Accessibility and Assistive Technology
Assistive Technology for Cognitive Limitations
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INTRODUCTION:
The purpose of this article is to provide a framework for understanding functional limitations related to Acquire Brain Injury (ABI) and to identify assistive technology and compensatory strategies that can be used to overcome limitations and enhance functional capacities in home, work and community settings. Our focus will be limited to the cognitive limitations associated with ABI and will not address the physical and sensory limitations that often accompany ABI.
DIAGNOSIS: ACQUIRED BRAIN INJURY
Acquired Brain Injury, ABI, is the term used to describe an insult to the Central Nervous System resulting in functional disability and/or psychosocial impairment. This condition can be mild or quite devastating, depending on the severity and location of the incident. The specific nature of impairments can vary from one individual to another. Generally, the disease is characterized by a combination of physical, cognitive, and emotional deficits that must be addressed in the rehabilitation process. (1)
When considering the use of assistive technology it is preferable to assess the individual’s functional deficits and capacities in order to determine the most appropriate accommodations to support greater function. Proper assessment for AT alternatives should include a careful analysis of the activities that are being considered for the individual. In fact, the process begins with the activity and it is important to determine in detail what functional capacities are required to accomplish the specific activities in question. The effort of identifying the most appropriate AT involves filling in the gaps between what needs to be accomplished and what can be accomplished, given the specific functional capacities and corresponding deficits that may exist. (1)
Primary Characteristics of Brain Function:
In an effort to identify specific functional deficits that often occur following an Acquired Brain Injury this article will consider four aspects of brain function:
Perception – A person’s ability to perceive sensory stimulation accurately
• Understand speech
• Distinguish between written words / images
• Distinguish between spoken words / sounds
Expression – A person’s ability to provide verbal or non-verbal expressions
• Speak
• Write (express thoughts coherently)
• Write (form letters properly)
• Follow social norms (appropriate behaviors)
Memory – A person’s ability to store and retrieve information in either short-term or long-term memory
• Recall recent or past events or information
• Form mental image of things seen
• Form mental image of things heard
• Learn repetitive motor tasks
Processing – A person’s ability to understand perceived information and perform value-added functions
• Focus on a given task
• Organize / schedule tasks
• Problem solve
• Understand accurately perceived images / sounds
• Understand and complete self-care functions
Impairments Relating to Specific Brain Functions:
When one examines the functional impairments relating to each of the four basic categories of brain function, certain limitations can be identified. This is not an all-inclusive list, but it represents the more common limitations encountered in clinical practice.
Impairments Related to Perception
• Difficulty understanding speech (receptive aphasia). This condition prevents the person from being able to understand words that are spoken.
Impairments Related to Expression
• Difficulty producing speech (expressive aphasia). This prevents the person from being able to speak words even though they are aware of what they want to say. Speech may also be affected by poor cognitive motor function (apraxia). In this case, the person is unable to make the sounds necessary to form speech.
• Changes in behavioral speech. This may take the form of a flat affect or reduced control of behavior to fit social norms.
• Writing may be affected by the difficulty in producing legible handwriting with age-appropriate speed.
Impairments Related to Memory
• Short term and long term memory deficits can cause a person to forget specific task
• Procedural memory lost can affect a person’s ability to learn new manual tasks such as tying shoes.
Impairments Related to Processing
• Executive functions – the ability to complete higher level tasks such as time management, organization and judgment, can be diminished
• Poor organization and sequencing creates difficulty with spelling, grammar and sentence structure
• Dementia, resulting from diffuse damage to the brain, may affects a person’s ability to handle basic self-care tasks
• Emotional and behavioral changes may hinder a person’s judgment of socially appropriate behaviors.
• Attention and staying on tasks capacity may be diminished, affecting many aspects of work and daily living activities
Considerations for Accommodating Functional Deficits Relating to Acquired Brain Injury
In considering options for accommodating ABI deficits, it is important to include both compensatory strategies, as well as assistive technology. In many cases a combination of strategies and technology is used to create the best possible outcome. Below are listed some considerations that should be made toward reducing the effects of cognitive deficits relating to ABI.
Impairments Related to Perception (Receptive Aphasia)
An individual with receptive aphasia may have difficulty understanding what he or she hears. Interventions should focus on enhancing the ability to concentrate and be free from distractions while communicating. Minimizing background noise can help, as well as making sure the person is paying attention before starting a conversation. It is also helpful to keep communication simple and age appropriate. It may be difficult for the person to take notes in class because of the extra effort required to process incoming information. Consider providing someone to take notes or arrange to have a student make copies that can easily be shared.
Individuals who are experiencing difficulty recognizing printed words and symbols are described as having dyslexia. To assist with reading difficulties there are some basic approaches that will help. Recording for the Blind and Dyslexic provides a service that offers books on tape for individuals who are members of this program. An initial fee is required to become eligible to receive materials. A small annual membership fee is also required to continue participation in the program. There are thousands of books available that have been recorded and the program will arrange to record a specific book if requested. Another approach would be to use Digital voice recorders to retain messages and explain instructions.
Software and hardware originally designed to assist people who are blind can also be applied to help those with dyslexia. Optical Character Recognition (OCR) software converts scanned documents into electronic documents that can then be converted to speech using the computer sound card. A more simple computer accommodation involves using word prediction software that completes words as letters are typed.
Impairments Related to Expression (Expressive Aphasia, Dysgraphia, Behavioral expression)
The challenge of assisting individuals experiencing expressive aphasia is to find alternatives to assist with both verbal and written communication. Speech is often laborious and hard to understand and a need often exists to supplement spoken words with descriptive phrases. For this reason picture books can help support conversation because it can provide the context for what is being communicated and provide structure for the thought process.
With significant speech difficulties, Augmentative & Alternative Communication Devices (AAC) can be provided to replace speech that is lost or intelligible. There are various levels of AAC that are available and the type of system should be recommended after a comprehensive assessment provided by a Speech and Language Pathologist. An AAC device may offer either digitized speech using pre-recorded messages or synthesized (computer generated) speech. Words are chosen from a selection of icons that must be learned by the user. Menus can organize the icons to place topics in certain categories to ease in word selection. AAC devices can also be keyboard based for individuals with word literacy and the capacity to type.
For individuals who are challenged with difficulty creating written language, low-tech aids such as using a straight edge or writing template can be used to keep writing aligned. For individuals with adequate perception but experience difficulties with hand writing or keyboarding an option might be to use voice recognition software that allows the individual to speak words into a microphone as an alternative to using the keyboard. This option is becoming more and more effective as the technology improves. It does remain a challenge for many who experience either the lack of cognitive organization or temperament to self-correct incorrect words and learn voice commands to replace mouse movements. However, one of the beneficial features to voice recognition software is the capacity to use both voice and hand controls interchangeably.
Impairments Related to Memory (Visual, auditory, procedural, amnesia)
There are a number of memory aides that are designed for the general population that can offer support for someone with visual, auditory or procedural memory loss. Mnemonics represents an approach to learn strategies to enhance memory capacity and includes numerous techniques that can be learned and practiced. Rhyming is one of the many various approaches, i.e. “30 days has September, April, June and November”. Similarly, using multiple approaches to input can have a beneficial effect. For example, it might help to provide documentation in more than one format--visual, auditory and tactile. Simply using office technology can help, such as depending on email for communication. This provides an alternative to a phone call while creating a document for later reference. Medication reminders, watch timers and telephone dialers all represent simple electronic accommodations that represent conveniences for the general population yet significant accommodations for those with memory deficits.
Impairments Related to Processing (Attention to detail, executive functioning, visual & auditory functioning, dementia)
Cognitive processing covers a wide range of functions and represents the basic integration of the thought process. When there are impairments in this capacity the goal is to provide supports that can reduce disorganization and frustration. Simple strategies like creating clear lists of task/goals to be accomplished can be helpful. Day planners, either hard copy or electronic software have proved effective. Providing immediate feedback based on task performance is also helpful and in some cases having attendant care at home and job coaching at work can keep the individual on tasks. Improved organization can be achieved through using index cards to convey key pieces of information and color coded folders to categorize information.
Technology is available in the form of amplified listening systems that help the individual focus attention on the primary source of input. Similarly, noise-blocking devices can help as well as tracking and signaling equipment. Computer-related accommodations include spell checker and grammar checker software, writing organization software and time management and prompting capacity. As stated earlier, using email for communication, rather than the telephone, can offer better understanding and documentation for later reference.
A good source for up-to-date, thorough information on assistive technologies, adaptive environments and community resources for people with disabilities, including their families and service providers, can be found at www.assistivetech.net. This site is designed to help people find assistive technology (AT) solutions that match their needs by maintaining searchable databases of thousands of products and resource.
You can find out more about the various projects at CATEA by visiting their website.
References:
1. Cook, A.M., and Hussey, S.M., (1995) Assistive Technologies: Principles and Practice. St. Louis, MO, Mosby publishers.
2. Haynes, S. Model for Functional Application of Assistive Technology. RESNA Press, 2001.
Scott Haynes and Hunter Ramseur are Research Scientists with the Center for Assistive Technology and Environmental Access (CATEA) located with the College of Architecture of Georgia Tech. CATEA supports individuals with disabilities through:
• Expert services
• Research
• Design and technological development
• Information dissemination
• Educational programs