeeves) as a compensatory tool, and why is its use considered “cheating” by some educators and parents (Edyburn, 2005)?

A related concern is the concept of time in educational contexts. Time is fixed and accomplishment varies (Edyburn, 2005). This is not true in the case of sensory or motor disabilities where additional time (e.g., for an individual who is blind to cross the street using a long cane) is an accepted part of human performance. In vocational settings, completion time for a task also varies from individual to individual and is acceptable within wide limits. Why, then, is this not the case in an educational context? As Edyburn (2005) points out, restricting time, learning activities, instructional approaches, and other classroom variables to a “one-size-fits-all” constraint in educational settings means that high standards of performance cannot be achieved. Although many students with special needs are given extra time to complete an examination, the level of competence they achieve is still variable and time (even expanded time) is fixed. If achievement were to be fixed then each student would be allowed as much time as necessary to complete the task. If uniformly high performance and preparation for later vocational success are the goals, then compensation, using both hard and soft assistive technologies, must be an alternative for individuals with mild cognitive disabilities as it is for their counterparts with motor and sensory disabilities.

Considerations for Individuals With Moderate to Severe Intellectual Disabilities.

Several ways of characterizing cognitive needs have been used in consideration of assistive technology applications for individuals who have intellectual disabilities. One method considers the cognitive impairment exhibited, such as impairments in memory, language use and communication, abstract conceptualization, generalization, and problem identification/problem solving (Wehmeyer, Smith, and Davies, 2005). Assistive technology characteristics that address these impairments include simplicity of operation, capacity of the technology to support repetition, consistency in presentation, use, and inclusion of multiple modalities (e.g., speech, sounds, and graphical representations). Wehmeyer, Smith and Davies (2005) discuss assistive technology characteristics and approaches for each of these impairments. Many of these technologies are covered in the subsequent sections of this chapter.

Granlund et al (1995) take a different approach and define five content areas for technological assistance to individuals who have moderate to severe intellectual disabilities. The content areas, on the basis of cognitive structures, are the following:

Within these content areas, individuals with intellectual disabilities typically have difficulties in organization and reorganization, performing operations with cognitive structures, and symbolic representation. Within these content areas, adults with cognitive disabilities may encounter problems in activities such as choosing a leisure activity, using public transportation, being on time for work, and preparing meals. Typical assessment questions and assistive technology examples for each content area are listed in Table 10-9.

Wehmeyer et al (2004) described eight primary factors of cognitive ability: (1) language, (2) reasoning, (3) memory and learning, (4) visual perception, (5) auditory perception, (6) idea production, (7) cognitive speed, and (8) knowledge and achievement. They argue that the promise of technology for aiding individuals with intellectual disabilities lies in enhancing human capacity in these areas rather than compensating for deficits. An important element in this approach is the application of the principles of universal design (see Chapter 1) to ensure that mainstream technologies are designed in such a way that individuals with a range of intellectual abilities can access them. The design of the human technology interface (see Chapter 2) in the HAAT model is an example of the difference between a compensation approach and the concept of enhancement of the technology characteristics to make it more accessible. If an individual with an intellectual disability has difficulty accessing a screen because of language problems (e.g., reading), one approach is to use a compensatory approach and provide auditory output instead of text, avoiding the necessity for reading. If the problem is too much clutter on the display, then the best approach may be to simplify the display (i.e., enhance it) so that the information is more accessible. The following sections of this chapter describe technology approaches that use both enhancement and compensation strategies. For individuals with intellectual disabilities, Wehmeyer et al (2004) present a thorough literature review of approaches that have been taken to enhance performance in each of the eight cognitive factors.

Considerations for Individuals With Acquired Disabilities.

Individuals with acquired cognitive disabilities resulting from injury (e.g., TBI) or disease (e.g., CVA or dementia) retain a wide variety of remaining cognitive skills. The majority of assistive technologies and strategies that have been used to aid persons with acquired cognitive disabilities are designed to compensate for deficits by building on remaining strengths (LoPresti, Mihailidis, and Kirsch, 2004). Collective technologies and strategies that help a person with cognitive deficits function more independently in certain tasks have been called assistive technology for cognition (ATC) (LoPresti, Mihailidis, and Kirsch, 2004) or cognitive prosthesis (Cole and Mathews, 1999). An ATC or a cognitive prosthesis is an entire system of hardware, software, and personal assistance that is individualized to meet specific needs. A more accurate descriptor would be cognitive orthosis because the intent is to augment cognitive function rather than to replace it. However, Bower (2003) uses “prosthesis” in his description, which states that a “cognitive prosthesis is a computational tool that amplifies or extends a person’s thought and perception, much as eyeglasses are prostheses that improve vision…a cognitive prosthesis magnifies strengths in human intellect rather than corrects presumed deficiencies in it. Cognitive prostheses, therefore, are more like binoculars than eyeglasses.” As the HAAT model (see Chapter 2) implies, a cognitive prosthesis includes a custom-designed computer-based compensatory strategy that directly assists in performing daily activities (Institute for Cognitive Prosthetics, http://www.brain-rehab.com/definecp.htm). It may also include additional technologies such as a cell phone, pager, digital camera, or low-tech approaches.

Memory.

Memory aids are those devices or software packages that augment or replace memory by providing a means to store commonly used information or aiding in the retrieval of information. These devices can be subdivided into three categories on the basis of their primary tasks: recording, word completion/prediction, and information retrieval. Recorders are devices that store information that can be replayed at a later time to aid in the recall of facts or appointments. The most common devices in this category are those that record voice information as short memos. This feature is often built into PDAs, cell phones, and small dictaphones. Word completion and prediction solutions are software packages that aid memory during a written communication task by giving a user a series of contextually significant words/phrases that he or she may wish to use. This technology is also discussed in Chapter 7, where its use was to speed up time to input text or to reduce the number of required keystrokes.

Information retrieval systems are devices or software packages that categorize and organize words/phrases so that they may be retrieved through associations. A number of information retrieval aids have been designed that use palm top computers (often called personal digital assistants or PDAs). Features of these devices that are particularly useful include small size for portability, flexibility in programming for customization, large storage capacity, a variety of input and output modalities, and interfacing to other technologies (e.g., desktop or notebook computers, cell phones) (Szymkowiak et al, 2005). When PDAs are used with individuals who have disabilities, two usability issues arise: changes in sensory processing and the small size of the keyboards and screens. Individuals with cognitive limitations from aging, injury (TBI or CVA), or dementia often have accompanying visual problems (declining acuity and contrast sensitivity, including color discrimination). The interconnectivity of PDAs provides the opportunity for interfacing with the Internet to retrieve a much wider range of information. However, small screen and keyboard features are particularly limiting in long sessions of data retrieval (Szymkowiak et al, 2005).

PDA daily schedulers and reminder alarm devices (both of which are produced in a wide variety of formats) (Figure 10-5) are technologies that tend to provide the most immediate benefit to people with TBI (Kim et al, 1999; Van Hulle and Hux, 2005), CVA, and aging (Szymkowiak et al, 2005). Software packages for these devices have also been designed to include prompting cues to aid memory (Bergman, 2002). These specially designed systems can be customized to meet the needs of a specific user and they have user-friendly interfaces and are easy to carry (Gorman et al, 2003). The PDA-based information retrieval aids require the user to display some degree of sensory perception, language use, memory, or learning skill to be of practical benefit. Because the software can be customized, the complexity of these functions can be adjusted to fit the skills of a wide variety of users. The following case study illustrates the application of a PDA as a memory and organization aid.

Memory Message (Saltillo, www.saltillo.com/) (Figure 10-6) is a commercially available memory aid designed to assist individuals by reminding them of activities and tasks throughout the day. The small size (6.3 inches × 4 inches × 1.1 inches, 12.5 ounces) makes the device easy to carry. A standard clock face is built into the front of the device that shows the current day and time, and a button is available to provide audible time information. Up to 280 alarms can be set with 40 separate recorded instruction messages. When an alarm occurs, the user can either acknowledge the alarm (by pressing “OK”) or have it repeated by pressing (:?”). A caregiver programs alarms and messages through a keyboard. Alarms can be set for a single event or for a recurring activity. The WatchMinder2: Training and Reminder System, which is described in the time management section, can also serve as a memory aid.

Time Management.

Time management technologies are those devices that aid in the planning, prioritizing, and execution of daily and time-dependent tasks. One class of devices uses an alternative format for representing time to make it more accessible to individuals with intellectual disabilities. Examples of such devices are the Quarter Hour Watch (made by Handitek AB, Sweden, available from ZYGO Industries, Portland, Ore., www.zygo-usa.com) (Figure 10-7), a device that offers an alternative and potentially more intuitive representation of the passage of time (Granlund et al, 1995). The Quarter Hour Watch uses an entirely different concept of time by presenting a 2-hour time frame in 8 one-quarter-hour steps. Rather than clock hands or numbers, the watch display has eight circles, one for each quarter hour. The user of the watch must understand elapsed time rather than absolute time based on standard clocks. Events are represented by pictures on plastic chips (about the size of 35 mm slides) that are placed into the Quarter Hour Watch. A care provider sets the time of the event on the back of the plastic chip, which is read by the watch. When the chip is inserted into the watch, the display indicates how much time remains until the event should occur. If the time to the event is greater than 2 hours, then all eight circles are dark. After each quarter hour, a circle turns from dark to light until they are all light. At that time a signal sounds and the circles flash. The individual using the watch chooses the chip (e.g., time for favorite TV program, time to go to work) and then is able to tell when that time has arrived.

The WatchMinder (Irvine, Calif., www.watchminder.com) (Figure 10-8) is a device that reminds a user when a given, preprogrammed task or event is scheduled to occur. This device was designed for people with attention deficit disorder, ADHD, LD, chronic diseases, stroke, or brain injury. A silent vibrating reminder system or beeping alert, with 30 programmable alarms, is included with both a training and reminder mode. The reminder mode is for remembering specific tasks such as taking medication and doing homework or chores. The training mode is for behavior change and self-monitoring. Box 10-2 shows preset messages for the WatchMinder2. This device can also be programmed with three personalized messages. The WatchMinder2 has two possible schedule modes: fixed (every 2, 3, 5, 10, 15, 20, 30, 45, or 60 minutes) or random (central processing unit randomly chooses from 2, 3, 5, 10, 15, 30, and 60 minutes). The person programming the device chooses one of these modes and the daily start (S) time and end (E) time.

The 24-hour Electronic Time Panel (Saltillo, www.saltillo.com/) (Figure 10-9) is a planning board or day planner that facilitates the sequencing and organization of an individual’s tasks and events for a given period of time. This panel helps teach concepts such as understanding units of time (e.g., “How long is an hour?”) and elapsed time (e.g., “Why can’t I have lunch now?”). This device also helps individuals to independently answer daily life questions (e.g., “Do I have time to eat before the bus comes?” or “How long until we go swimming?”). Like the Quarter Hour Watch, the 24-hour Electronic Time Panel uses a lighted display on the one side with increments of 15 minutes from 7 am to 11 pm. A similar column of lights on the other side shows the times from 11 pm until 7 am. The time slot adjacent to each light can be labeled with an activity by using text, pictures, or other symbols. The current time is represented either by a column of lights starting with the current time and proceeding in 15-minute intervals or by a single dot of light. The time until a desired activity is indicated by the length of the column of lights from the present time to the start time of the event. Alarms can be set for each 15-minute increment. The Electronic Time Panel can be used in an individual living arrangement, group living setting, or a classroom.

Davies, Stock, and Wehmeyer (2002) evaluated a palmtop-based time management and scheduling system (Schedule Assistant, AbleLink technologies, Colorado Springs, Col., www.ablelinktech.com) designed for individuals who have intellectual disabilities. The Schedule Assistant was evaluated in a pilot study with 12 participants who had intellectual disabilities. Each participant was asked to complete an eight-item schedule using the Schedule Assistant and using a traditional written schedule. A care provider entered a schedule of daily events into the Schedule Assistant and the device provided visual and auditory (speaker or earphone) prompts that correspond to those events at the appropriate time. A typical use of this type of device is shown in Figure 10-5. The reminders can be replayed automatically until acknowledged or by a request from the user. Results showed that participants required significantly less assistance when using the Schedule Assistant than with the written instructions, leading to the conclusion that electronic scheduling and prompting systems have value for individuals who have intellectual disabilities.

Prompting/Cueing/Coaching.

Prompting systems are those devices or software packages that inform a user that an action should be taken and provide visual, verbal, or auditory cues as to how to accomplish a task. In most cases the systems allow a care provider to enter the relevant information regarding events, times, and frequency. Some devices also allow collection of data regarding ease of use, and others feature communication with a central station for data logging, emergency assistance requests, or tracking of an individual’s actions and location.

Prompting people to take their medication is one of the main uses of prompting systems. Low-tech medication reminders, boxes with seven or more compartments labeled by the day or type of medication, have been in widespread use for many years. However, these devices do not alert the person that it is time for the medication. If an alert is needed, then electronic medication reminders are required (Mann, 2005). A watch-based medication reminder (e.g., Cadex Medication Reminder Watch, http://www.cadexproduct.com/?source=overture&OVRAW=http%2F%2F%3Acadexproducts.com)%5C&OVKEY=http%20cadexproducts.com&OVMTC=standard) provides up to 12 daily reminders that have an audible alarm and a display of the required medication. Although this format is convenient because of its small size, it has a small display and limited memory. Pagers and cell phones are also used as medication reminders (e.g., MedPrompt Medical Paging System, www.medprompt.com) with dosage, type of medication, and instruction provided by text messaging from a central service. Software for PDAs (e.g., On-Time-Rx of Palm OS, www.ontimerx.com) provides medication alerts with detailed information regarding pill type and dosage, a medication log, refill reminder, and emergency information (Mann, 2005).

The ISAAC Cognitive Prosthesis System is a wearable and highly customizable device that provides procedural information and personal information storage (Cole and Dehdashti, 1998). This system is a fully individualized cognitive prosthetic system that assists the user to live and work more independently through the organization and delivery of individualized prompts and procedural and personal information. A care provider enters the content with use of an authoring system. The content is then delivered to the individual with a cognitive disability in English or Spanish as synthesized speech, audio, text, checklists, or graphics. Prompts can be delivered on the basis of specified conditions, such as the time of day, to prompt for an action by the user. User input is through a pressure-sensitive touch screen.

Mihailidis, Fernie, and Barbenel (2001) developed a prompting system for handwashing to assist individuals who have dementia. The system, called COACH, uses a video camera, personal computer, and artificial intelligence software. The system monitors progress of the person and provides auditory prompts when steps are skipped or mistakes are made. The system also learns the patterns of the individual users and adapts its settings and cues to match them. In a single subject design study with 10 elder participants, the COACH system led to significant improvement in completion of hand washing tasks without caregiver assistance (Mihailidis, 2004).

Individuals with Alzheimer’s disease often have periods of forgetfulness and disorientation. The disorientation can lead to wandering behavior that is unsafe to the person and very worrisome to the caregivers and family. Global positioning systems (GPS) have been used to assist these individuals by providing their location to the caregiver (Mann, 2005). The GPS Locator Watch (Wherify, www.childlocator.com/) is designed to track children, but its features apply well to persons with dementia. The watch has a wireless transmitter/receiver that transmits the location of the person and allows transmission of information to the watch. To prevent individuals whose disability makes it difficult to understand the purpose of the watch and who try to remove it, the watch has an electronically activated lock to keep it in place. The lock can be remotely released for removal. The device also has a built-in pager, clock, and emergency call function. A navigational device based on a GPS cell phone, called Opportunity Knocks, was designed specifically for people with cognitive limitations (Kautz et al, 2004). This device learns the patterns of the user, and uses that pattern to help the user find the most familiar (not necessarily the shortest) route, recover from mistakes, and receive prompts when needed. If an error occurs (e.g., a user misses a bus stop that is routinely taken), the device verbally prompts the user with prompts such as “I think you made a mistake” or “May I guide you to [location]?” The user can indicate which location by touching a picture of it on the display of the cell phone. Then a mode of transportation (e.g., walk or bus) is chosen in the same way. Using the stored patterns, the system then directs the user to that location. Using stored information, the system can also determine whether the user is on the wrong bus and direct him to get off at the next stop. Instruction can then be provided to get the person back on track to his or her destination.

The concept of a smart house (Figure 10-10) has been used to denote living environments in which automation is used to provide automatic functions including monitoring, communication, household functions (lights, air conditioning/heating, door locks), physiological measurements, and medication alerts (Mann, 2005). Smart houses have the potential to allow individuals with cognitive limitations greater independence, and in the case of elderly individuals, a chance to stay in their homes rather than move to group living facilities. Mann (2005) describes levels of smart house from basic communications (Internet, phone) through complex monitoring and tracking of the resident’s health, behavior, and needs. The core of the smart house is a processing and communication system linked to a sensory array. One example of a monitoring application is described in the following case study. The system aids a user in performing common tasks of daily living by assessing the person’s current physiological state and the state of various utilities throughout the home and providing the user with feedback should they become disoriented or confused on a given task (Haigh, Kiff, and Ho, 2006). Mann (2005) describes several smart house projects.

The COACH and the smart house are examples of context-aware cognitive orthoses (LoPresti, Mihailidis, and Kirsch, 2004). Each of these systems provides cueing and prompting on the basis of a combination of prestored information and data obtained from sensors in the environment. The use of context-based information can relieve anxiety, reduce the cognitive load, and overcome a lack of initiation by the individual using the device. In terms of the HAAT model, this functionality provides important information about one of the four elements of the model: the context. LoPresti, Mihailidis, and Kirsch (2004) describe other examples of context-aware cognitive orthoses.

Low-tech devices can also aid a user in performing a task by providing concrete feedback as to the proper course of action to undertake. For example, a microwave button shield only lets a user see/use those buttons that are needed for a specific task or raised lines on paper give a user an idea of where symbols should be placed to enhance readability. Task-specific jigs enable people to perform tasks that they may not otherwise be able to perform. For example, weighing and counting tasks in manufacturing and assembly can be difficult for workers who have cognitive disabilities. One approach to modifying weighing and counting is to use a talking scale connected to a controller that provides prompting and feedback as necessary (Erlandson and Stant, 1998). For counting tasks, a bin with a specified number of locations is weighed. If the bin is properly filled, the weight is correct and the user is prompted to proceed with the next step. If the weight is too low, the user is told to check all the bins, and if it is too high the user is prompted to be sure only one element is in each bin. For weighing, objects placed on the scale are compared with stored weight limit values, and the user is prompted if the weight is above or below the weight range. Visual and auditory prompts are included. Erlandson and Stant (1998) describe the successful use of this system in a nail counting task for a construction supply company by a woman with mild intellectual disability.

Prompting systems have been used with autistic individuals for initiation, maintenance, or termination of an activity (Goldsmith and LeBlanc, 2004). Coyle and Cole (2004) reported a decrease of off-task behavior in three autistic students when an auditory timer was used to prompt self-monitoring of on-task behavior in classroom settings. Taber et al (1999) similarly reported a decrease in teacher-delivered prompts and in off-task and inappropriate behavior in a 12-year-old student when a self-operated auditory prompting system was used. Tactile systems were investigated in a few studies to increase verbal initiation (Shabani et al, 2002; Taylor and Levin, 1998) and to seek assistance when lost (Taylor et al, 2004).

Although most of the studies report a positive outcome of a prompting system, these reports consist of mainly preliminary or anecdotal results, with small, if not single numbers of case studies. More systematic studies should be conducted to demonstrate the efficacy of prompting systems in assisting social initiation in individuals with ASD. With the increasing popularity and advancement in small electronic devices (e.g., cell phones, PDAs, MP3 players, etc.), these systems could provide a more cost effective and socially valid assistive technology for ASD.

Stimuli Control.

The family of stimuli control devices includes technologies that address attention or perception problems by limiting or manipulating the information presented to the user. They can be subdivided into three categories that best capture their intended application: noise reduction techniques, visual field manipulation, and media presentation techniques. Auditory (noise reduction) devices are those devices that filter out extraneous noise so the user may focus on one specific source. An example of such a system is a transmitter/headphone receiver link between a student and teacher in a classroom setting similar to those used for students who are hard of hearing (see FM systems in Chapter 9). Visual stimuli can be altered in a similar fashion, through the use of prism glasses or special lenses that correct for double vision or neglect (e.g., in TBI).

Media presentation is an important design consideration for many visual display applications. Web sites, computer monitors, and other visual displays need to be carefully designed to avoid extraneous information that might be distracting to a person with an attention disorder. By reducing clutter, increasing clarity, and simplifying visual displays, information can be presented in a way that is best perceived and understood by a broad target audience. Key concepts in Web design for individuals with cognitive disabilities are shown in Table 10-10. The WebAim project (Center for Persons with Disabilities, Utah State University, www.webaim.org) has many useful resources for making Web sites accessible to individuals who have cognitive disabilities. These include evaluation packages to check Web sites for accessibility, guidelines for developing accessible Web sites, and tools for making Web sites more accessible to this population.

Internet access for individuals with intellectual disabilities can provide benefits in self-esteem and self-confidence, independence in vocational and living contexts, opportunities for training, self-directed activities, and use of their time for pursuits that are stimulating and informative (Davies, Stock, and Wehmeyer, 2001). Unfortunately, access to the Internet for this population is often limited by standard Web browsers that require high-level cognitive skills, particularly in reading and writing. A pilot project was designed to compare a specially designed Web browser (Web Trek, AbleLink Technologies, Colorado Springs, Col., www.ablelinktech.com/_desktop/webtrek.asp) with a standard browser (Internet Explorer, Microsoft, Inc., Redmond Wash., www.microsoft.com) (Davies, Stock, and Wehmeyer, 2001). Web Trek uses graphics, reduced screen clutter, audio prompts, and personalization and customization to maximize accessibility to individuals with intellectual disabilities. Twelve participants evaluated the two browsers in three tasks: searching for a Web site, saving Web sites to a favorites list, and retrieving sites from the favorites. Three measures of performance were used: independence (fewer prompts), accuracy (errors made), and task completion (completed with three or fewer prompts). All three measures showed statistically significant differences favoring the Web Trek browser, indicating that Internet access for persons with intellectual disabilities is feasible.

Concept Organization and Decision Making.

Concept organization strategies and software packages facilitate the organization, storage, and retrieval of related ideas/facts. An example is Inspiration, a software package for organizing concepts related to a central theme. Devices in this category may be used as a memory aid or as a tool to help with writing. For example, the interconnections drawn between various items are useful for creating a logical flow of thoughts when it comes to writing, or alternatively the graphical representation may be a helpful tool for committing things to memory.

Individuals with intellectual disabilities have a very high unemployment rate. The increasing complexity of the work environment is one of the major reasons for this high rate. People with intellectual disabilities are often not able to learn complex decision-making skills that are essential for work. Davies, Stock, and Wehmeyer (2003) carried out a pilot study with a PDA-based device (Pocket Compass, AbleLink Technologies, Colorado Springs, Col., http://www.ablelinktech.com/_handhelds/pocketcompass.asp) specifically designed to assist in decision making. The Pocket Compass uses graphic and audio prompts to guide a user through a decision-making process when participating in complex tasks. The decision-making process contains a branching sequence of cued steps with decision points based on a task analysis of the desired job activity. In the setup mode the work supervisor or care provider creates cueing sequences described by pictures and recorded audio instructions. Decision points in a decision-making process can be identified with these pictures and audio labels. Once a setup has been entered into the device, the user can move through the sequence of instructions and decision points by using the graphic and auditory prompts and making entries (beginning with START and then NEXT after each choice is presented) through a touch screen on the PDA. Up to four pictures can be presented at decision points. Forty participants who had intellectual disabilities participated in a pilot study of Pocket Compass in an activity developed from a task in which different pieces of software were packaged for shipping (Davies, Stock, and Wehmeyer, 2003). Participants using the device made fewer errors performing the task and fewer errors in decision points, and less assistance was required using the PDA than when they had only a job coach. Davies, Stock, and Wehmeyer concluded that technology can significantly assist persons with intellectual disabilities in accomplishing relatively complicated work-related tasks independently.

The Planning and Execution Assistant and Trainer (PEAT) (Attention Control Systems, Mountain View, Calif., www.brainaid.com/) is a PDA-based personal planning assistant designed to assist individuals with cognitive disorders resulting from brain injury, stroke, Alzheimer’s disease, and similar conditions (Levinson, 1997). PEAT uses artificial intelligence to automatically generate plans and also to revise those plans when unexpected events occur. PEAT uses a combination of manually entered schedules and a library of stored scripts describing activities of daily living (e.g., morning routine or shopping). Scripts can be used for both planning and for execution. Planning involves a simulation of the activity with key decision points presented and necessary prompts (auditory and visual) supplied to aid the individual through the planning process. The plan to be executed can be either the stored script or a modified script based on the simulation. The PEAT artificial intelligence software generates the best strategy to execute the required steps in the plan (LoPresti, Mihailidis, and Kirsch, 2004). PEAT also automatically monitors performance and corrects schedule problems when necessary.

Language Tools.

Many forms of assistive technology are language tools that assist with reading or writing. Many devices focus on the memory requirements of language. For example, word completion programs (see Chapter 7) are useful for people who are poor at spelling. They predict whole words on the basis of the first few letters typed by the user. A list of possible word choices is presented, and the user need only recognize the intended word from that list. Dictionaries and thesauruses are low-tech alternatives to word completion programs because they also operate on the basis of using word recognition to rectify deficiencies in word retrieval. For TBI, word prediction software programs have all shown to be useful in clinical trials (Kim et al, 1999; Van Hulle and Hux, 2005).

Word prediction has been shown to be a promising strategy for improving text entry speed of students with learning disabilities as they move from hand writing to computer writing by using a word processor (Lewis, 2005). Word prediction programs written specifically for students with learning disabilities (for example, Co-Writer, Don Johnston, Inc, Volo, Ill., www.donjohnston.com) include features that make them more effective. In addition to simple word prediction, these programs often include dictionaries to suggest alternatives that increase the richness and interest of the writing on the basis of the topic being discussed, and they can be personalized for an individual student. Another program is WordQ (http://www.synapseadaptive.com/quillsoft/WQ/wordq_description.htm), which takes into account phonetic spelling mistakes.

Studies of the impact of word prediction on writing abilities of students with learning disabilities have led to mixed results (Sitko, Laine, and Sitko, 2005). In small sample studies, word prediction programs have been shown to improve writing by addressing word finding problems. When coupled with speech synthesis, the results are improved further. Results vary for word completion versus word prediction (see Chapter 7), with word prediction being more effective because it includes the context of the sentence as well as that of the word.

Spell checking programs are helpful to students with learning disabilities as editing tools, but grammar checkers are not (Lewis, 2005). Spell checking programs are designed to primarily detect typographical errors, not misspellings resulting from phonetic errors (Ashton, 2006). Thus, the target word for a student with a leaning disability, who is spelling phonetically, is often not the first word listed by the spell checking program. Despite this limitation, students with learning disabilities were able to detect their target word 95% of the time, even if it was not the first word listed (Ashton, 2006). The reason for the lack of success with grammar checkers is that they often rely on text to have correct spelling (Lewis, 2005). When evaluated on the basis of types of spelling errors made by students with learning disabilities, spell checkers vary widely in effectiveness (Sitko, Laine, and Sitko, 2005). Spell checking programs are most effective when they are integrated into a word processing program.

Concept mapping is a process of conceptualizing information by using graphics and text. The Inspiration concept mapping software (Inspiration Software, Inc, Beaverton Ore., http://www.inspiration.com/) is designed to help students in grades 6 through 12 to plan, organize, and write research papers (Figure 10-11). Its alternative format for representing ideas with both text and graphics, its ability to import concepts from the Internet and other sources, and the provision of a large number of templates make Inspiration useful to students who have learning disabilities (Ashton, 2005; LoPresti, Mihailidis, and Kirsch, 2004). Inspiration also allows the student to toggle between text and concept map as they develop their reports. With use of Inspiration, eighth grade students who had LDs produced essays that were significantly above their pretest levels in number of words, concepts included, and holistic writing scores (Sturm and Rankin-Ericson, 2002).

Alternative Input.

Alternative input technologies offer the user different modalities for providing input commands or information to a device. One example is voice recognition software (see Chapter 7). Voice recognition can be useful for generation of text input by individuals with cognitive disabilities that limit their ability to write (LoPresti, Mihailidis, and Kirsch, 2004). Users are able to enter information or commands to a computer through voice dictation instead of mouse and keyboard. For TBI, speech recognition programs have all shown to be useful in clinical trials (Kim et al, 1999; Van Hulle and Hux, 2005). Voice recognition can be very effective in improving writing for students with LDs (Sitko, Laine, and Sitko, 2005). A person with an LD may be able to verbally articulate thoughts very well but, because of visual processing problems, may have trouble getting words down on paper: “the words jump all over the page.” Automatic speech recognition provides an alternative for this type of individual.

Voice memo recorders are used in a similar manner, replacing pen-and-paper or keyboard entry as a means of storing messages for future reference. For those who are unable to make the fine motor movements required for handwriting, a portable notebook computer (e.g., Neo by AlphaSmart, www.alphasmart.com/) with abbreviation expansion or word completion/prediction (see Chapter 7) may be more efficient. Buttons with descriptive pictures and text may make the function of input controls more obvious.

The Aurora (AUtonomous RObotic platform as a Remedial tool for children with Autism) Project investigated the feasibility of robotic toys serving therapeutic roles in improving social interaction in autistic children (Dautenhahn and Werry, 2004). Children were presented with an interactive robot toy, which was programmed to sense and imitate the children’s movement. Although the long-term therapeutic effect of the toy is still unknown, preliminary findings and anecdotal reports from the project suggest that robots can potentially serve as a mediator in facilitating interaction between autistic children and their peers or other adults (Dautenhahn and Werry, 2004; Robins et al, 2004) and encouraged playing. Robins et al (2004) reported an increase in mutual gaze and gaze following among three autistic children and the experimenter during interaction with a robotic toy, suggesting that joint attention was established. The Aurora Project is an innovative application of alternative input using robotics as an intermediary through which a person with autism can communicate with others. Because individuals with autism often demonstrate deficits in interpreting and predicting human behavior, interactions with robots can provide a relatively simplified, safe, predictable, and reliable environment.

Alternative Output.

Alternative output technologies offer users a nontraditional means of acquiring feedback or information from a device. Some individuals are more visually oriented, and print or screen displays work well for them. For others information is easiest to access in auditory form. Synthesized or digitized speech output is often used for auditory information. The principles of electronically generated speech and its application in augmentative communication systems are discussed in Chapter 7. Many devices that were originally developed for individuals who have limited vision make use of synthesized speech to enhance or replace a typically visual output. Examples of these devices include text-to-speech screen readers for computer applications, talking calculators, a tape measure with speech output, and bar code scanners (see Chapter 8).

Synthesized speech and digitized speech (see Chapter 7) are both used to provide auditory information to children and adults with intellectual disabilities (see prompting and cueing section in this chapter). Synthesized speech associated with a word processor (for example, Write Outloud, Don Johnston, Inc, Volo, Ill., www.donjohnston.com) for students with LDs can provide an additional modality that is helpful in writing and editing. The greatest benefit may be in reducing the most common misspellings (i.e., those that are “non-real” words such as “thar” for “there” as opposed to word substitutions such as “to” for “two”) (Lewis, 2005). Synthetic speech output also was useful when the spell checker could not suggest any words because of gross misspelling. The impact of speech output is more significant for younger learners than for secondary students. In some cases, the impact of speech synthesizers in providing writing assistance to students with LDs is less significant than the effective use of spell checkers and word prediction (Lewis, 2005). However, as illustrated by the following case study, auditory output by speech synthesis is an effective tool for students with reading or writing difficulties associated with LDs (Sitko, Laine, and Sitko, 2005). Students can often detect errors in their writing more easily if they hear the words as opposed to reading them in written form. Adding speech synthesis to the presentation of screen-based text provides a multimodal output that also assists in reading and writing.

Because many individuals with LDs have greater comprehension of auditory than written information, synthesized speech output in “talking books” or “e-books” has been shown to be effective in improving reading abilities (Ashton, 2005). E-books have a number of features that are useful for students who have LDs. For example, words can be highlighted in the text as they are spoken or the document can be presented in an enlarged font. For students who need spelling practice, a spelling activity can be selected that uses the words from the story. Using software and on-line tools, teachers can create their own e-books (Ashton, 2005).

The Readingpen (WizCom Technologies, Ashton, Mass., www.wizcomtech.com/), an assistive reading device (Figure 10-12), is a hand-held scanner that is designed specifically for school-age reading levels. As the pen is moved across a word or full line of text, the text is spoken aloud. Using a children’s dictionary and thesaurus, the device also provides information to the student about word meaning and alternative words through a three-line built-in display. The pen provides a portable way for people with reading difficulties, LDs, or dyslexia to get immediate word support when they are reading. The scanned text may be spoken word by word or line by line. An earphone connection is available for privacy.

Altering the visual appearance of the computer screen can also aid individuals with disorders such as dyslexia (LoPresti, Mihailidis, and Kirsch, 2004). Changing features such as font size; background/foreground color combinations; contrast; spacing between words, letters, and paragraphs; and use of graphics can all improve access to screen-based information.

Tracking and Identification.

This final category consists of technologies that involve the tracking and identification of people or items. Such devices often provide an extra degree of safety for users who might not have the cognitive skills required to work their way out of problematic situations. For instance, the SmartChip (www.smartchip.com/) ID is a wearable electronic device that stores critical information about the user. If the user became lost, the stored information can be made available to someone who could make use of this information to ensure the user got home safely.

Another method of tracking is home monitoring systems that can keep track of the status of a person with cognitive disabilities. These systems include monitoring of the environment within a house (e.g., gas or smoke detectors), cardiac parameters (heart rate, arrhythmias), objects, and people (e.g., sensors that determine whether a person has left his or her bed by monitoring the weight applied to a pressure sensor place under the bed frame), and emergency call (a button that is pushed and automatically dials a central station). The suppliers (for example, in Canada, www.lifeline.ca/, in the United Kingdom, http://www.tunstall.co.uk/home.asp, and in the United States, http://www.lifestation.com/?ASK=Medical-Alert) of these systems describe many case examples on their Web sites that illustrate how these systems can make it possible for persons with memory loss, wandering, and other cognitive limitations to continue to live at home (see the following case study). These systems are often incorporated into the Smart House concept discussed in this chapter.

1. Pick a specific cognitive disability, an activity, and a context and describe how the HAAT model (as described in Chapter 2) would be applied to determine the best assistive technology approach (hard and soft technologies) for that individual.

2. How do assistive technology approaches differ for congenital and acquired cognitive disabilities?

3. Pick a specific disorder and describe both the cognitive skills that are likely to be available for use of an assistive device and those that may need to be replaced or augmented by such a device.

4. List the major characteristics of mild cognitive disabilities as they relate to the use of assistive technologies.

5. List the major characteristics of intellectual disabilities as they relate to the use of assistive technologies.

6. List the major characteristics of dementia that may be aided by cognitive assistive technologies.

7. In terms of recommendation of assistive technologies, how do CVA and TBI differ from other acquired cognitive disabilities and from each other?

8. How do the considerations for mild cognitive disability, intellectual disability, and acquired disability differ? What are the implications of these differences for the application of assistive technologies?

9. Why is ADHD not considered an LD?

10. What interventions are commonly applied to the treatment of LDs?

11. Describe the differences between remediation and compensation as they apply to cognitive disabilities.

12. How do the terms remediation and compensation differ when applied to sensory (Chapter 8 and 9) or motor (Chapter 7, 11, or 12) disabilities as opposed to cognitive disabilities?

13. What are the currently available assistive technologies that are beneficial to children with ASD? What are the efficacies and feasibilities of these technologies in replacing or augmenting skill deficits?

14. What are the characteristics of PDA-based time management systems for persons with intellectual disabilities?

15. Describe the general characteristics of memory aids.

16. Contrast the use of memory aids in intellectual disabilities, dementia, and TBI.

17. Describe how systems designed to provide prompting, cueing, or coaching are applied to assist persons with intellectual disabilities.

18. How do applications of prompting, cueing, or coaching systems differ between applications for individuals with intellectual disabilities and those with dementia.

19. What is meant by the term stimuli control, and how is this concept applied to Web page design?

20. What are the major challenges in using assistive technologies to address the problems faced by individuals with dementia?

21. How can word completion and word prediction benefit students who have LDs? What are the limitations in this application?

22. What are the most commonly used alternatives to printed text output?

23. What is concept mapping and how can it benefit students who have LDs?

24. What should be considered when recommending a time management device for a stroke patient?

25. What is a cognitive prosthesis? Describe how these devices are applied to assist individuals with TBI.