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Computer assistive technology for people who have disabilities: computer adaptations and modifications.

As all areas of society continue to become more technologically oriented, individuals with disabilities are benefiting and becoming more integrated into American society. Society, as well, benefits from this increased participation of individuals with disabilities, their greater independence, and their decreased reliance on public services. Assistive technology (AT) has increased functional abilities, independence, and access to mainstream society, creating a method of equalization between persons with and without disabilities.

Rehabilitation counselors need to be familiar with computer assistive technology (CAT) as consumers are receiving increased benefits with the help of technology. It provides a valuable tool to enhance the lives and employment opportunities for these individuals. Empowerment of consumers through technology facilitates self-direction in life choices, and this self-directed empowerment augments the rehabilitation process.

The purpose of this article is to describe some of the basic components of computer systems that can be modified to help consumers with disabilities more easily access and use these devices. Rehabilitation professionals can recommend these adaptations and modifications for their consumers. Basics of computer assistive technology are introduced first. Three areas of CAT are then covered; the first section is "Adaptations and Alternate Input Devices." Adaptations to the standard keyboard or mouse may provide the type of accommodation that meets the individual's needs or desires. This section discusses the following adaptations: alternative keyboards, keyguards, switches, mouse modifications, pointing and typing aids, eye-tracking technology, Morse Code, optical character recognition, scanners, and voice recognition technology.

The second section, "Alternative Input Processing Aids," describes basic features that operate as specific tools or macros that enable users to accomplish tasks more readily. This includes abbreviation expansion, word prediction, cognitive retraining software, reading and writing aids, electronic reference tools, and browser accessibility.

The final section, "Alternative Output," concerns the process where the consumer uses the computer to output information. This includes talking word processors, large print/magnification, CCTVs, refreshable Braille displays and embossers, screen readers, and speech synthesizers.

Computer Assistive Technology

Consumer Satisfaction with Technology

A method to evaluate consumer satisfaction and success with technology is to look at the number of individuals who continue to use the technology that has been provided and those persons who discontinue use. Studies (Phillips & Zhao, 1993; Riemer-Reiss & Wacker, 2000; Scherer & Galvin, 1996; Tewey, Barnicle, & Pert, 1994) have shown that abandonment rates are generally within the 30% to 40% range. These studies indicated that when consumers have more involvement in the selection process, the likelihood is greater that technology will continue to be used. A consumer-driven approach provides the individual with feelings of ownership and responsibility, often leading to continued use of AT (Riemer-Reiss & Wacker, 2000). Other important factors to consumer continued use involve ease of operation of the computer, and the provision of AT that best fits one's needs. Relative advantage (characteristics of the device itself) and compatibility also are highly related to continued use (Rogers, 1995).

AT devices allow consumers to function more independently in school, at home, and on the job. Technology involves tools for enhancing independence. Rehabilitation counselors can best assist consumers by evaluating their individual and personal needs and desires. By providing the most effective computer adaptations to meet consumers' needs, the opportunity of satisfaction and continued use become enhanced.

Technology and the Rehabilitation Professional

Riemer-Reiss (2003) reported that enhancement in rehabilitation professionals' assistive technology training and education was related to an increase in their AT selection and referral.... professionals who are educated in technology are more likely to recommend it for their consumers. This researcher noted that many rehabilitation professionals in her sample emphasized the need for additional education in AT; the research findings point to the significance of an ongoing, thorough education in AT.

Assistive technology was initially defined in the Technology-Related Assistance of Individuals with Disabilities Act of 1988 (P. L. 100-407) as "any item, piece of equipment, or product system, whether acquired commercially or off the shelf, modified, or customized, that is used to increase, maintain, or improve functional capabilities of individuals with disabilities" (Scherer, 2000, p. 185). Yet, assistive technology is more than computers, circuit boards, cables, and mechanical devices; it is the integral process of assisting individuals with disabilities, especially those with severe disabilities, to maximize their human potential. Computers are a basic form of societal participation, comprise one part of AT services, and are used in the configuration, design, and use of other related technologies (Anson, 1997). Computer assistive technologies take into consideration the unique characteristics of each individual, his or her capabilities and limitations, needs and desires. Consumer input is an essential aspect of the process. A consumer's needs and desires are matched with the characteristics of conventional (general purpose) computers and system modifications (Bentz, 1998; Cook, 2002).

Computer Components and Applications

Basic components of computer systems are input devices, processors, memory, storage, and output devices including the monitor screen, sound, and printed text (Bentz, 1998). Software contains the ideas, concepts, operating systems, and data that is stored electronically. Computer hardware refers to objects that can actually be touched including, for example, disc drives, keyboards, and computer chips. Applications are software productivity tools that perform commands initiated by the user; they include word processing, databases, spreadsheets, graphics, and communication tools (Alliance for Technology Access, 2000; Cook & Hussey, 2002).

Vanderheiden (1996) defined the term "transparent access" as the fundamental interaction technique necessary for general purpose computers, CAT devices, and software programs that are compatible and capable of running on the same operational system. Cook and Hussey (2002) stated that an essential part of adaptive computer technology is the concept of transparency, which is the ability for all programs to operate without interference from other programs. Two basic components of transparent access are that (a) all the computer operations must be accessible, and (b) all general software must also run on adapted computers. Anson (1997) further clarified transparency as software programs that operate so intuitively that the user can concentrate on tasks at hand rather than be concerned with accommodating functions. Computer assisted technology must allow the general computer functions to continue uninterrupted and without interference.

Adaptations and Alternate Input Devices

The most common computer input methods are accessible by either a standard keyboard or mouse. Moderate adaptations to these devices may provide the type of accommodation that meets an individual's needs and desires to more efficiently and effectively operate a computer. CAT input consists of the following: alternative keyboards, keyguards, switches, mouse modifications, pointing and typing aids, eye gaze technology, and Morse Code. Specialized software that provides alternative input includes optical character recognition, scanners, and voice recognition technology (Cook, 2002; Vanderheiden, 1996). The premise of computer assistive technology relies on processes of accommodating an individual with an alternative keyboard, mouse, or other input device that is similar to the general input components of a computer.

Alternative Keyboards

Alternative keyboards or keyboard patterns have several different features. Expanded keyboards require a greater range of motion and are used when targeting a small key is impractical. Contracted or mini-keyboards are applicable for consumers with fine motor control but limited range of motion; the keys are compacted to fit in a smaller area. Access methods include fingers, hands, fists, feet, pointers, and mouth sticks.

Chording keyboards are organized with a small number of keys and require the user to depress a combination of keys at the same time in order to produce characters. Another alternative keyboard has the most commonly used characters located on the home row. Keyboards can be two-handed, with right or left-handed patterns. Some keyboard designs cluster the most common characters in the center to facilitate a consumer who can use only a single finger to type. Ergonomic keyboards are designed to lessen repetitive stress injuries (Reed, 2002; Star, 2001).

Many CAT vendors manufacture programmable keyboards (Alliance for Technology Access, 2000). Keyboards are multi-purpose, typically larger for target-access accommodations, and can adjust smaller key choices for range of motion adaptations. Programmable features include customization of phrases, words, letter and number combinations, through the use of overlays. Virtual or on-screen keyboards appear on the computer screen and contain word completion and customized keyboard layouts. Access is by various methods, such as a mouse, trackball, touch screen, joystick, head wand, eye gaze, or pointing device.

Programmable and virtual keyboards are dependent on software programs that accommodate on-screen keyboard access by mouse, switch, joystick, trackball, or other input device. There are many features, such as word prediction, abbreviation expansion, and touch screens. Direct input-selection or activation occurs when the user touches the screen or accesses it with various soft point touching devices. The configurations of touch screen accommodations vary and organizational strategies range from a full keyboard to a single, large-switch device (Alliance for Technology Access, 2000; Bower, Kaull, Sheikh, & Vanderheiden, 1998-1999).

Keyboard Emulating Interfaces

These are devices that allow adaptation between general purpose computers and an alternative input method that does not contain compatible operating system circuitry. For example, an augmentative and alternative communication (AAC) device that is used for communication can be adapted to perform the various functions of the keyboard. AAC devices are "technologies that enable persons with limited speech or no usable speech to visibly display their words or speak through the assistance of electronic communication devices with voice output" (Scherer, 2000, p. 185).

Keyguards, Moisture Guards, and Label Overlays

Keyboard coverings accommodate various needs ranging from precision enhancement, protective measures, and character placement (Anson, 1997). Keyguards are rigid coverings, placed over keyboards, designed to accommodate limitations in accuracy. A variety of commercial key guards are available. Moisture guards are thin, plastic coverings that protect the keyboard from spills or drooling (e.g., such as may occur with cerebral palsy). Alternative or label overlays modify the layout or character design of the keyboard; the software program reconfigures the layout. Objectives include strategies that may ameliorate fatigue, add tactile information, accommodate visual clarity and color contrast, and increase speed (Bentz, 1998; Cook, 2002).

Switches

Physical limitations preventing direct selection on the keyboard are accommodated with alternative indirect approaches. Switches are single, multiple-switch array, or multiple-input interfaces. The type of switch or array is determined during evaluation based on a consumer's sensory, spatial, activation capabilities, and skills. Single switches include paddle-type, wobble, lever, light beam, pillow, and "puff and sip" designs (Cook & Hussey, 2002). Evaluators determine the best type of switch based on individual characteristics and considerations of position, mounting, and placement requirements (Alliance for Technology Access, 2000).

Trackballs

A trackball is a standard computer device that replaces the conventional mouse. Advantages include stationary position, no cord tangling, less hand movement, and ability to use with a pointing device. The major limitation is the dexterity required to hold down a button with one finger while pivoting the ball with another. Features enable the user to access a computer with less effort and include lock down buttons for easy dragging, buttons to perform computer operations, adjustable speed, and a range of sizes and shapes (Alliance for Technology Access, 2000).

Mouse Sticks

A mouth stick or pointer used as a mouse can enable the user to activate and operate a computer. The hardware contains a specially modified knob; alternatively, the operating codes can be adjusted to have a particular character change with a mouse function. An occupational therapist, physical therapist, or clinician measures the stress that activation force propels back to the user. Any type of unique adaptation needs careful evaluation if it is to be used over long periods of time.

Hands-Free Mouse

Head movements can control the hands-free mouse adaptation. The standard mouse is replaced by on-screen keyboard software that translates the user's proportional movements controlled by the direction of a head pointer or comparable device.

Pointing and Typing Aids

Head movements typically use pointing devices to activate computer keyboards or switches (Bower et al., 1998-1999). Additional effector sites include the mouth, chin, hand, foot, or any site with adequate motor control. Pointer varieties are light pointers, infrared devices with a reflector worn by the user, and wands or sticks used to strike keys. Aids are fastened to the user's body with head or chinstraps, attach to arm or wrist supports, and clasp to hand or finger guards. Input devices that can be accessed with typing aids include trackballs, touch screens, switches, specialized software such as mouth sticks, and alternative keyboards (Alliance for Technology Access, 2000).

Eye-Tracking Technology

Eye-gaze technology can track the movement of one eye to activate a computer. The individual must have enough head control and ability to gaze directly at a camera. Derived from military eye control systems, the camera is typically attached to the head; however, the weight of the camera requires the head to be positioned and supported. Current research promises enhanced eyeglass systems. Bower et al. (1998-1999) described innovative eye gaze technology that features virtual reality goggles with an integrated camera and viewing screen to provide communication through icon choice. The user chooses targets by gazing at the icons on the computer screen; the camera, integrated within the a goggles, tracks eye gaze movement and relays input information for processing. "

Morse Code

The majority of Morse Code systems use audio feedback to verify the code. Various systems use eye technology; however, squinting rapidly produces fatigue. The majority of programs use various switch arrays; multiple switch arrays activate input speed, with a "puff and sip" user able to type at a competitive rate (Anson, 1997).

Optical Character Recognition (OCR) and Scanners

Optical character recognition technology accesses a computer by scanning information that is converted to text through software applications. The OCR process consists of scanning the image, blocking out graphics or other non-text information that confuses the scanning technology. An assistant or the user edits the information by comparing it to the original work. Scanners work with pictures or graphics and do not need OCR software to translate to general purpose computer software (Alliance for Technology Access, 2000; Cook & Hussey, 2002).

Voice Recognition Technology (VRT)

Bentz (1998) described VRT as a communication process that analyzes sound based on speech collected from thousands of samples that have been compared statistically in order to develop a speech model. Individual characteristics require a clear and consistent voice. Microphone systems have the capabilities of blocking background or tactile display noises, and assist with defining voice clarity (Scadden, 1998). Software applications necessitate either discrete or continuous speech. Discrete speech requires the user to pause between words. Continuous speech allows common conversational speeds of input when user speech is sequenced and enunciation is refined.

Alternative Input Processing Aids

As reported by Cook (2002) and Cook and Hussey (2002), application programs include basic features that operate as specific tools or macros, enabling the user to accomplish tasks with less typing and quicker performance time. This process shortens the procedure of opening a toolbar or menu icon and accessing a command button, and saves several dexterity and hand-to-mouse movements.

Keyboard shortcuts or "hotkeys" are customization features that allow the user to create individualized access keys (Anson, 1997). AutoCorrect is a feature that permits the user to program shortcuts for capitalization of all first letters of sentences, replace typos with text as they are typed, and correct errors. AutoText allows a user to create automatic text words or phrases that are frequently used. Included is a "sticky-key" feature that allows a consumer to access the shift, control, and alternate keyboard keys by pressing one key at a time. This feature provides a solution for someone who cannot depress two keys simultaneously. Repeat keys assist the user by allowing an adjustment for timing how long a key can be held down before it begins to repeat. Filter keys act by ignoring repeated keystrokes; toggle keys create beep tones when certain keys are pressed (Bower et al., 1998-1999; Cook, 2002). Included within this section are abbreviation expansion, word prediction, cognitive retraining, reading and writing aids, electronic referencing, and browser accessibility.

Abbreviation Expansion

Software designers have provided an encoding process that allows a computer or AAC user to type (input) a series of letters that automatically prompt the software program to insert expanded text to complete a word or sentence (Anson, 1997). The abbreviation can be recorded as a "hot-key" shortcut. Cognitive limitations that affect conceptualizing, encoding, memorization, or recall may limit a consumer's ability to use this feature (Cook, 2002).

Multiple adaptive keyboard programs provide abbreviation expansion, dual word prediction, and speech output. They feature a complete keyboard control that allows shortcut key combinations in sequence rather than simultaneously, and accepts time and repeat rate modifications (Bower et al., 1998-1999).

Word Prediction

Performance enhancers included in general purpose computer programs offer macros that prompt the computer to predict words and frequently used phrases (Cook, 2002). Word prediction is designed to shorten typing effort through input and processing. A software tool provides a list of predicted words based on the user typing the first two letters of the desired word. Word prediction software programs have vocabularies of 5,000 to 10,000 words. Benefits of word prediction include reducing keystrokes, assisting with word recall, increasing vocabulary through word prompting, and improving typing speed (Anson, 1997; Bower et al., 1998-1999).

Cognitive Retraining Software and Reading Tools

Computer assistive technology tools designed to assist individuals who need to rebuild skills, train memory, acquire independent living skills, overcome learning disability barriers, and have accommodating or alternative formats for reading are termed cognitive retraining and reading software (Scherer, 2002). Strategies include activities, stories, games, and exercises (Alliance for Technology Access, 2000).

Reading Comprehension Software

Goals of reading comprehension software are to implement and improve reading skills. User groups range from pre-kindergarten through adult. Programs start at basic levels of letter recognition, and accelerate as comprehension levels advance or focus on development of a particular skill over an extended course. An array of products vary in objectives from practicing letter-sound recognition and word-sentence building; using graphic, sound, or animation; and vocabulary acquisition tools, including educational and assessment instruments.

Writing Aids and Comprehension Software

Educators, researchers, and technologists have designed software products that use electronic medium to improve writing skills and enhance individual abilities. Objectives are improvement in areas of brainstorming and classification skills, sequencing, outlining, sentence completion, and proofreading for educational and professional environments (Reed, 2002; Scherer, 2002).

Electronic Reference Tools

Processing programs that convert print materials to alternative mediums using formats such as sounds, music, video, and are presented in timelines or tables are termed electronic reference tools (Scherer, 2002). A multisensory approach assists with transferring information from data or images to statistics and provides a method of locating information electronically. The user is typically someone with a need to access information presented in a combination of learning styles--visual, auditory, and tactile. For example, the display of a world atlas is framed with pictorial icons (e.g., watch, book) that when activated by the keyboard or computer mouse, presents information regarding time, culture, or geographic significance.

Browser Accessibility

Browser accessibility features enable consumers who have alternative sensory communication needs to locate and access Web pages (Alliance for Technology Access, 2000). Browsers are computer software programs that interpret Hyper-Text-Markup-Language (HTML), the underlying Internet protocol that defines how messages are formatted and transmitted.

Alternative Output

A major goal of the output process is to produce what an individual needs or desires. The four types of AT output are motor, visual, auditory, and tactile (Cook & Hussey, 2002). Computer assistive technologies assist with significant output performance used by consumers. Visual, auditory, and tactile output provide sensory feedback. Transient visual display or visual indicators give output only when a device is turned on; hard copy output is visual (print) or tactile (Braille). Computer screens, displays, and scanners are transient. Visual indicators are prompts on the computer screen, display codes, or scanning symbols for communication, mobility, and environmental devices. Auditory displays present information in two ways: as indicators (beeps or tones), and as speech synthesis through electronic spoken language. CAT uses auditory indicators to give messages (warnings, cues, and instructions) for users who have visual impairments (Anson, 1997). Computer assistive technology output consists of talking and large print word processors, CCTVs, refreshable Braille displays and embossers, screen readers, and speech synthesizers.

Talking Word Processors

As indicated by Anson (1997), talking word processors provide speech synthesis and auditory feedback of information that allows text to be written, edited, and arranged. Keystrokes are confirmed by echo without requiring visual attention to the screen. Certain programs feature speech editing capabilities to correct computer speech pronunciation.

Large Print Word Processors and Computer Magnification Software

Large print word processors convert characters to large print without losing full view of a program; software includes auditory output and other utilities, such as word prediction. Most talking word processors do not have the capabilities of a screen reader. Computer magnification software works with word processing programs to magnify the monitor screen (Cook, 2002; Star, 2001).

Closed-Circuit Television Magnifiers (CCTVs)

Although not computers, CCTVs are widely used to read material at the same time that entries are made into a computer program. They use electronic magnification through television cameras or photo arrays that accommodate low vision users with enlarged images displayed on a monitor screen. Magnification has adjustment ranges determined by the size of the television monitor with maximum range from 45 to over 60 times the original (Alliance for Technology Access, 2000).

Refreshable Braille Displays

Refreshable Braille technology, as noted by Anson (1997) and Scadden (1998), allows Braille to change as information changes through electro-mechanical tactile pins contained in a keypad device. Pins lift to form Braille characters and are replaced by the next line when the user activates a switch. The term "refreshable display" reflects the process of reading one line of text at a time, erasing and reading the next, as the device cannot translate a full screen of text on a single display. A significant advantage is that an electronic circuit controls the displays and Braille keyboards and is able to store data electronically, thus reducing the bulk storage of embossed Braille. Most devices are lightweight, compact, and easily portable.

Braille Embossers

These specialized printers use an embossed heavyweight paper to print Braille that has been translated by an optical character recognition software program (Cook, 2002). Disadvantages include the bulk and expense of embossing paper and scanning for particular information when it is difficult to edit text. Features vary between product designs and may include speech output to assist navigation through printer function, two-sided embossing, and print graphics.

Screen Readers

Screen readers are software applications that work with speech synthesizers to translate text into speech. Three technology components are required: environmental interface (camera, scanner, and OCR), information processor (text-to-speech or Braille software), and output display (voice synthesized or Braille printer). Features include graphic translation; screen portion-selection; compatibility with internal or external speech synthesizers; and rate, pitch, and volume control (Alliance for Technology Access, 2000).

Speech Synthesizers

Speech synthesizers involve both hardware and software products. They work with software applications to translate alphabetic characters, including numbers and punctuation marks, and speak aloud (Reed, 2002). Many speech synthesizers come with text-to-speech programs that produce phonetically correct speech from electronic text. This option strengthens compatibility options for use with other applications, including AAC devices (Scadden, 1998).

Conclusion

Rehabilitation professionals need comprehensive training in technology and how CAT can be incorporated into rehabilitation plans and programs, especially for consumers with severe disabilities. Through a greater understanding of the adaptations that can be made to AT devices and equipment for consumers with disabilities, counselors can more readily assist in successful adaptation. Technology is a valuable tool that has improved and will continue to enhance the lives and employment opportunities of people who have disabilities and chronic, disabling conditions.

References

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Anson, D. K. (1997). Alternative computer access: A guide to selection. Philadelphia: F.A. Davis.

Bentz, B. (1998). Module XI: Characteristics of computer access technology. In RESNA (Ed.), Fundamentals in assistive technology (2nd ed., pp. XI-1 - XI-18). Arlington, VA: RESNA.

Bower, R., Kaull, J., Sheikh, N., & Vanderheiden, G. C. (1998-1999). Trace resource book: Assistive technologies for communication, control and computer access. Madison, WI: Trace Resource and Development Center.

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Cook, A. M., & Hussey, S. M. (2002). Assistive technologies: Principles and practice (2nd ed.). St. Louis, MO: Mosby.

Phillips, B., & Zhao, H. (1993). Predictors of assistive technology abandonment. Assistive Technology, 5(1), 36-45.

Reed, B. J. (2002). Assistive technology. In J. W. Andrew & C. W. Faubion (Eds.), Rehabilitation services: An introduction for the human services professional (pp. 198-237). Osage Beach, MO: Aspen Professional Services.

Riemer-Reiss, M. L. (2003). Rehabilitation professionals' perceived competencies in assistive technology selection and referral: A preliminary analysis. Journal of Applied Rehabilitation Counseling, 34(2), 33-36.

Riemer-Reiss, M. L., & Wacker, R. R. (2000). Factors associated with assistive technology discontinuance among individuals with disabilities. Journal of Rehabilitation, 66(3), 44-50.

Rogers, E. M. (1995). Diffusion of innovations (4th ed.). New York: Free Press.

Scadden, L.A. (1998). Module VI: Characteristics of technologies for people who are blind or people who have low vision. In RESNA (Ed.), Fundamentals in assistive technology (2nd ed., pp. VII-1 - VII-10). Arlington, VA: RESNA.

Scherer, M. J. (2000). Living in the state of stuck: How assistive technology impacts the lives of people with disabilities (3rd ed.). Cambridge, MA: Brookline Books.

Scherer, M. J. (Ed.). (2002). Assistive technology: Matching device and consumer for successful rehabilitation. Washington, DC: American Psychological Association.

Scherer, M. J., & Galvin, J. C. (1996). An outcome perspective of quality pathways to most appropriate technology. In J. C. Galvin & M. J. Scherer (Eds.), Evaluating, selecting, and using appropriate assistive technology (pp. 1-26). Gaithersburg, MD: Aspen.

Star, T. (2001). Matching assistive technology for consumer rehabilitation: Match guidebook and referral index. Unpublished master's thesis, California State University, Los Angeles.

Tewey, B. P., Barnicle, K., & Perr, A. (1994). The wrong stuff. Mainstream, 19(2), 19-23.

Vanderheiden, G. C. (1996). Computer access and use by people with disabilities. In J. C. Galvin & M. J. Scherer (Eds.), Evaluating, selecting, and using appropriate assistive technology (pp. 238-274). Gaithersburg, MD: Aspen.

Martin G. Brodwin

California State University at Los Angeles

Elizabeth Cardoso

Hunter College

Tristeu Star

California State University at Los Angeles

Professor Martin Brodwin; Charter College of Education, DiVision Administration and Counseling, 5151 State University Drive, Los Angeles, CA 90032. Email: mbrodwi@calstatela.edu
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